Building pyramids on Planet Zog

7/30/2019 Building pyramids on Planet Zog

http://slidepdf.com/reader/full/building-pyramids-on-planet-zog 1/4

SERVICE REDESIGN

SPEECH & LANGUAGE THERAPY IN PRACTICE Autumn 20078

We are great believers in spotting any po-

tential challenges on the horizon and

proactively seeking means and methods

o addressing them beore they come

ully to ruition, or beore someone else comes along

and decides on our agenda. When we set out to discuss

the government’s recent papers and the challenges that

Children’s Centres would bring to our paediatric service,

we never suspected that a wholesale reorganisation

would emerge – or indeed that the enthusiasm and mo-

tivation rom each and every member o the team would

mean that our initial thoughts o a three to fve year plan

would turn into an almost overnight revolution…

A. THE SERVICEMiddlesbrough Primary Care Trust provides speech and

language therapy services or children in the Middles-brough and Redcar Cleveland areas in the North East o

England. (The speech and language therapy service or

adult neurological / acquired disorders is provided by

South Tees Acute Trust.) The population is in the region o

300,000 and there are 4,000 new births each year. The lo-

cality has nine Sure Start projects that are developing into

ourteen Children’s Centres, and our wards all into the

‘top ten’ most deprived in the UK (www.statistics.gov.uk).

Much o the population resides in urban areas, but there is

a proportion o rural and arming communities.

The service had a paediatric department (catering

or mainstream clinical work as well as language units

/ resource bases and assessment classes / support bases

in mainstream schools), a Sure Start department cover-

ing all nine projects, and a special needs department

(including children with learning disability, physical

disability, hearing impairment and autistic spectrum

disorders). There are 22.4 whole-time equivalent (wte)

speech and language therapists and 12.5 wte speech

and language therapy assistants supported by 4.2 wte

administrative sta.

Children aged 0 to 4 years living within Sure Start ar-

eas received therapy in homes, Sure Start Centres and

local nurseries. All other mainstream children received

therapy at one o three community clinics sited across

the patch; so children rom around 100 schools in an

area spanning 50 by 10 miles were travelling or any-

thing up to an hour each way to attend therapy. Need-

less to say, non-attendance was an issue. Children with

special needs attend specialist pre-school and educa-

tional provision, where therapy is provided.

A number o actors led us to consider a ull restruc-

turing o the service, including:

The National Service Framework or children, young

people and maternity services (DH, 2004) and Every

Child Matters (www.everychildmatters.gov.uk)

The Primary Care Trust move to locality working or

Public Health teams

Evidence rom the KITE randomised controlled trial

(Broomfeld, 2005)

Concern about ongoing non-attendance at commu-

nity clinic appointments

Concern about time lost rom schooling when chil-

dren did attend

Feedback rom parents indicating they wished to

have more accessible servicesFeedback rom education proessionals having ex-

perienced better joint working and improved liaison

rom Sure Start speech and language therapy teams

Transition rom Sure Start to Children’s Centres

Feedback rom our own sta about the benefts o

working within Sure Start teams and within localities.

B. THE PROCESSA planning week was set aside in October 2004, where

all senior speech and language therapy sta met to

conduct a SWOT (Strengths, Weaknesses, Opportunities,

Threats) analysis on current provision, determine what

our ideal service provision would be, and identiy an im-

plementation plan. All sta in the service were involvedon the frst day, identiying their wishes and concerns as

well as ideas and expectations, to inorm the process. We

1.

2.

3.

4.

5.

6.

7.

8.

9.

READ THIS IF YOUR

SERVICE

HAS PROBLEMS

WITH NON-

ATTENDANCE

LACKS EQUITY

NEEDS A CHANGE

•

•

•

Building pyramidson Planet Zog

Photos show zone teams

as they head of on a

team-building treasure

hunt.

Below let to right:

East zone, Central zone,

South zone, East

Cleveland zone, North zone, Eston zone,Redcar

zone.

A paediatric speech and language therapy service based in local communities andoering equitable provision appropriate to clinical need may sound like the stu o science fction but, as our superheroes Nikki Joyce and Jan Broomfeld relate, withcareul planning it is well within our orbit.



