Dr Dai Lloyd AM
Chair, Health, Social Care and Sport Committee
Senedd Cymru
Cardiff Bay
Cardiff,
CF99 1NA
28 July 2020
Dear Dr. Lloyd MS,
Re: Health, Social Care and Sport Committee inquiry into the impact of COVID-19 on health and social care in Wales
Thank you for meeting with ourselves, the Chartered Society of Physiotherapy and the Royal College of Occupational Therapists last month. We were very pleased to hear that rehabilitation will be a key strand under consideration as part of the committee’s wide ranging inquiry into the impact of COVID-19. Following our meeting and your specific questions around rehabilitation demand both for COVID patients and other key groups, we have compiled some additional information below. This is supplementary to the broader evidence we provided to the committee last month. We hope this will be helpful in informing the committee’s deliberations and would be happy to discuss further or provide more information if required.
COVID 19 and rehabilitation needs
Early modelling from Welsh Government suggests that 11% of those who have had COVID-19 may need rehabilitation at home, 6% may need rehabilitation in a bedded facility, such as a care home or community hospital and 1% may need inpatient rehabilitation[1].
While the communication, swallowing and respiratory rehabilitation needs of people recovering from COVID-19 are emerging, early data suggests 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
● neurologic symptoms manifest in a notable proportion of patients with COVID-19. Emerging clinical data suggest approximately 25-30% of COVID-19 survivors are presenting with new neurological impairments.[2]
People may face any of the above issues to differing degrees.
Speech and language therapists will have an important role to play in supporting post-COVID patients. 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.
While it is currently difficult to estimate demand in detail, speech and language therapy services across the UK are currently collecting clinical data with the support of the RCSLT dataset, to inform further modelling and understanding of rehabilitation needs. This data will link into a larger professional dataset under development by the Intensive Care Society (ICS).
SLT Services in Wales report increased referrals across all acute services with the impact of COVID-19 exacerbating pre- existing conditions and more acuity seen on wards due to rapid discharge from intensive care units to free bed capacity. Swallowing difficulties appear particularly prevalent with one service estimating that up to 91% of post intensive care patients require support in this area. Services also report increased occurrence of associated mental health difficulties due to COVID-19 with patients presenting with increased anxiety and depression.
Rehabilitation for non-COVID patients
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 receive the specialist professional support they require. As a profession, we are aware of the high level of unmet need for speech and language therapy services. This need is being driven by a range of factors including an ageing population; the increasing incidence of chronic disease; earlier identification of conditions across all age groups; and improved survival of infants who are premature, chronically ill or have a disability and of adults who experience a stroke, progressive neurological disorders, head injury, or life-threatening illness, such as cancer.
The statistics below present a snapshot of likely swallowing and communication needs of patients from key client groups within the community.
Needs
· At least 40% of stroke survivors will initially experience some difficulty swallowing. If left untreated, swallowing difficulties can result in pneumonia, increased hospital admission and lengthier stays in hospital.[3]
· Around a third of people will have some level of communication difficulties (called aphasia or dysphasia) following a stroke.[4]
· Changes to swallowing affect eating and drinking for up to 80% of people with Parkinson’s and become a major issue as the condition progresses.[5]
· Speech problems (dysarthria) occur in more than 80% of people living with Motor neurone disease.[6]
·
Research has found
that dysphagia (swallowing difficulties) affects 50-60% of
head and neck cancer survivors.[7]
Pre-COVID rehabilitation provision in Wales
Our members tell us that despite the impact of high quality rehabilitation on quality of life and long-term NHS and social care costs, community rehabilitation is often piecemeal and varies significantly depending where you live in Wales. Data from one health board suggests that only 53% of stroke patients are seen within recommended timeframes and only 25% of progressive neurological disorder patients are previously know to SLT, suggesting that patients are only being referred to SLT for crisis management and there are missed opportunities to engage in advanced care planning and active treatment.
Members have commented that often, community care packages (including their availability) do not provide the communication support needed (in terms of numbers of hours needed for intervention, education and support by speech and language therapists) as the capacity for independent living dwindles. These packages frequently do not recognise the need for older people to have adequate communication abilities and the need for adequate nutrition if swallowing is compromised. This also increases the demand on family members who also need support and education as how to best assist the older person to maintain the best functional ability at home. This situation is exacerbated by the impact of shielding and social isolation as a result of the pandemic.
These concerns about the provision of community rehabilitation provision are echoed in two recent reports by Senedd cross party groups. A 2020 report from the Stroke Association, based on evidence collated as part of the Stroke Cross Party Group inquiry, revealed that 21% of stroke survivors in Wales reported that they did not receive enough support after a stroke[8] with only a minority of stroke survivors receiving therapies at guideline levels[9]. The report recommends that ‘Health boards must take immediate steps to improve their therapy provision and bring delivery of therapies closer to RCP guidelines.’[10]
The Wales Neurological Alliance has also recently undertaken an inquiry into the impact of the Welsh Government’s neurological delivery plan. The report recognises that there has been investment in neurological rehabilitation but highlighted that there remain low levels of availability of community services stating;
‘Many poor experiences were described by contributors, in particular in relation to a lack of availability of community based services such as physiotherapy, speech and language therapy, occupational therapy, continence advice and support, services that help people to be physically active, mental health services and emotional support. ‘[11]
The reports and feedback from our members suggest that sustained focus and continued investment is required to improve community rehabilitation services.
Next steps
Without doubt, the impact of COVID-19 and the resultant clinical presentations will present significant challenges for already stretched community teams. The pandemic has enabled the transformation of SLT services to incorporate telehealth and telephone options. Moving forward, telephone screening, telehealth, accessible digital therapy resources and digital platforms should all be considered.
It is vitally important, however, 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 rehabilitation 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. We have included a number of good practice examples at Annex A highlighting how services are being redesigned to better meet patient need.
We hope this paper will be helpful in supporting the committee discussions around the importance of rehabilitation. We would be happy to provide further information if this would be helpful.
Yours sincerely,
Policy Adviser, Wales
ANNEX A
Good practice examples
SLTs at front of door in A and E
In Swansea Bay University Health Board, an SLT has been funded to work alongside other allied health professional colleagues in reducing unnecessary admissions for swallowing difficulties therefore reducing, unnecessary NG tubes, risk of pneumonia, malnutrition, dehydration and improving patients’ wellbeing. The service is relatively new but a trial; of similar 7 day service in another Welsh local health board indicated projected annual cost-savings of £998,748.
Communication partner training
Based on evidence on the effectiveness of communication partner training and current barriers to accessing face to face intervention due to COVID 19, ABUHB is currently implementing and enhancing group communication coaching groups to focus on communication partner training virtually. Initial outcomes suggest skilled communication partners can facilitate and support the communication activities and participation of people with aphasia and improvement in carer wellbeing scores on the Therapy Outcome Measure scale. Making best use of resource, ABUHB is engaging and co-producing maintenance programmes with the Stroke Association..
Voice therapy
With the global outbreak of COVID-19, video conferencing applications have seen an approximate five fold increase in usage. Services are predicting to see high demand for voice therapy from the working aged population due to consistent use of video conferencing which contributes to a persistent increase in vocal volume. A number of services are working closely with ENT colleagues and revisiting traditional pathways. Work undertaken includes changes to triage systems with ENT prioritisation based on referral information only and those suitable for vocal hygiene groups being seen by SLT without ENT review. This has a two fold effect in reducing the ENT waiting list and speeding up access to SLT for intervention. SLT can then monitor responsiveness to interventions and if clients are not responding as they clinically should, SLT can review with ENT colleagues to prioritise those that require endoscopy for visual assessment.