1.

work from what clients want and what evidence suggests you should provide
2. be aware that the same route to an end place doesnt suit everyone
3. build in opportunities to stop over, divert and revisit as needed
4. act in partnership with voluntary agencies and other professionals
5. aim for equity and consistency through shared standards
6. increase confidence through being organised and transparent
7. ensure adequate induction and updates for staff in new procedures
8. think about the benefits of generic groups for clients
9. make specialist opinions accessible.
Practical points: care pathways
l am negotatng
care pathways
Too oten, speech and anguage therapy
and other servces are dcut or cents
to access and negotate, and therapsts them-
seves are not aways cear whch way to
turn. Do care pathways oer a way ahead'
are pathways are becomng amar to us as
a way o descrbng, pannng and mappng a
cents journey va derent routes rom
reerra to dscharge. Dependng on the
nature o the cents needs ths journey may
be through speech and anguage therapy
ony, or nvove a range o heath and
assocated servces workng together wth the
cent and amy.
But how do we know ths snt yet another
ad' Are there practca benets or cents
and servces' Do care pathways hep us to
acheve evdence based practce' And how do
we ensure that a care pathway oers easy
access or a, and snt a euphemsm or
passabe wth care'
Our two contrbutors descrbe how care
pathways can be a transport network
worthy o our nvestment.
Neil Smith is a specialist speech
and language therapist with
Portsmouth City NHS Primary
Care Trust at Rowner Health
Centre, Gosport, Hants,
tel. 023 92 511500,
e-mail smuff70@hotmail.com.
Cecilia Yardley is Director of
Services for Speakability, 1 Royal
Street, London SE1 7LL,
tel. 080 8808 9572,
e-mail
speakability@speakability.org.uk.
The charity Speakability exists to
reduce the barriers faced by
people with aphasia.
you
need to spread your
expertse more wdey
want to pass more power
to servce users
ke to be organsed n your
approach
Read ths
how l...
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 (
Therapists had highlighted that writing reports for children with fluency
problems was difficult, therefore a fluency report format identifying areas
which should be commented on was introduced.
Equity of service
By this time joint assessment clinics were being used successfully within
the department but there was a lot of information I wanted to share
with staff, and I had to find a way to present it. In the end we decided
that, to ensure equity of service, all therapists should have access to
what is now called a fluency pack when assessing children who present
with dysfluency (figure 2). It is designed to be in line with current
research and flexible in that, if new or updated information becomes
available, it can be adapted quickly.
All new staff to the trust spend a session with me as part of their induction
to provide an overview of the service for dysfluent children. This time is also
used to discuss the fluency pack and standards. All community clinics now
have a fluency pack and specific training is arranged regularly - approxi-
mately every three months - for new staff to attend and for any other staff
members who have not previously attended or would like a refresher.
Alongside this course I recommend therapists attend another training
package, an overview of therapy approaches. This looks at the assess-
ment procedure and appropriate management for dysfluent children and
teaches intervention techniques and strategies the therapists can actu-
ally use (slow speech, modification, interaction therapy) as well as
informing them of approaches such as Lidcombe, McGuire and Starfish
which can be used by other people. This is so they have a minimum level
of awareness and understanding of several approaches and can refer on
if need be or if specifically questioned by parents. Therapists are advised
to contact me in the first instance if parents request further information.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003
how l
y appointment three years
ago as a specialist in stam-
mering was a new venture for
me. Dysfluent children make
up a small percentage of a community ther-
apists caseload, adults with a stammer even
less, therefore specialist training in dysfluency
is not a priority. Yet our knowledge of stammering and how to manage
it is constantly growing and we know that timely, appropriate interven-
tion for children works (Christie, 1999). I had a daunting task in only
three sessions a week, but the job description gave endless opportunity
as it stated that I should ...develop the service for dysfluent children....
My first priority was to devise short and longer-term aims for the service
(figure 1). Initially, I distributed newsletters to help share stammering
related issues and to keep fluency at the forefront of therapists minds.
The newsletters informed staff of times I would be available for discussion
and highlighted small projects I was working on such as collating clinic
resources and equipment lists. They also included resources that I had
available and information on current theory.
Allowing therapists access to my specialist time was at first difficult to
achieve as colleagues had children they wanted to discuss urgently or see
jointly. In the beginning I used my fluency sessions to see children with their
community therapist to help with the backlog of such cases. However it soon
became apparent that this was very time-consuming, involved extensive
travelling across the trust and was erratic with regard to service delivery.
To deal with this, I subsequently developed joint assessment clinics.
Portsmouth City NHS Trust is split into three wide geographical areas. I
devised a rolling joint assessment programme so that one day per month
was arranged whereby if therapists had any particular problems with any
child they would refer them via a standard form to the clinic where we
would see them together (January - division 1, February - division 2 and so on).
These sessions gave therapists specific and structured access to my spe-
cialist time. Joint assessment clinics gave therapists working in the com-
munity time to discuss cases in greater depth with me in order to develop
a structured management plan. In effect, they became practical training
sessions giving staff confidence in working with this client group and
information which could be applied to other cases in the future.
To address longer-term aims, trust-wide standards were developed to
ensure consistency and equity of service across the department. These
were in line with current evidence based practice. Standards were pre-
sented in a flowchart format to give therapists visual guidance to help
the assessment procedure.
The standards include diagnostic criteria of beginning, borderline,
intermediate and advanced (Guitar, 1998) and a profile of risk (amend-
ed from Cook & Botterill, 1999). The parental interview and language
based assessments were deemed compulsory.
N
Unbockng
the pathway
How do you deveop a specast servce or chdren who
stammer n three sessons a week' Ne Smths work on a
care pathway or dysuent chdren n Portsmouth coud
be equay apped to other communcaton dcutes
whch have a ow ncdence n communty caseoads but
need targeted and tmey nterventon.
Figure 1 Short and longer-term aims
short-term aims:
1. to increase awareness of stammering related issues within
the department
2. to develop therapists confidence in working with this client
group
3. to give therapists access to specialists time (informal and formal).
longer-term aims:
1. to develop equity of service
2. to encourage skill mix and ongoing confidence
3. to provide a service which is in line with current practice and
research
4. to provide appropriate training packages to staff.
Figure 2 Contents of fluency pack
- procedures when working with dysfluent children
- pre-assessment telephone discussion
- parental interview
- child interview
- school aged screening assessment
- profile of risk (prognosis tool to be used with all new referrals)
- child assessment summary sheet
- guidelines for writing fluency reports
- venues / dates for forthcoming joint assessment clinics
- joint assessment referral forms
- stammering newsletters
- information / leaflets (based on those produced by the British Stammering
Association):
how parents can help young children who are non-fluent
information for referral agents
information for teachers
information for parents of children under five
what is stuttering?
stuttering prevention
ways to reduce demands on at risk children
- appendix 1 (the development of stuttering - diagnostic criteria)
- space at the back where therapists can keep copies of any information they
have seen or read which they feel is relevant and for any further information
distributed by the specialist.

