Welsh Parliament Health, Social Care and Sport Committee consultation on the impact of impact of the Covid-19 outbreak, and its management, on health and social care in Wales.
About the Royal College of Speech and Language Therapists
1. RCSLT is the professional body for speech and language therapists, SLT students and support workers working in the UK. The RCSLT has 17,500 members in the UK (650 in Wales) representing approximately 95% of SLTs working in the UK (who are registered with the Health & Care Professions Council). We promote excellence in practice and influence health, education, care and justice policies.
2. Speech and Language Therapy manages the risk of harm and reduces functional impact for people with speech, language and communication support needs and/ or swallowing difficulties.
3. Speech and Language Therapists (SLTs) are experts in supporting children, young people and adults with speech, language and communication needs and training the wider workforce so that they can identify the signs of SLCN, improve communication environments and provide effective support.
Response to the pandemic
4. Since the outbreak of the COVID-19 pandemic, the RCSLT in Wales has been very proud of how our members have responded to the unprecedented challenge facing the nation. As with all other health, social care, education and justice professionals, the working lives of our members have changed, in some cases very significantly. We salute how speech and language therapists in have adapted to this situation so they can continue supporting people with communication and/or swallowing needs.
5. Across Wales, SLTs have worked tirelessly to ensure that people with COVID-19 receive as much support as possible. They are using their specialist skills to provide interventions and rehabilitation, both within and beyond intensive care units, to support immediate and longer-term recovery of communication and swallowing problems and respiratory management. SLTs have also been redeployed to other roles across the health and care system such as testing sites and supporting the establishment of field hospitals as part of the health and social care response to the national emergency.
6. Previously, there has been very little investment in SLT roles within intensive care with three funded posts across the whole of Wales. The pandemic has highlighted the key role SLTs play within the multidisciplinary team, supporting critically ill patients in their rehabilitation and clinical management of communication, voice, swallowing, ventilator and tracheostomy weaning. We strongly recommend that this learning lead to further funding of these vital posts to ensure that SLTs form a key part of the Intensive Care workforce and survivorship is promoted post intensive care in local health boards across Wales.
Impact on existing services
7. Beyond COVID, within adult SLT services, most face to face contact has been put on hold in response to the redeployment of many adults SLTs to support the COVID effort, wishes of many of those shielding not to have health professionals in their home and social distancing requirements. Exceptions have been made for the most urgent dysphagia cases but very little communication therapy has taken place and key targets such as SNAP for stroke will not be met. Referrals have also been significantly lower due to the closure of clinics for clinical areas such as neurology etcetera.
8. Services for children and young people in Wales commonly utilise a preventative, tiered approach –universal/targeted/specialist, to ensure the most effective use of speech and language therapy (SLT) resource. This approach relies heavily on working closely with other agencies such as schools and childcare settings. The closure of most of such settings as a result of the pandemic has necessitated a rethink in how services are delivered. Most face to face contact has also been paused although there are a number of exceptions to this for the most vulnerable children and young people with swallowing difficulties and those who are at significant risk of harm. In addition to challenges with regard to settings and partners, the number of paediatric staff redeployed to adult services and other COVID-19 work varies significantly by health board area with some teams virtually intact and others working on a skeleton staff.
9. In response to these challenges, paediatric and adult SLTs have quickly adapted to new ways of working such as;
· Clinicians contacting clients and families by phone
· Letters being sent to outpatient families giving e-mail and phone contacts for the service ensuring processes for queries to be answered
· Telehealth and prioritisation of all caseloads (follow up and new patient) for offering telehealth (includes children with SEN statements, clients with significant swallowing difficulties).
Telehealth
10. Our members advise us that SLT services within local health boards (LHBs) are at different stages in relation to access to new technologies. Those services which are already making use of Attend Anywhere report that telehealth brings a number of advantages. For example, it has been welcomed by a number of vulnerable service users and has enabled support groups to be set up across wide geographical areas for rarer clinical areas such as dysfluency. In services trialling new technologies, there has been a widespread acceptance of telehealth by both clinicians and families as a means of delivery in a difficult environment. However, a number of our members have raised concerns around the effectiveness of telehealth for particular clinical areas, and the ability of all client groups to access the technologies. Many speech and language therapy clients are classed as vulnerable. In the recent RCSLT survey, 29% of clients did not have access to teleworking so technology was a barrier to remote therapy provision[2]. The RCSLT has recently updated our guidance to ensure best practice in this area[3].
11. SLTs report that much has been learnt from the initial response to the crisis and its impact on services. It is envisaged that telephone and telehealth solutions, where they have proved to be effective, will be utilised far more widely moving forward for example for ‘check ins’ with clients, or initial triaging. For those patients who will still need to be seen face to face, social distancing presents very real challenges which need to be worked through. Many of these are very practical in nature e.g. issue of competing demands on accommodation and potential lack of suitability of rooms, increased demand for PPE-and ensuring sufficient supplies are available, time taken to don and doff PPE with knock on effects on numbers of clients able to be seen.