SERVICE REDESIGN

SPEECH & LANGUAGE THERAPY IN PRACTICE Autumn 2007 9

had no external acilitator, identiying that two key mem-

bers o the management team were better placed to take

on this role. A crucial element was that each day ended

with the setting o the agenda or the ollowing day. The

timetable or the week was:

C. THE MODELThere were our major elements o the new service deliv-

ery model (fgure 1):

the caseload, including the Health Promotion aspect

o Sure Start – ‘Children’

the sta ng – ‘Service’

what we were going to do – ‘Delivery’,

where we were going to do it – ‘Location’.

Each element, based on the ‘triangle o need’, ormed a side

o a our-sided pyramid, and each element had three tiers.

1.

2.

3.

4.

1. Children (gure 2)

The base level addressed all children – regardless o any

communication need, the middle level addressed all

children with communication delay, and the top level

addressed all communication disordered children.

2. Service (gure 3)The base level addressed the nature o the locality teams,

the middle level addressed management o children with

communication delay, and the top level addressed spe-

cialist speech and language therapists within the service.

3. Delivery (gure 4)

The base level addressed health promotion and pre-

vention work, the middle level addressed assessment,

training and consultation, and the top level addressed

specifc speech and language therapy intervention.

4. Location (gure 5)

The base level incorporated working within the child’s

locality, the middle level incorporated structured set-

tings accessed by the child, and the top level addressedspecifc speech and language therapy locations.

D. IMPLEMENTATIONBetween October 2004 and September 2005, we inte-

grated our Sure Start and mainstream paediatric speech

and language therapy sta and reorganised into seven

locality teams which matched the developing Public

Health teams and the Local Authority Education clusters.

Each ‘Core Speech and Language Therapy Team’ consists

o a team lead (a senior / specialist therapist), together

with generalist speech and language therapists, speech

and language therapy assistants and administration and

clerical sessions. In addition, each specialist therapist is at-

tached to a core team, and each team has allocated timeand support rom a designated member o the speech

and language therapy management team. Each team has

been relocated to a base within their locality and has re-

sponsibility or the whole child population therein.

Each core team is responsible or

a. Caseload management – assessment and intervention

in homes, nurseries and schools within their locality

b. Training and liaison with education colleagues

c. Screening, including conducting Sure Start Language

Measures

d. Health promotion activities, linked with health visitors

and Children’s Centres

e. Gathering eedback and evaluating their practice

. Onward reerral and identifcation o children

requiring specialist input

g. Implementing care plans according to departmental

care pathways

Monday am All staf involved:Presentation by representativesrom the two Local Authoritieson Children’s CentresPresentation rom speech andlanguage therapy managementteam about aims and objectivesor the week Brainstorming session or all staf to identiy their wishes andconcerns, ideas and expectations

Monday pm Senior staf:Current acts and gures aboutthe population and caseloadsCollation o evidence and policiesDecision to move to locality

working

Tuesday Blue sky thinking – what wouldthe service look like i we werestarting rom scratch without anyresource or policy restrictions

Wednesday Determining the key elements o the service delivery model

Thursday Adding detail to the model – whowould do what to whom

Friday Identiying the action planTimescale or implementationPlan or consultation with keystakeholders – Primary Care Trust,Local Authorities includingEducation, parents, Sure StartmanagersPreparation o a presentation orall staf

Tuesday Full staf meeting to reveal theproposed model

•

•

•

•

•

•

•

•

•

Figure 3 Service

Specialistteam

Input rom core team,MDT and parents

OthersResponsibility with SLTA,

nursery, schoolInput rom SLT, specialist team as required

Core TeamInput rom specialist team, MDT, parents as required

Figure 1 The our elements

Children Service Delivery Location

Figure 2 Children

Disordered

Delayed / diferent

All children aged 0 - 16

Figure 4 Delivery

SpecicInput specifc

to disorderFrom specialist team

Assessments, training,diagnostic therapy

Support oered to core team

FocusedInput ocused on communicationInput and monitoring by others

SLTA doing specialist interventionTraining by SLT service

Assessment by core team SLTCore team SLT involved with “at risk” amilies

Holistic2 Year screening by core team SLT

Health promotion • Prevention • Training • Environmental enrichment

Figure 5 Location

SLTspecic

locationsUsed or low incidencedisorders and located

according to prevalence

Community o child’s residenceHealth settings, schools, nurseries, homes

EverywhereAll locations that the child and amily may access


http://slidepdf.com/reader/full/building-pyramids-on-planet-zog 3/4SPEECH & LANGUAGE THERAPY IN PRACTICE Autumn 200710

