HC 1048-III Health CommitteeWritten evidence from the Royal College of Speech and Language Therapists (PH 178)

1. Summary of Main Points

1.1 The RCSLT welcomes the opportunity to submit evidence and information to the Health Select Committee inquiry into public health. We would welcome the opportunity to present oral evidence to the Committee to provide additional information around communication difficulties.

1.2 The RCSLT is concerned that government policy contains no mention of the public health role of speech and language therapists or the importance of primary prevention work to tackle children’s poor communication skills, particularly in areas of high social deprivation.

1.3 Speech, language and communication needs have a serious impact on the quality of life of individuals and their family and lead to poor educational achievement and underdevelopment of key skills that are essential for a high performing economy. Nearly 20% of the population may experience communication difficulties at some point in their lives. It is essential that the importance of communication as a public health issue is recognised.

1.4 The ability to communicate is the key life skill. Evidence demonstrates that it is vital to intervene as early as possible in a child’s life to identify delayed speech and language development and to provide appropriate support to improve their life chances.

1.5 We are content for any part of this evidence to be made public or included in the Committee’s report.

2. The Royal College of Speech and Language Therapists

2.1 Formed in 1945, the Royal College of Speech and Language Therapists (RCSLT) is the professional body for speech and language therapists, students and support workers working in the UK. The RCSLT represents over 15,000 members, including nearly 95% of the speech and language therapists (SLTs) working in the UK.

3. Speech and Language Therapist’s Contribution to Public Health

3.1 For children’s services, the public health role of the work of SLTs is an intrinsic part of the intervention role. For children’s services the best models of commissioning are those with strong joint commissioning between health and local authorities. Many local authorities are taking the lead in commissioning the universal (public health) element of speech and language therapy services for all children through SureStart and Children’s Centres and by working in partnership with their health colleagues to secure a “whole systems approach” to care pathways.

3.2 For adult services: SLTs have a key role in public health, particularly through early intervention, the treatment and rehabilitation of long term conditions and through the promotion of activity to improve mental health, independence and quality of life amongst vulnerable adults. This includes involvement in the treatment and rehabilitation of chronic and long term conditions to support adults with speech, language and communication needs to go back to work, to maintain good health and wellbeing and quality of life.

4. Prevalence of Speech Language and Communication Needs (SLCN)

Communication disorder is the most common disability seen in childhood, affecting up to 10% of children in society. 7% and 10% of five year olds entering school have significant speech, language and communication needs that require ongoing support. 1% of children have severe, specific and long term speech language and communication needs (SLCN).

Up to 55% of children in areas of high deprivation entering school have delayed speech, language and communication skills which prevent them from learning to read and write.

Unless children with SLCN are identified and supported at the earliest stage they are at risk of being unable to form relationships, express themselves emotionally, access education or contribute towards society.

Evidence shows the link between delayed speech and language development and offending behaviour. 70% of young offenders have SLCN.

90% of the 1.5 million people in the UK with a learning disability have SLCN.

Stroke is the most common cause of disability in adults in England and 50,000 people who have a stroke every year have ongoing communication difficulties.

700,000 people with dementia have SLCN and the figure rises each year.

5. The Creation of Public Health England within the Department of Health

5.1 The creation of Public Health England will provide vital input to the overall well being of the nation. It is recommended that Public Health England learn from best practice on the commissioning and delivery of speech and language therapy services to secure seamless care pathways for children and adults with speech, language and communication needs. It is recommended that guidance should be produced on the use of public health funding for local authorities and this should include the vital public health role of speech and language therapists.

6. The Future Role of Local Government in Public Health

6.1 Communication must be recognised as a public health issue and ways are found to improve the communication skills of children and adults. If communication is not recognised as a fundamental life skill within public health guidance then there is a high risk that no-one will commission speech and language therapy services to some of the most vulnerable people in society.

6.2 The Health and Social Care Bill and the Government policy on public health has no mention of the public health role of speech and language therapists and the importance of primary prevention work to tackle children’s poor communication skills, particularly in areas of high social deprivation.

