Agenda item

Purpose: To consider the stammer service provisions for children in West Berkshire.

Catherine Woolley from STAMMA gave an overview of the report on the need for and benefit of specialist stammering services. It was noted that they used the terminology of a ‘stammering service’ rather than a ‘fluency service’. Catherine Woolley explained that they were contacted earlier this year by members of Berkshire Healthcare Foundation Trust (BHFT) who had raised concerns that staff were leaving the service and were not being replaced. They were concerned about the service and the impact on children. Catherine Woolley advised that they were interested to learn more about the BHFT service review and how the options might be implemented. Catherine Woolley noted that she was concerned that option 1 relied heavily on the Michael Palin Centre which might not have provided therapy and it would have been a challenge for local families to travel to London.

Catherine Woolley highlighted a further concern about the reduction in staffing levels leading to a significant change in service provision over the last 6 – 12 months and the resultant impact on children and young people in West Berkshire. The Chairman noted that resources were a national issue in speech and language therapy and asked what could be done in relation to retention and recruitment. Catherine Woolley advised that there was a significant impact from Covid on speech and language therapy. She noted that many Trusts had a specialist clinical pathway for speech and language therapy and that stammering was the third core pathway of speech and language therapy that required specialist support. Catherine Woolley advised that there was a psychological risk associated with stammering particularly with stigma and attitudes towards people who stammered. The care pathway was holistic in providing support, resilience and social communication skills. She advised that generalist speech and language therapists might not have had the time and experience to provide that. Catherine Woolley agreed that recruitment and staff retention was an issue. She noted that staff needed to be encouraged to stay longer. Staff needed time to share learning and skills, and that clinical supervision and training was needed to retain and recruit staff.

Councillor Tony Linden asked what the implications were for residents of West Berkshire.  He noted that it was a rural area which was a challenge for service provision and that there were areas of deprivation. Catherine Woolley advised that it was difficult to assess the impact of stammering on someone. She highlighted that it had a big impact on someone’s life, such as the negative stereotyping and resultant behaviours towards people who stammered. She gave an example of employment tribunals and the impact on education. There could have been teasing and bullying. Young people who stammered were more likely not to attend school and had higher levels of anxiety and depression which impacted on their mental health in the future as adults. It was not the case for every individual but these were potential impacts if not given specialist support. Catherine Woolley explained that for some, speaking more fluently was the end goal but for others they needed support to help resolve underlying anxiety, fear and sense of self. The importance of the specialist service was having time, space and capacity to provide holistic therapy.

Councillor Alan Macro noted that BHFT were rated as a one (Extremely good) in 2019 and asked where Stamma rated BHFT now. Catherine Woolley confirmed it would probably be a two (Good) now due to the levels of staffing and provision of the service.

Rebecca Ginary, Interim Head of Children’s Community Services at BHFT, gave an overview of her report and the 3 options they had for the service review. She noted that it was timely to carry out the review of the service and noted that BHFT received very positive feedback from service users over the last 10 years that they had been running the service in a similar way. Rebecca Ginary agreed with Catherine Woolley on the importance of early intervention, the right training and the appropriate levels of competence, and noted that BHFT valued the specialist input of colleagues within the service. Rebecca Ginary explained that the current stammering service (currently called fluency) was based within the wider Children and Young People Integrated Therapies (CYPIT) which included speech and language therapists, occupational therapists and physiotherapists who worked across Berkshire. She highlighted that it was important to see the current fluency service in the wider context. She explained they were commissioned by the Integrated Care Boards (ICB) and Local Authorities to provide services for children with and without EHCPs (Education and Health Care Plans). The current caseload for all children in the county accessing speech and language therapy services from CYPIT was 6066. The number of children accessing the stammering service was between 40 and 60. She confirmed they needed to provide the right and timely input but highlighted this was a small number in the context of their service which included children with other specialist needs. They needed to risk assess in the context of the wider population and the increase in demand for all services had grown significantly since Covid. They had had a 200% increase in children put forward for assessments of an EHCP. Rebecca Ginary noted there was a national crisis in recruitment.

Rebecca Ginary moved on to the review of the fluency service. She noted that permanent roles could not be recruited to during the review of the fluency service. They did approach staff to cover extra hours and advertised for temporary staff. Unfortunately there were not any staff to cover whilst the review of the service took place. However, Rebecca Ginary reassured the Committee that it was not their intention for the service to stay as it was. They were risk managing all children during the interim. Some of the feedback they had received from staff internally was that many did not feel confident to meet the needs of children and young people who stammered. Many referenced the importance of the internal specialist team that they could refer to. Rebecca Ginary highlighted that the generalist staff who worked in schools had relationships with the children, staff and families that was really valuable. With the right support from specialist therapists embedded in the generalist teams, they felt they could have increased capacity to pick up and meet the needs of those children at lower risk of a stammer that would be pervasive and ongoing. Therefore children could be dealt with more swiftly than they would if being referred to an internal service. The direction they were going in terms of a recommendation was to step away from the idea of a separate stammering service but to have a specialist stammering pathway within the main service. It would include some specially trained therapists with additional experience, knowledge and understanding who held responsibility for their own continuing professional development including networking, training and development. 

