Organisation submitting example
Central and North West London NHS Foundation Trust/Hillingdon Community Health
Local authority/local area:
The context and rationale
This example describes Hillingdon Speech and Language Therapy (SLT) service’s journey to provide better access to their services for pre-school children with speech, language and communication difficulties. Their aim was to ensure that all children with a speech, language and communication need (SLCN) within Hillingdon were seen within 6 weeks of referral or sooner, through parents directly accessing SLT drop in triage. At the same time, a need was identified for a universal preventative health promotion/early intervention service to promote early communication and early identification of children with speech, language and communication difficulties.
In June 2009, the Hillingdon Speech and Language Therapy (SLT) service recognised a need to provide better access to their services for pre-school children with speech, language and communication difficulties. At the time, assessment of children was being offered within a traditional clinic environment. Parents were offered a booked appointment with a speech and language therapist and the appointment was for up to 45 minutes. Available appointments were limited and resulted in waiting times of up to 13 weeks to access the service. This waiting time was considered to be too long, and resulted in an increase in parental anxiety. It also affected the ability to provide early intervention and waiting times needed to be reduced. Therapists researched ways to redesign the service to improve access and provision for the service users and to ensure that all children would access the service within six weeks of referral. A ’drop-in triage’ model was agreed.
At the same time, a need had been identified for a universal preventative health promotion/early intervention service to promote early communication and early identification of children with speech, language and communication difficulties. Discussions were held with the Local Authority (LA) children’s centres and extended services exploring the LA commissioning an extended SLT service into children’s centres.
• Following the Bercow review, a Speech, Language and Communication Need (SLCN) multi agency operational group was set up to carry out a strategic review of the Bercow recommendations and a local review of provision.
• This group comprised: children’s centre managers, early years’ team, educational psychologists, specialist language teachers, speech and language therapists.
• The SLCN provision within the borough was mapped and a plan produced to develop a more coordinated service utilising the resources more effectively, producing coordinated resources for parents and families, and reducing overlap.
• Through this mapping exercise, a need was identified for a preventative model to provide a universal service for families within Hillingdon to promote good practice developing speech, language and communication skills, to improve early identification of children with speech, language and communication difficulties, and to ensure earlier intervention could be provided.
• Through close working with the London Borough of Hillingdon’s schools and extended service manager, children’s centre managers, and modelling the service on the service already being provided by Hillingdon SLT services into Brent children’s centres, it was proposed that a service should be commissioned by the children’s centres, to support a wider and fuller roll out of a preventative health promotion/early intervention model. This would be across all localities, prioritising the importance of early communication development, early identification and intervention.
• To ensure early identification and intervention, and access to appropriate intervention and advice, families needed to be able to access the SLT services more quickly. A ‘drop-in’ screening triage model was explored. This could be provided within children’s centres and allow a more family friendly, natural communication environment for assessment of children’s speech language and communication skills.
• Staff from Hillingdon SLT service visited City and Hackney Primary Care Trust (PCT) to observe an established TIWI (Talking walk in) service - a drop-in triage assessment service provided within children’s centres. Ideas to adapt this service to a suitable model for Hillingdon were agreed with children’s centres and implemented.
• The Hillingdon SLT service already provided a successful model of health promotion into Brent children’s centres, which was identified as appropriate for adaptation for the Hillingdon children’s centres to extend the offer beyond screening/triage. This extension to the SLTs drop-in triage was funded by the children’s centres.
• To ensure that all children with a speech, language and communication need (SLCN) within Hillingdon are seen within six weeks of referral or sooner through parents directly accessing SLT drop in triage, for timely assessment of any communication concerns. Parents/carers to be provided with timely advice, information and signposting to promote optimal early development.
• To target prevention, early identification and intervention for SLCN including a core offer of health promotion within an accessible family friendly environment. This offer to critically include training to early years staff to support prevention, early identification and intervention of early communication development in young children.
Benefits for service users
1. An easily accessible service for all.
2. Ease of access for assessment and quick advice without the need for a formal referral.
3. Maximum six week wait for assessment - but can be seen within five working days if parents can travel to a different children’s centre.
4. Improved access for families not accessing health clinics/traditional points of access, with the support of children’s centres acting as local ‘hubs’.
5. Child and parent friendly environment.
6. More natural and less intense environment for pre school children than the medical model of a one-to-one assessment in a clinical room. Promotion of more naturalistic communication and accurate observation/assessment of a child’s real communication.
