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No borderline
Figure 1 Assessment pathway (children who have a hearing impairment)

IF YOU WANT TO BE CONFIDENT AND CONSISTENT PROVIDE A SEAMLESS SERVICE HAVE MORE TIME FOR THOSE MOST IN NEED

SPEECH AND LANGUAGE THERAPY CHILDREN WHO HAVE A HEARING IMPAIRMENT PATHWAY FOR ASSESSMENT
Christina Barnes

Historically, trust boundaries have caused problems for our clients, and led to charges that the NHS operates a postcode lottery. Now, Christina Barnes and colleagues in a regional special interest group in deafness have developed a care pathway to improve equity of service for clients wherever they live.

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e - just a pathway
Figure 2 Intervention pathway (preschool)

SPEECH AND LANGUAGE THERAPY CHILDREN WHO HAVE A HEARING IMPAIRMENT PATHWAY FOR INTERVENTION PRE SCHOOL

pecial interest groups are a crucial part of a speech and language therapists continuing professional development (RCSLT, 1996). In South Wales and the West we recognise this by having a strong membership of our special interest group in deafness. Many of our members travel long distances to attend our termly meetings and, whilst we always seek to have outside speakers, we share from our own experience (presenting case studies, reflecting on particular areas of work), report back on courses, and contribute on Royal College matters, for example the competencies project. We all benefit from the non-managerial group supervision that is afforded in this context; indeed, clinical queries / clinical supervision is a standing item on our agenda. Over time it became clear that we should address the issues around our working practice, to aim for continuity of provision in spite of variations in funding across health service boundaries. We began this process in March 2002 in response to a request from the All Wales Managers to develop a care pathway of intervention and assessment. A care pathway is a process by which a clinician may be prompted to make appropriate decisions regarding clinical management. We began by looking at various pathways that had been devised previously. Of these we found the phonology pathway (Owen et al, 2001a; 2001b) to be most user-friendly, as it took the form of a flow chart that was easy to follow. We broke into buzz groups and brainstormed the essential information that we wanted to include. Our objectives were that the care pathway should be client needs led as far as possible an aid to clinical management decision-making transparent enough to be understood by other speech and language therapists transparent enough to be understood by other health and education professionals. As creating one pathway would be far too busy visually - and consequently confusing - we focused on three pathways, one for assessment (figure 1) and two for intervention (preschool and school aged, figures 2-3). As a member of the team that had developed the phonology pathway, it naturally fell to me to take the lead role. The progress towards the final draft was slow, mainly due to our meeting schedule. Between the following three meetings the pathways were edited and revised, and group proof reading led to further revisions. We aimed to make the care pathway as user-friendly as possible to all members in their various contexts. We arrived at our final draft in June 2003 and are now putting it into full practice. As far as possible, a colour code was used to prompt the user of the care pathway: Green: exit / moving towards discharge Red: clinical decision action point Blue: question to aid clinical decision-making Black: clerical action point Orange: warning (is this the right decision? Are there extraneous circumstances?) We decided it was appropriate to quantify the levels of service a client should expect to receive, and produced a document based on unpublished work by the speech and language therapy department in North Bristol. It aids clinical management decision-making within the care pathway framework, and is therefore printed on the reverse of both intervention care pathways (figure 4).
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Figure 3 Intervention pathway (school age)

SPEECH AND LANGUAGE THERAPY CHILDREN WHO HAVE A HEARING IMPAIRMENT PATHWAY FOR INTERVENTION SCHOOL AGE

Figure 4 Levels of service (Based on work by the North Bristol Trust speech and language therapists)

LEVEL CRITERIA FOR PROVISION Level 1 Advice and communication with other agencies required Childs communication needs are best met within their daily environment, eg. ...childs profile may include: a) General language delay b) Immature speech c) Listening and attention control difficulties The most appropriate deliverers of the communication programme / targets are the daily communication partners Named carer / worker / assistant is available and able to follow advice

Level 2 As above PLUS The deliverers of the programme will require specific training eg. ...childs profile may include: a) Phonological difficulties b) Mild receptive and / or expressive language difficulty c) Use of communication aid or other AAC required d) Specific social communication difficulty Level 3 At this point therapy CANNOT be delivered by any other agency / person due to the specific nature of the work High level of liaison with other agencies required Carers and other professionals working with the child will require specific training and a high level of support ...Childs profile may include: a) specialised phonological or articulation work b) specific receptive language difficulties c) specific expressive language difficulties d) need specific resources

We are now in a position to work with these documents throughout our region. They can be easily laminated and slipped into a therapists briefcase for reference. We hope that, through use of these documents, children will receive an appropriate level of service; that more therapy time will be available to those children with significant needs, and that it will be clearer which clients should be either discharged or transferred to other clinical caseloads. Thus, the specialist speech and language therapist within a trust may release a little more time for the consultative, advisory and training aspects of their role, and therapists new to this branch of the service will be able to make clinical judgements with more confidence and consistency, safe in the knowledge that their colleagues around the region are working in a similar way. (See case examples in figure 5a-b.) We also feel that the care pathway may be used as a tool in communicating our role and decision-

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Figure 5a Using the Assessment Pathway (school age)

MANAGEMENT Written communication programme with targets. Planned with carer or teachers as appropriate. Main carers and professionals informed as appropriate. Agreed implementation strategy to include: a) Identified carer / worker / assistant to be responsible for implementation of the targets / programme b) Terms of speech and language therapy involvement outlined and agreed c) Evaluation date agreed As above PLUS An agreed number of sessions with named worker / carer and child, as appropriate, for demonstration purposes only