SERVICE REDESIGN

tegic direction o the service. It comprises fve Clinical

Co-ordinators, a Consultant speech and language thera-

pist and a Proessional Lead. Each person has a clinical

specialism and acts in a specialist capacity. In addition,

the Clinical Co-ordinators have specifc management

responsibilities representing the whole service, such

as child protection, clinical supervision and audit. TheConsultant has responsibility or research and develop-

ment and acilitating evidence based practice. The Pro-

essional Lead has responsibility or sta and fnancial

management.

The two case examples in fgure 6 show how the mod-

el is working in practice.

E. OUTCOMESWe have recently consulted a range o parents to obtain

eedback about our reconfgured service. All responses

were extremely positive; in particular, they liked

Children being seen in schools and nurseries, as they

know the setting and they don’t need to travel

Less time being lost rom the curriculumThe same small team stays involved throughout

The service is exible to meet the needs o amilies and

children

They see speech and language therapists and teach-

ing sta talking to each other

They still have the opportunity to attend their child’s

appointments

They get termly (at least) updates by phone or post

about their child’s progress; they also still get ‘home-

work’ packs to practise

They like seeing speech and language therapists at Chil-

dren’s Centre activities, so they can chat inormally about

concerns without having to have been properly reerred.

We are in the process o conducting a ormal evaluation

with our education and health colleagues. However, com-

ments about the ollowing issues have been made inor-

mally to us rom both inside and outside the service:

Better access to speech and language therapists by

teaching sta - and o teachers by speech and lan-

guage therapy sta - to get advice, ask questions, and

discuss kids we’re worried about

Fewer inappropriate reerrals

Better attendance at appointments, so therapy is more

eective

The service is ar more exible and responsive to client

and school need

Children hardly miss any class time now

Cycle o discharge and re-reerral has all but ceased

– children are maintained on the active caseloadthroughout their pre-school years (at least)

Reerrals now made o harder to reach amilies who

wouldn’t have attended central clinic but do (usually

attend school

Increased contact with health visitors, maternity sta

and Children’s Centre teams has increased reerrals o

very young children, oten with complex needs. This

has led to earlier access to the child development cen-

tre, earlier multidisciplinary team assessment, earlier

diagnosis and appropriate support in place when the

child starts school.

Sure Start health promotion activities are being rolled

out across the patch

Multidisciplinary / multi-agency working is becominga reality.

In terms o acts and fgures, reerrals have doubled

in the space o a year rom 289 in Jan-June 2005 to 540

in Jan-June 2006, with ewer inappropriate reerrals be-

ing received. The total active caseload is 2843. The active

caseload in each zone is between 226 and 312, and the

active caseload managed by specialists is between 25

and 169. Non-attendance has dropped rom 780 in the

year 02-03 to 360 in 05-06.

Feedback rom reerrers is that they are now more aware

o who we are, where we are and what we do and thereore

they are more likely to reer. They are also more confdent

that the child will access the service as we are based in

schools and the community. The implications o this or the

service are that some o the preventative Sure Start activi-

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

Figure 6 In practice

Connor was seen at home by a speech andlanguage therapy assistant or a Sure StartLanguage Measure at 2 years old. At thattime he had an expressive vocabulary o 30single words and the assistant encouragedhis mum to attend the Sure Start Parentand Toddler Group. The assistant visits thegroup each month. When on the next visitmum expressed concerns about Connor’seeding, the assistant supported mum inmaking a ormal reerral to the speechand language therapy service. Connor wasassessed at 30 months by the core teamspeech and language therapist who eltthat he would beneft rom assessment bythe dysphagia specialist.The dysphagia specialist therapist oereda joint assessment appointment with thecore team therapist at the Parent and Tod-dler Group. Guidance or management o the di culty was given to both mum andthe core team.During the next three months, the core

team therapist became increasingly con-cerned about Connor’s developmentalmilestones and reerred him to the spe-cialist pre-school assessment provision.Multidisciplinary assessment identifedmoderate global delay with specifc com-munication di culties. He was given aplace in the local Children’s Centre nurserywhere his di culties could be addressed.The core team will continue to support thenursery and mum to maximise his commu-nication potential.

h. Ensuring equity o speech and language therapy provision

across the whole patch, whilst meeting local need.