7. Family friendly ‘one stop shop’ environment; siblings can attend and play without impeding the assessment process.
Benefits for Hillingdon partners
1. Assurance of fast SLT access and assessment for families within six weeks. Parents given immediate feedback and information at the time of attending.
2. Children to be assessed in a more natural communication environment, therefore more likely to speak freely and participate. The group environment promotes assessment of social communication, play skills or parent child interaction. Less time required to ‘break the ice’ and to coax child into play, therefore more productive, efficient and effective use of time.
3. Faster throughput and more productive: parents who require reassurance oradvice only and then discharge, can be seen and actioned within a much briefer slot. More children can thereby be seen in the same clinical session
Children requiring group intervention can be signposted quickly and directly, following screening
4. More joined up working with all partners and professionals across agencies, including link health visitor’s, early years staff, LA specialist support services. Families can therefore be signposted to other services under the one roof. Wide range of shared learning or CPD (continuing professional development) opportunities for staff and partners.
5.Supports the five Every Child Matters Outcomes and importantly is fully aligned with the direction of national NHS policy and recommendations e.g. Transforming Community Services and The Improved Allied Health Professional Offer:
• Providing care in accessible settings.
• Developing creative approaches to service provision from the perspective of users and improving service efficiency and effectiveness.
• Increased use of self referral.
• Reduction in waiting times-offering “immediate” access.
• Developing new ways of engaging with parents who find it hard to connect with traditional services.
• Offering services in a range of settings.
• More joined up and integrated working between health and other partners.
Further details about the practice
Achieving Aim 1
To ensure that all children with a speech, language and communication need (SLCN) within Hillingdon are seen within six weeks of referral for timely assessment of any concerns re. speech, language or communication development. Parents/carers are provided with timely advice, information and signposting to promote optimal early development.
• SLT staff met with the schools and extended services manager to discuss the aims and rationale behind the services. Benefits were identified for the child and the family, children’s centres and the SLT service.
• Meetings were held to discuss how these services could be provided within the children’s centres. SLT attended children’s centre managers’ meetings to discuss benefits and Bercow review recommendations.
• A 3 month pilot scheme was agreed upon. Existing services were realigned to allow support for the childrens centre staff. Two pilot centres were chosen. There was good support from the children’s centre managers and their staff.
• A monthly two hour SLT screening triage session was held within thetwo pilot children’s centres.
• A list was jointly agreed of the requirements and format for the drop in sessions.
• Parental advice sheets were produced and put into packs by the SLT service.
• The existing SLT case history form was adapted into a more accessible form for parents to part fill in at the triage screening.
• Observation sections were added, and parent reported and SLT observed behaviours were separated.
• Promotion: a flier was produced describing the triage session, to be handed out to parents by referrers, children’s centres, and health visitors and displayed in prominent places for example in libraries.
• Referrals were accepted as before, but children were invited to the children’s centre triage rather than the traditional clinic appointment for the two pilot areas.
• All initial assessments whether parent generated or formal referrals were seen at the children’s centres for the two pilot areas. The other clinics continued with the traditional SLT assessment procedure.
The following format was agreed:
• Identified room to be set up as a parent and toddler group with appropriate high interest toys and activities around the room that would also provide positive communication opportunities.
• Chairs set up in two different areas for the SLT and the parent/s.
• A member of staff from the children’s centre was identified to support with the triage sessions.
• Children’s centre support member to meet and greet the families, complete centre registration details, and give the parents a referral and case history form (if a ’drop-in’). Parents would be given information about how the triage session would be run and what to expect.
• Children/families would be seen in order of arrival.
• In one centre the children would be invited to attend a stay and play session in an adjacent hall, until the SLT was able to see the child. The children’s centre staff would then bring them into the triage session.
• In the other centre the children would all play together in the room and the children would be assessed in order of arrival.
• This allowed both models to be piloted for future reference and review.
• The therapist would take further case history details from the parent, discuss any parental concerns, referrer concerns, observe and assess the child within the same environment. The child could then be informally observed playing with other children, on their own or with parents.
• SLT provided the parents with immediate feedback or advice and explained what would happen next.
• Parents given a feedback form to evaluate the service.
Children would be either:
• Invited to a SLT group in the local clinic.
• Invited to attend for further assessment.
• Given advice and discharged/sign posted to other health/children’s centre services, if appropriate.
Following the three month pilot, and feedback/joint evaluation, all managers agreed to roll out across all 18 children’s centres This involved centre managers planning and timetabling sessions. The service has now been running for two years (May 2010).
Achieving Aim 2
To target prevention, early identification and intervention for SLCN including a core offer of health promotion within an accessible family friendly environment, including training to early years staff to support prevention, early identification and intervention of
early communication development in young children.