PPE
12. The RCSLT has, throughout the period of the COVID-19 outbreak, sought to ensure that speech and language therapists and those with whom we work have the appropriate personal protective equipment (PPE), in line with the best evidence available. We have raised concerns about the non-inclusion of certain SLT procedures on the list of aerosol generating procedures (AGPs) as part of the UK wide PPE guidance, and taken steps to present the evidence base for the inclusion of a range of speech and language therapy interventions as AGPs in reviews of the guidance, with the support of key bodies such as the Intensive Care Society.
13. Given this situation, the RCSLT has produced guidance for members regarding the balance to be struck between our own guidance and any different approach taken by local employers. This guidance is regularly reviewed in line with the most up to date evidence as the situation evolves. We are pleased that the vast majority of local health boards in Wales have recognised the need for PPE for speech and language therapists in these circumstances.
14. We strongly welcome the establishment of an expert group by Public Health Wales and Improvement Wales to look at the impact of the pandemic on people with dementia and are pleased to have representation on this group. Following recommendations from this group, it was very positive to see the public call out by the Life Sciences Hub for interest in producing clear masks.
15. There is a communication challenge for all regarding reduced clarity and audibility while wearing PPE. This is exacerbated for certain groups such as the deaf community and those with hearing impairment, who may rely on lip reading to communicate on an equal basis. It is also the case that the appearance of opaque PPE may be distressing or confusing for others with communication challenge, including potentially people with aphasia, autism, with dementia or with learning disability. The RCSLT is supportive of investigating the procurement and use of clear face masks where appropriate as part of PPE provision. This mask will need to have the required levels of protection as part of the manufacture. We also support the undertaking of research to test these benefits[4].
16. We understand that Welsh Government has recently sent a letter to health boards stating that clear masks are currently not available for NHS Wales with confirmation from Public Health Wales that even if provision was possible, it would not address the issue immediately, due to design, production and safety testing requirements. We are aware that Public Health England is sourcing supplies from America and urge that Public Health Wales continues to explore options for the procurement of clear face masks.
Rehabilitation
17. While the communication, swallowing and respiratory rehabilitation needs of people recovering from COVID-19 are emerging, early indications suggest that for some there will be a prolonged impact on their quality of life. In particular, people affected more severely by the COVID-19 virus and those who required intensive care treatment may suffer from a whole range of associated problems lasting for months and even years. The consequences of life saving interventions such as sedatives, mechanical ventilation, oxygen therapies and tracheostomy may lead to a myriad of problems:
● voice disorders;
● swallowing muscle weakness with a need for restricted diets or artificial feeding via a tube;
● chronic respiratory compromise impacting on the coordination of swallowing and breathing which carries an increased risk of chest infection and further lung complications;
● cognitive communication disorders potentially limiting return to work and daily life;
● psychological trauma and post traumatic stress disorder; and
● chronic upper airway narrowing or stenosis requiring complex multidisciplinary team management
People may face any of the above issues to differing degrees.
18. Speech and language therapists will have an important role to play in supporting these people. The rehabilitation of their communication and/or swallowing disorders needs will require careful planning and speech and language therapy input into the multidisciplinary approach will be essential. Speech and language therapy delivered in the community will be vital in order to prevent any negative health consequences and to optimise long-term outcomes.
19. While ensuring the rehabilitation and recovery of COVID-19 patients, it is also essential that people who do not have COVID-19 related issues, but acquire communication and/or swallowing needs (for example through having a stroke or being newly diagnosed with a progressive neurological condition or cancer) receive the specialist professional support they require. Equally, it is vital that children with delayed language or other developmental delays have their needs identified and supported. If they do not, both children and adults are at significant risk of negative outcomes, including on their mental health with potential extra costs to the public purse.
20. We welcome the increasing focus on the importance of rehabilitation by Welsh Government and the swift publication of the post-COVID pathway. However RCSLT Wales wish to highlight that the long-term response to the pandemic will place significant extra demands on speech and language therapy services not only to manage the backlog of existing and new non-COVID-19 people, but also to incorporate additional COVID-19 referrals. This will be a particular challenge in Wales where we are aware rehab provision is already in many cases patchy and inadequate.
21. It is vitally important, therefore, that sufficient resources are provided to ensure that these services are able to respond in as timely and appropriate way as possible. This may also include the need for additional speech and language therapy resource and training for colleagues to provide the support COVID-19 patients with long-term rehabilitation and recovery needs require. If these potential extra resources are not made available and rehab not prioritised, there may be negative consequences for the physical and mental health of people with communication and/or swallowing needs and their families which in turn may result in greater costs to the public purse.
Further information
22. We would be happy to provide any additional information required to support the Committee’s decision making and scrutiny. For further information, please contact:
Policy Adviser, Wales