6.3 Speech, language and communication needs are the most common disability experienced by children or adults. However as an “invisible” condition there is little understanding of its significance and it is often overlooked. Speech, language and communication is now recognised as the foundation life skill and the single most significant factor in determining a child’s life chances - it is the means by which we form relationships, make choices and access education, employment and society. A delay in developing speech and language skills is a key factor in predicting future disadvantage and the single greatest barrier to social mobility. Educational underachievement affects the performance of the UK economy. Our economy has become increasingly dependent on communication-based employment; the fitness of the person of the 21st century will be defined increasingly in terms of his or her ability to communicate effectively. The economic impact on society of people whose communication disability renders them unemployable is significant and growing year on year. One study showed that 88% of unemployed young men had a language difficulty. The UK has between 10 and 25% lower output per hour than France, Germany and the US. Much of this can be attributed to a poorer level of skills and a shortfall of capital investment.

6.4 The RCSLT seeks urgent reassurance regarding the funding of speech and language therapy services in the new commissioning and public health arrangements. The RCSLT is concerned that local commissioners may lack understanding of therapy services, such as speech and language therapy and as a result it will fall between public health and health responsibilities.

6.5 It is vital that when public health, currently undertaken by the NHS, is transferred to local authorities, it does not become separated from the work of the NHS, resulting in fragmentation in service commissioning. Speech and language therapy services are currently delivered through a set of commissioning and funding arrangements particular to each locality (often isolated or led by one agency) and lack integration into mainstream service provision. Therefore the reforms could further destabilise the fragile arrangements that persist in some areas.

6.6 The RCSLT is concerned that services may become disjointed under the new plans. For example early years services will continue to be funded from local authorities under public health funding however this has an overlap with health care intervention. Programmes such as screening programmes need to be commissioned as a whole programme without a potential separation of the screening element or universal public health services from the assessment and intervention elements, including rehabilitation (often health, education and social care). The transfer of public health funding to local authorities needs to emphasise universal work including speech and language therapy. Public health guidance should emphasise the need for local authorities to work with commissioning consortia (via the health and wellbeing board). The vital public health role of speech and language therapists should be included in guidance on the use of public health funding under to local authorities.

6.7 It is important that, whilst public health is focused on prevention, the link to intervention services is clear. It should be highlighted to local authorities that many services, whilst not supporting prevention or cure, are based on rehabilitation and increasing quality of life for example stroke services.

6.8 The public health work of speech and language therapists should be funded by a reallocation of priorities within existing public health spend, towards the early intervention/life course approach now recommended by DH, which will yield greater health benefits than much current provision.

7. The Role of Health and Wellbeing Boards

7.1 To ensure that Health and Wellbeing boards achieve coordination across health, education and social care services it is essential that Health and Wellbeing Boards have input from appropriate clinicians to support and inform their commissioning function.

7.2 The RCSLT calls for a speech and language therapist or an allied health professional to be guaranteed a place on every health and wellbeing board. SLTs and AHPs are in a unique position as the only clinical professions able to combine knowledge and skills from all areas of health, social care and education. Their involvement in commissioning provides innovative ideas for redesigning services, integrating teams and sectors and delivering the QIPP agenda. 

7.3 Health and wellbeing boards must not be created separately from the work of the NHS; their role is integral to health promotion. Health and Wellbeing Boards need to consider wider determinants of health. A lack of health representatives will prevent close health scrutiny and result in further fragmentation of services and patient pathway delivery.

7.4 It is essential that the establishment of new commissioning bodies results in greater coordination and more robust scrutiny of speech and language therapy provision in order to safeguard access to speech and language therapy for vulnerable groups.

8. The Role of Joint Strategic Needs Assessments

8.1 As it stands there is little to encourage local authorities or partner commissioning consortia to consult with appropriate individuals. Given the importance of ensuring integrated working, particularly with regard to services for children or vulnerable adults, there should be a duty to consult with appropriate health professionals who work across sectors such as education, health and public health and who have expertise with regard to children and vulnerable adults.

8.2 Speech and language therapists should be included in all public health commissioning decisions and be named as part of the workforce to contribute to the JSNA. SLTs are woven into the fabric of public health in this country. They are in the vanguard of creating a service based on people being healthy rather then a service based on fixing ill-health.

8.3 Children are a key population group for the JSNA and academic progress is identified as a measure for children in terms of outcomes – SLT has a role to play. It is essential that the JSNA addresses inequalities and identifies levels of SLCN. Vulnerable people with communication needs require timely identification and provision of services to improve their life chances and reduce burdens on other services as their needs deteriorate. SLTs hold data on population groups of children with SLCN which would be invaluable for the JSNA. Failure to actually capture the communication needs of children will result in a substandard assessment which will in turn have a detrimental affect upon the consequential joint health and wellbeing strategy.