• A programme of children’s centre staff training, development and resources was planned to support the prevention, early identification and intervention to extend beyond SLT screening. The therapists started by attending sessions run in the children’s centres and advising staff and managers on developments to build on the existing provision to provide an enhanced communication setting/environment for attending children and families. This linked with and complemented work within the government funded ECAT (Every Child A Talker) project taking place in early years settings. Established practice was adapted from work that the Hillingdon SLT service was running within Brent children’s centres.
• The SLT was involved in planning and running stay and play and rhyme time sessions within the children’s centre with their staff. The learning and practice was then extended across other stay and play/rhyme time sessions running at the centres.
• The therapists were involved with modelling and training staff on early identification of SLCN.
• A folder of resources and information was jointly developed with the LA early years service and distributed to all health visitors, GP practices, early years settings, and children’s centres and modelling encouragement and advice on how to use these resources was provided.
• Areas for parent training were identified and for centres able to provide a crèche, parent training delivered.
• All centres were given a menu of training that could be delivered to staff to choose from.
• SLTs were also available for more detailed 1:1 assessment if required following triage screens. Children identified with therapy needs were referred to local therapy groups as quickly and smoothly as possible.
Evidence and evaluation - making a difference to children, young people and families
Drop-in triage sessions:
The success of Aim 1 has been based on:
Qualitative information provided through reported outcomes by parents, children’s centre staff and therapists
Quantitative information provided by the RIO computer reporting systems used in Hillingdon.
The service has met the aim to provide quick access to assessment and advice. All (100%) of children have been offered assessment within six weeks of referral. This time frame is measured monthly through RIO reporting systems. The majority of children are seen within an even shorter time- with some families accessing the service in the same week as a concern arises.
Parents were provided with evaluation forms following attendance at the triage session. Of the 376 children seen for assessment, 263 evaluation forms were returned. This equates to 70% return rate. The results of the evaluation forms have been analysed – the Small Talk feedback and evaluation report is available from the C4EO team.
Numbers of children seen between Jan- Sept 2011
Initial appointments - 463(334 Jan- Sept 2010)
Requiring SLT - 292
Referred on to CDC(Complex needs) - 20
Discharged with advice - 64
129 more children have been able to access the SLT service with the new drop in triage model compared with the traditional clinic model, in the same period of time. These children have been identified earlier than would have been possible through the clinic model. They have all accessed information and advice within six weeks of concerns being raised by their parents, nursery, health visitor and a referral being made.
The parents reported positively about the children’s centre service. They commented on the benefits of an informal approach where the children felt happy and played well; feeling that the therapist has a true understanding of their child’s communication skills; the fact that their children did not know they were being assessed.
Therapists reported that the children and parents were more relaxed. The therapist can observe the children playing and communicating with other children, and observe parent/child interaction within a natural environment. Within the traditional clinic format, the child would be placed in an unnatural environment: in a small room with a parent and SLT. The therapist would then try to promote communication and assess the child’s speech and language skills within this unnatural environment.
Children’s centre staff commented that parents like the ability to ’drop-in’. If a parent has a concern they can be seen within four days. If they want to wait to be seen at their nearest children’s centre, they will still be seen within a calendar month. They have reported that information about the drop in service is widely advertised and parents are coming to the centre to enquire about the small talk sessions. Staff said that they feel more confident in signposting parents to the sessions as soon as a problem is highlighted, Within the old model they would have waited longer, because they did not want to “waste the therapist’s time”. Again this ensures that children are being identified earlier and intervention can be provided more quickly.
Of the children seen by the service, 64 were assessed, given advice and discharged. Although these children did not require speech and language therapy at that time, some of these children could potentially have been at risk of developing difficulties later. For these children the session provided timely intervention and advice with appropriate information and modelling to parents to develop their children’s early communication skills, reducing the likelihood of future difficulties. Where parents were concerned but no difficulties were identified, the therapist was able to reassure the parents and thereby reduce the stress and worry of their concern. These children were also signposted to other sessions within the children’s centre that could provide their parents with support.
Because the speech and language therapists are visiting the children’s centres each month, a closer working relationship has developed. The therapists are able to use informal opportunities to develop the children’s centre staff’s knowledge and skills identifying and working with children with speech, language and communication difficulties.
This occurs through:
• Children’s centre staff helping within the sessions.
• New staff observing sessions .
• Staff attending local group therapy sessions to support their families.
• Homework packs for all therapy sessions are available to the children’s centre staff.