We have a number o specialist therapists, covering

specifc language impairment, specifc speech disorder,

dysuency, ENT and clet lip and palate, autism spec-

trum disorder, learning disability, physical disability and

AAC, hearing impairment and dysphagia. Each specialistis responsible or:

i. Specialist diagnostic assessment and intervention

ii. Providing advice and support to all core teams

iii. Operating ‘surgery’ time or core teams, including

conducting visits and directing therapy

iv. Reviewing and developing specifc care pathways

v. Providing training to colleagues both within and

outwith the service

vi. Conducting evaluation and appraisal o best current

evidence base

vii. Working together with the management team to

continuously evaluate and develop the service.

The speech and language therapy management team

is responsible or the operational management and stra-

Sarah was reerred or speech and lan-guage therapy assessment by her nurs-ery teacher. She was assessed at 3 years 9

months in nursery by the core team thera-pist who identifed signifcant speech di-fculties. Sarah was then placed in an earlyspeech skills group with her peers, run bythe speech and language therapy assistantin her nursery. Ater hal a term, at 4 years,Sarah was still very di cult to understandand all involved were expressing concern.The specialist therapist was consulted andit was agreed that Sarah should receive aperiod o diagnostic assessment. She wasgrouped with three similar children romthe locality and the intervention was de-livered in a local Children’s Centre locationby the specialist therapist supported bya speech and language therapy assistantrom the zone.Sarah was identifed as presenting with in-consistent deviant phonological disorder.A period o intervention ollowing the CoreVocabulary approach (Dodd et al ., 2006)then occurred; this was run weekly in nurs-ery by the specialist therapist, with both thezone therapist (or the purposes o training)and a zone assistant present. The zone as-

sistant then conducted a second weeklypractice session at home in order to keepmum involved. Ater a term o input, Sarahhad made good progress and was recently jointly re-assessed by the zone and specialisttherapists. Her next period o interventionocusing on specifc sound targets has beenplanned jointly and is being implementedby the speech and language therapy assist-ant; weekly support is available rom thezone therapist and monthly update discus-sions with the specialist are planned.



SERVICE REDESIGN / RECOMMENDED READING

SPEECH & LANGUAGE THERAPY IN PRACTICE Autumn 2007 11

ties have reduced to increase time or direct intervention.

We have also become smarter about putting children

on review. Because we are more accessible and have

provided training into schools, education colleagues are

more comortable with monitoring the children and re-

reerring and we provide them with clear guidelines as

to what to look or and when to re-reer. This helps tokeep the numbers manageable.

F. NEXT STEPSThe ormal evaluation is just beginning – this will be an

ongoing process and will inuence uture modifcations

to the service. However, we have a ew outstanding mat-

ters to be addressed:

We need to consider the issue o ensuring parents are

ully engaged when children are seen in school

At present, much o the restructure has ocused on

the ‘mainstream’ element o the service, although the

special needs specialists have been involved through

surgery time and the inclusion agenda. However, a

ull review o the special needs speech and languagetherapy service is planned during 2007

The broader issue o mainstreaming the Sure Start budg-

et and securing unding or the service developments

we have identifed as a result o being more accessible is

on the agenda, but we hope that our integrated model

will have put us on a sounder ooting. Our stakeholders

have been extremely supportive o the reorganisation

to date which can only be to the good.

We are hugely grateul to the Primary Care Trust boards

and the Local Education Authority o cers or their support

and enthusiasm, and or sharing the vision with us. We are

grateul to all the parents who contributed to our thinking

through various eedback mechanisms beore, during and

ater the reorganisation. And we are indebted to every sin-

gle member o sta, whether therapist, assistant or admin-istrative o cer, or the initial drive and the ongoing com-

mitment to building pyramids on Planet Zog!

Nikki Joyce is Proessional Lead and Jan Broomfeld is Con-

sultant Speech and Language Therapist or the Children’s

Speech and Language Therapy Service o Middlesbrough

Primary Care Trust. For urther inormation please contact

them at [email protected]

ReerencesBroomfeld, J. (2005) ‘The case or ying KITEs’, Speech & Language

Therapy in Practice Winter, pp. 14-17.