9. The Role of Joint Health and Wellbeing Strategies

9.1 In developing the Joint Health and Wellbeing Strategies the workforce should include speech and language therapists or allied health professionals. SLTs and AHPs work autonomously with patents, they are not support staff. Their involvement and input is crucial to all commissioning decisions.

9.2 At local levels much can be achieved by speech and language therapists contributing to the development of the local Health and Wellbeing Strategies, agreeing priorities and delivery mechanisms designed to deliver best outcomes for communities. This joined up approach across health and local government will help to align priorities and services according to patient need.

10. Arrangements for Public Health Involvement in the Commissioning of NHS Services

10.1 There is an assumption that GPs have a good understanding of public health. Building the capacity to address public health commitments should be a priority for consortia.

10.2 Under current proposals for commissioning of children’s community health services, commissioning consortia will hold the budget for speech and language therapy services. There are concerns that the commissioning consortia will not commission speech and language therapy services to provide the universal preventative work required for all vulnerable children as they may see this as falling within the public health remit. Therefore there is a mandate for close working between commissioning consortia and local authorities to provide seamless packages of care along patient pathways.

10.3 GPs can have a substantial impact on the public health agenda. However this will require a rethink about how the delivery of public health outcomes is incentivised, how GPs and GP practices become part of the wider public health delivery system and how contracts by the NHS Commissioning Board are designed. The primary influence on GPs will be through these contracts with the NHS Commissioning Board, therefore delivery of the wider public health agenda needs to be a fundamental part of these contracts. This will ensure that the public health agenda will have a firm foundation.

10.4 It is unclear how services will be commissioned for vulnerable patient groups who have conditions such as people with dementia or people with learning disabilities but do not require acute health intervention to lead an independent life.

11. The Future of the Public Health Workforce (including the Regulation of Public Health Professionals)

11.1 The future of the public health workforce is at risk by a lack of understanding of professional roles by commissioners, by fragmentation of education and training and by localised workforce decisions which could marginalise smaller professional groups.

11.2 We are concerned that this model may destroy the pipeline of future clinicians so that the model fails in five to ten years. How will the longer term implications of potential damage to the education and training of future clinicians be addressed and resolved?

11.3 The RCSLT supports any process that ensures the development of regulated professional expertise leading to enhanced clinical outcomes, experience and safety for patients. Public health professionals should be determined by their ability, knowledge and professional skills.

12. How the Government is Responding to the Marmot Review on health inequalities

12.1 The Marmot review “Fair Society, Healthy Lives” highlighted that health inequalities result from social inequalities and that there is a need for action to tackle the social determinants of health inequalities.

12.2 The Marmot Review showed that poor health in adulthood is strongly related to poverty and to factors in early childhood that affect development. What happens during the early years has lifelong effects on many aspects of health and well-being – from obesity, heart disease and mental health, to educational achievement and economic status. Marmot identified as a priority objective reducing inequalities in the early development of physical and emotional health, and cognitive, linguistic and social skills—and put giving every child the best start in life as the review’s highest priority recommendation.

12.3 Commissioning must address inequalities in access to services for children and adults with SLCN. Research has found that adults with SLCN have less access to primary care interventions for medical conditions as the interaction between themselves and the primary care team is affected as a result of their SLCN. This in turn exacerbates health inequalities.

12.4 There is a concern about ensuring that health inequalities are not increased. The Frank Field review on Poverty and Life Chances and the Graham Allen review on early intervention all highlighted the important of early identification and early intervention— communication is a key area. The RCSLT carried out a survey of our members and the results show that universal services are being hardest cut especially in areas of deprivation where up to 55% of children have speech, language and communication needs. The risk is that unidentified and unmet need costs the economy more and there is a clear link between educational failure and criminal behaviour, with up to 70% of young offenders having communication problems.

13. The Structure and Purpose of the Public Health Outcomes Framework

13.1 There is an assumption that GPs and GP practices have a good understanding of public health. Building the capacity to address public health commitments should be a priority for consortia. The RCSLT supports the proposal that incentives and drivers for GP activity should be specifically designed with public health concerns in mind, and that a proportion of the current value of QOF be devoted to evidence based public health and primary prevention indicators.

13.2 Given the future role of GPs as commissioners, the RCSLT recommends healthcare outcomes which relate to:

Early identification and intervention.

Facilitating and enhancing development in children.

Prevention of emotional and behavioural difficulties.

The speech and language needs of youth offenders.

Children with specific speech language and communication needs.

June 2011

Prepared 28th November 2011