Many staff members have taken up the opportunity to attend a session to support a family. They are encouraging parents to attend sessions, using their knowledge of what happens in the groups to explain this to parents and supporting the families using the skills they have learnt.
All children’s centres have accessed the health promotion model of SLT delivery. The speech and language therapist has observed and analysed the stay and play sessions provided by the children’s centre staff and through discussion with children’s centre managers and early years practitioners, improvements have been planned and carried out. (Stay and Play observation session is available from the C4EO team.)
All centres have taken up the opportunity to use the joint analysis of their stay and play sessions and have developed joint planning with the SLT. Each centre has been provided with a list of appropriate resources to encourage early communication skills including story sacks and visual support materials. The use of these has had a positive observed impact on the quality of the interactions in the stay and play sessions.
The SLT has used the sessions to increase understanding of opportunities to model ‘good’ communication skills. These have been observed through the stay and play analysis These changes can then be incorporated into all the stay and play sessions throughout the centre.
Training sessions have been offered to parents on:
• Normal language and speech sound development
• Observe wait listen
• Special time and following child’s lead
• Attention and listening
• Commenting and asking questions.
• Communication boards have been produced in all children’s centres providing information on speech and language development, useful contacts and websites, leaflets on encouraging children to talk etc.
• There is greater understanding and confidence regarding SLCN.
• There are more appropriate referrals from children’s centre staff - the quality of the referrals for children being referred by children’s centre staff has improved.
• Support for SLT sessions and some children’s centres staff supporting parents has been provided as well as attending SLT sessions with families.
• Joint working with dentistry is happening to provide training ‘bottle to cup’.
Over 100 families have been encouraged by children’s centres staff to attend drop-in triage sessions. These families have been able to access SLT earlier and gain the advice and support they needed.
Clinical audit report and Chit Chat TfC case study are available from the C4EO team.
Sustaining and replicating your practice
Drop-in triage sessions
• This service is valued both by the SLT service, parents and the children’s centres. The centre managers have recognised the benefits and how the service complements the health promotion work. At present the children’s centres are still able to provide suitable rooms for the drop in triage sessions.
• Some centres do not have the staff to welcome and process the children as they arrive. This has meant that the SLT has to manage this within the centre.
• Where possible SLT students have been used- and this has proved a very valuable use of students. The feedback from them is that this is a very interesting placement and they have learned a great deal in their time.
• SLT assistants are used where it is possible. This has affected the opportunities for CC staff to observe and learn more about SLCN. The triage session is a good learning environment. Staff members have fed back how much they learn whilst listening to the advice parents are given by the SLT. This has increased their confidence when talking to parents about SLCN.
• On rare occasions, sessions resulted in too many children attending. It was necessary to turn families away. Because of this, changes have been introduced to ensure triage.
• Sessions are now planned with the first hour for booked slots/children referred into the SLT service and the second hour for drop in children. This has ensured that the booked children are seen- as parents were not happy if they attended for a booked appointment and were then waiting for long periods of time to be seen.
• Due to the success of the sessions a waiting system has had to be introduced to control the number of children waiting for a drop in assessment. Centres know how many slots are available at each session, and can ensure that if more children arrive than there are slots for, this is quickly recognised. Parents are given contact details to book into a slot on another day if they wish. A booked slot will ensure that they will definitely be seen when they attend. This ensures that parents are not kept waiting for long periods of time to be seen.
• As part of the joint working and learning it is important that there is feedback to the Centres. Providing case studies helps to track the benefit of the service to the families involved.
In the centres where there is a designated member of staff for the sessions, this has been invaluable. The staff member is able to settle the children and build up a rapport with them. They are able to give observations to the SLT. They have more time to explain the session to parents and can ensure that families are seen in the correct order.
• Following successful work into stay and play /rhyme time sessions, these have now been adapted to ensure a good communicative environment. Staff members are more confident in discussing SLCN with families and now recognise when to refer to SLT triage sessions.
• There is good use of visual support, and all centres have communication boards and advice for parents easily accessible.
• Following discussion with the children’s centre managers, it was decided to develop the service to be a more targeted model. Speech and language therapy groups are now being run within the children’s centres, with training for staff to run these groups independently.
• Children within the outreach nurseries are being targeted also.
• SLT is still monitoring stay and plays/rhyme time sessions to ensure the good practice developed is continuing.
• Ongoing review and adaptation is necessary to ensure needs are continuing to be met.
Funding issues and the financial climate does mean that services need to be flexible. It is not always possible to ensure funding into a new financial year. Job security/maintaining staff can therefore be an issue.
t. 020 7833 6825
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