Great Britain. Department o Health, Department or Education

and Skills (2004) National Service Framework or children, young

people and maternity services.London: The Stationery O ce. [On-

line at www.dh.gov.uk]Dodd, B., Holm, A., Crosbie, S. & McIntosh, B. (2006) ‘A core vocab-

ulary approach or management o inconsistent speech disorder’,

Advances in Speech-Language Pathology 8(3), pp. 220-230.

*Planet Zog is a place or situation ar removed rom what is cur-rently happening, and a general name or any sci-f planet.

1.

2.

3.

Recommended ReadingRecommended Reading Given the overwhelming amount o inormation available, we need to be selective in what we read. Even then

we fnd that papers do not always include an explicit link between the theory / experiment and its direct or

indirect implications or practice. Articles in journals have gone through a painstaking process o peer review

but it is ultimately or you, the reader, to judge whether the stated result is a) valid and b) clinically important

– in other words, why and how the article will change your practice.

In this occasional section, readers explain why they would recommend a particular article rom a peer re-

viewed journal to their colleagues. While this is a personal response that ocuses on clinical importance and

practicalities, the author may also wish to comment on actors such as study design / validity and statistics /

statistical signifcance.

Jane Armstrong says:

“This article about treatment e cacy or chronic cough was emailed to

me by my reerring ENT Consultant. In our current climate o everything

being evidence based it is nice to see an article which shouts the vir-

tues o speech and language therapy in the area o voice and cough

management. For those o us who work with voice and / or cough, this

article is a welcome sight.

There are our components to Vertigan et al.’s treatment method or

chronic cough:

1. Education

2. Strategies to reduce cough

3. Reduce laryngeal irritation / improve vocal hygiene

4. Psycho-educational counselling

The placebo group got a course on healthy liestyle education which included relaxation, stress manage-

ment, exercise and diet.

Both groups attended our intervention sessions with a qualifed speech and language therapist.

1. Education

Ideas:

No physiological beneft rom cough

Capacity or voluntary cough control

Futility o repeated coughing

Negative side eects o repeated coughing

Benefts o cough suppression

2. Cough suppression

Ideas:

Anticipate when a cough was about to occur

Pattern and degree o warning beore the cough

Implement a strategy to suppress or replace the cough

3. Vocal Hygiene

Ideas:

Reduce laryngeal irritation

Maximise hydration in order to reduce stimulation o cough receptors

Relaxed breathing exercises provided or those with inspiratory dyspnoea

4. Psycho-educational

Ideas:Address some dierences between behavioural and medical treatment

Aim to acilitate acceptance o a behavioural approach

Facilitate internalisation o control over their cough

View the cough as something individuals do in response to irritating stimuli rather than a phenomenon

outside o their control.

This approach is designed to reduce the load on the larynx by improving the e ciency o voicing and promot-

ing adequate breath support and oral resonance. Lots o home practice was encouraged.

The results show a signifcant improvement in those people who were receiving the treatment rather than the

placebo. And to quote rom the article, ‘in conclusion, clinical judgement and symptom ratings support the

hypothesis that speech pathology treatment is an eective behavioural intervention or chronic cough which

could be considered a valid alternative or individuals whose cough persists despite medical intervention.’”

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

SLTP

REFLECTIONS

DO WE THINK AHEAD SO WE CAN FORGE

OUR OWN PATH OR DO WE WAIT FOR

OTHERS TO DECIDE IT FOR US?

DO WE GIVE SERVICE REDESIGN THE

PLANNING TIME AND ATTENTION TO DETAIL

THAT IT NEEDS?

DO WE LISTEN TO WHAT CLIENTS, STAFF

AND THE WIDER TEAM SAY WORKS BEST?

•

•

•

VOICE / CHRONIC COUGH

Vertigan, A.E., Theodoros,

D.G., Gibson, P.G. & Wink-

worth, A.L. (2006) ‘E cacy

o speech pathology man-

agement or chronic cough:

a randomised placebo con-

trolled trial o treatmente cac y’,

Thorax, December 61, pp.

1065 - 1069. [Available via

www.thorax.bmj.com.]

Jane Armstrong is an independent speech and language therapist in Edinburgh.

Documents

Building pyramids on Planet Zog