A secondary school special educational needs coordinator referred Harriet early in year 7 (chronological age 11;0y). She had a statement of special educational needs and had transferred to secondary school from a moderate learning difficulties unit. Her mild, mixed sensori-neural and conductive hearing loss had only been identified within the previous six months and she had been prescribed a hearing aid for her right ear. I offered an initial interview in school and completed a full assessment of auditory memory, auditory discrimination, receptive language, expressive language and phonology. Evaluation of the assessments, liaison with the learning support team and other reports identified a child who was performing well on many language-based tasks. Despite the moderate learning difficulties statement she was performing within the average range on vocabulary tests, formulating sentences and listening to paragraphs (CELF-3UK). Harriet had significant difficulty with auditory recall, performed just below average on the TROG and found Oral Directions (CELF-3UK) very challenging particularly the elements related to
Figure 5b Using the assessment and intervention (preschool) pathways

left/right orientation and those containing more that four information carrying words. Her baseline secondary cognitive ability tests had identified a child of low ability in the language (written), spatial and quantitive sub-tests. Teachers found her difficult to understand, as she tended to speak rapidly and quietly. Her support teacher found her profile to be rather more consistent with a child with a specific learning difficulty (dyslexia) rather than a moderate learning difficulty. However, her language profile was not typical of a child with specific learning difficulties. Thus the question Is the language delay of concern considering all factors eg. hearing age, level of ability and degree of hearing loss? was difficult to answer... and the conclusion uncertain has led to a period of monitoring and evaluation which will include a re-referral to the educational psychologist by the special educational needs coordinator. However, I felt it was appropriate to include a report with initial advice on management and strategies. If no further concerns are expressed before her next annual review, Harriet will be discharged from the speech and language therapy service.

Background: Jason is 2;5y. Mother contracted cytomegalovirus whilst pregnant. Profound sensori neural deafness on one side. Suspected moderate-severe conductive on other side. Not being offered grommets, as risk of damaging only ear with useful hearing for speech. Some minor physical / coordination problems but otherwise development seems appropriate. Severe problems with dribbling. Attends nursery three sessions per week. Teacher of the deaf sees fortnightly. Pathway for assessment: Does he have a hearing impairment? Yes Is it sensori neural loss? Yes, but also congenital conductive. Offer Assessment with teacher of the deaf - done. Evaulate assessment - done. Is language delay a concern - yes (Language delay of over a year. Only just beginning to use single words meaningfully. Parents using key signs.) Write report, advice etc. Go to intervention pathway

As above PLUS It is appropriate for the child to receive an intense period of direct therapy for an agreed period of time Development of specific resources is required

Pathway for intervention (pre-school): Has child been identified as needing intervention? Yes Does child meet local resources criteria? Yes Evaluate level - 2 Provide programme and training: Advice given at nursery, home and to teacher of the deaf. Attendance at special needs review meeting with mum, paediatrician, physiotherapist, nursery, teacher of the deaf Offer special training to parents eg. Hanen: Mum invited to attend fortnightly communication group for parents of preschool deaf children. Parent interaction advice given at home. Provide language programme in consultation with other professionals / suggest targets: Advice given for individual education plan. Teacher of the deaf responsible for applying for additional funding. Has child made progress? Yes, but re-evaluate - still requires ongoing support at level 2. Termly visits planned to support family and regular meetings with nursery and teacher of the deaf to help plan individual education plan. (Anna Duncan, speech and language therapist)

making to other professionals - for example, that it is not the specialist role to treat language delay resulting from otitis media with effusion. We are also aware that, unfortunately, the history of some posts may make it challenging to reduce the level of service, say if a particular school has had therapy provided for three sessions a week. We hope however that, by use of the pathway and explanation of the levels of service, others will acknowledge that a client needs led service benefits all. We will audit the pathway over time to evaluate if it is possible for speech and language therapists working in the specialist area of paediatric hearing impairment and deafness to provide an equitable service across health service boundaries. Christina M. Barnes is a specialist speech and language therapist with West Wiltshire NHS Primary Care Trust, tel. 01225 766161. This article was written on behalf of members of the South Wales and West Region Special Interest Group in Deafness,

and the care pathways are based on work by the speech and language therapy department of West Wilts and North Wilts PCT.

References
Owen, R., de la Croix, H., Lewin, J., Lawer, E. & Davies, S. (2001a) A first class team. Speech & Language Therapy in Practice Spring: 16-20. Owen, R., Lewin, J., Lawer, E., de la Croix, H. & Davies, S. (2001b) Equity of service: A protocol for management of children with speech problems. International Journal of Language & Communication Disorders 36 (Supp): 110-4. Royal College of Speech & Language Therapists (1996) Communicating Quality 2: Professional standards for speech and language therapists.

www.harcourt-uk.com Hanen, see www.hanen.org Parent-child interaction therapy: an alternative approach to the management of childrens language difficulties, see I CAN training at www.ican.org.uk TROG (Test for Reception of Grammar) - version 2 now available from Harcourt Education, www.harcourt-uk.com

Resources
CELF-3UK (Clinical Evaluation of Language Fundamentals) from Harcourt Education,

DO I PARTICIPATE FULLY IN SPECIAL INTEREST GROUPS? DO I CONSULT EFFECTIVELY ON NEW DEVELOPMENTS? DO I MAKE DECISIONS THAT ARE CLIENT NEEDS LED AND TRANSPARENT?

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