Rebecca Ginary noted this was aligned with how they were looking to develop many aspects of their services. She stated that current demand outstripped capacity in every element of the service and so they had to think creatively about how to maximise capacity and how to develop services so that those children at highest risk were supported. They did not have capacity to work with all children on an individualised basis. The premise across all services was about empowering those closest to the children to better understand and identify needs, and to understand strategies that could be embedded. There were a small number of children for whom this was not enough and so they were looking at signposting to a specialist pathway, such as the stammering pathway that was being reviewed.

Councillor Andy Moore asked for clarity regarding the outcomes that were being looked for in the stammering service and how long individual patients were worked with. Rebecca Ginary advised it was hard to say an average length of stay within a specialist pathway as it was very individual. She advised they worked in an impact based way. Rather than looking at the diagnosis they looked at what impact it had on their day to day lives and on their education. It was unlikely the stammer would ever go away and so there would be times when it was more difficult. The expectation was that children would go in and out of the service depending on what they needed at that time. They did not think it was helpful to keep children on the acute caseload unless they were actively involved in supporting them. The service review showed a number of children were on the caseload without being seen for over a year.

Catherine Woolley highlighted that the intensity of support from speech and language therapy required by people that stammered could be very acute and needed a significant period of input at times. She stated this was different to some of the other pathways in speech and language therapy. Whilst the child might not be on the caseload for long, they might have needed regular input and interventions often on a weekly basis. Catherine Woolley noted concern that generalist staff might not have had the capacity to provide that with so many other children on their caseload.

Councillor Linden asked for more information on how the fluency service worked with Early Years providers and in schools, including state schools, academies and private schools. Secondly he also asked for more information on the preferences of the options presented. Rebecca Ginary explained that every school had a named speech and language therapist regardless of the funding and whether children had an EHCP or not to ensure they worked in a joined up way. The same was the case for Early Years settings. In terms of the fluency service, where the risk could be safely managed by the therapist based in school with advice and support from a specialist (where the child was at low risk of their stammer becoming pervasive or persistent) the support would happen through the school and parents. For children needing a higher level of intervention this would not be picked up by the generalist therapist as it would not be practical for them to deliver high level intervention. Rebecca Ginary confirmed that children without an EHCP were funded by the ICB and that was based on where their GP was. They would go to whichever school they were attending or be invited to a clinic during the holidays. Therapists largely tried to work in schools as that was more beneficial. For children with an EHCP, the issuing Local Authority funded whatever input was defined within the plan. As BHFT were the registered provider they would be required to deliver that. There were currently no requirements for a high level input within EHCPs.

In relation to the 3 options, Rebecca Ginary stated that they did not have an intention to close down the service or pathway. They wanted to refine how the pathway looked to maximise capacity and to grow the skills of the generalist team to create more capacity. Their preference was either option two or option three. They were leaning towards option three as the most cost effective and best use of resources. This would be Band 6 therapists with the use of assistance in schools for lower risk children. However they still had focus groups with service users and parents in January which would inform the final decision. There were pros and cons with both options. Rebecca confirmed that she agreed with the benefit of a Band 7 therapist in the team. However it was not something they had in other specialisms. They were looking to have a specialist pathway to make sure they were managing the risks appropriately. They would confirm with the Health Scrutiny Committee when a decision was made. 

Catherine Woolley requested to make a comment regarding the two options. She acknowledged option three had advantages to enable generalist speech and language therapists to feel confident to provide a universal level of intervention. However with option three, Catherine Woolley explained there was a danger to rely on speech and language therapists to deliver the bulk of the stammering intervention. They were not qualified to a degree level and there was a risk of a big burden on them. There was a real benefit of the Band 7 highly specialist pathway as with other clinical pathways. The Chairman clarified that Catherine Woolley and Rebecca Ginary would maintain a dialogue as they moved forward. Rebecca Ginary also confirmed that there was a place for generalist staff, many were very skilled and had many years of experience. She also added, in terms of increasing capacity, that they were looking to develop their online offer. Many of the young people liked online support since Covid as it was found to be really accessible. The service was investing in digital developments and in having pre-recorded training packages and delivering online training in schools. For whichever option was chosen they would look at a rolling programme of training for all staff including a mandatory refresher in stammering.

Councillor Macro asked for the reason for doing the service review given it was highly rated. He also noted the poor result to the consultation exercise and asked if BHFT understood why that was. Rebecca Ginary explained that they were in the process of asking patients why there was not more positive engagement. She noted that they were finding that there was a low response for all consultations since Covid. With regards to the rationale for the review, Rebecca Ginary advised that there was a responsibility for spending public money and they recognised the huge increase in demand versus capacity on the service more widely. They acknowledged they could not provide an exceptional service for a small number of people if there were unmanageable caseloads in other parts of the service. The wider service pressures combined with the timing of staff leaving the service, meant it was the right time to carry out the service review.

Councillor Moore asked why there had been a 200% increase in demand since Covid. Rebecca Ginary advised that a lot of the demand was in the early years and so these were children born or were toddlers during the pandemic who were not socialised in the same way and were not out and about meeting other children. They did not have the same opportunities to interact and to develop their language and communication skills. In addition there was a large cohort of children on an EBSA (Emotionally Based School Avoiders) pathway who, following the pandemic, found returning to school was overwhelming for them. Therapists were therefore visiting some children in their homes and so they needed to adapt their service to do that. Rebecca Ginary noted that it was not entirely due to Covid as there had been increases in EHCP assessments since 2016.

The report was noted and it was requested that a report return to the Health Scrutiny Committee when a decision had been made regarding the option chosen by BHFT.