A typical care pathway for a stammering child in Portsmouth City NHS

Primary Care Trust is summarised in figure 3. Our speech and language
therapy service offers an open referral system and the guideline is to see
all new referrals within six weeks. However, to be in line with current
research (Christie, 1999), we aim to see children who are referred with
fluency problems as close to the referral date as possible.
Pre-assessment telephone contact is optional and is designed to give
parents broad advice without going too far into wider issues, to offer
immediate strategies for use at home and to gain an impression of levels
of fluency and concern. Parents are sent a leaflet about stammering
with their initial appointment.
Every family attending initial assessment will receive a parental question-
naire (based on Rustin, 1987), and observations will be made on the nature
of the childs stutter, secondary features, social skills, anxiety and avoidance.
Preschool children receive language assessments as appropriate. School-
aged children receive formal language assessments on their vocabulary
development and their receptive and expressive language levels.
Therapists then develop a profile of risk (Cook & Botterill, 1999) and
make a diagnosis. Diagnostic criteria are borderline, beginning, inter-
mediate and advanced (Guitar, 1998).
Therapists have a list of therapy approaches and techniques which cor-
respond to the diagnosis made (beginning stutterer = general advice,
Lidcombe approach, shaping; intermediate stutterer = general advice,
social skills, brief therapy; and so on). These are used as a guideline to
suggest possible strategies or techniques suitable for children presenting
at a particular level. The timing of therapy is obviously important and
factors including age, anxiety levels, parental concern and willingness to
participate and change are all considered.
Several review options are available including routine three or six
month review. The preferred method is to encourage parents to contact
the department after approximately four weeks for a progress report
and to discuss any further issues which may have arisen since the last
appointment. This allows the therapist to gauge whether or not any further
intervention is required at that time.
We suggest that parents contact the service immediately if they need
any further advice, information or another appointment. This open
review system places the onus on the parents and, if we do not hear
from them within six months, they are discharged. This is clearly
explained to them in the session and in their report.
Secondary and tertiary levels of service are also available. Therapists
can refer for a joint assessment with the specialist within the trust and
there is always the possibility of referral to the Michael Palin Centre for
Stammering Children in London.
At discharge the child / parents are told about re-referral procedures
and are given advice on relapse and what to do if further concerns arise.
So, were my original aims for the service (figure 1) met?
Newsletters raised awareness of stammering issues within the department
initially, and now any new information, advice or articles of particular inter-
est or relevance are circulated to ensure that every therapist has access.
More confident
A recent drop in requests for joint assessment appointments suggests
that therapists are more confident to deal with stammering children
autonomously. Also, recent questionnaire findings showed increased
levels of confidence and reduced anxiety when working in this field.
Therapists still use informal telephone contact to discuss cases and often
this is now all that is required. The fact that colleagues are making less
use of specifically allocated specialist time has been viewed as a very
positive step within the department.
As the standard fluency pack is now being used across Portsmouth and
South East Hampshire, this has ensured equity in that all children
referred receive the same assessment procedure and general advice.
Any new research or theoretical frameworks for practice are shared as
appropriate and are added to the pack in place of old information to
ensure the whole system is fully up-to-date. All staff working in com-
munity clinics will have received both the introductory and overview
training packages in the near future and both packages are soon to be
regarded as compulsory elements in our in-service training.
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003
how l
Figure 3 Care pathway for dysfluent children
Italics = COMPULSORY ELEMENTS
PARENTAL INTERVIEW
PRESCHOOL CHILD
LANGUAGE ASSESSMENTS
- Renfrew Action Picture
Test
- British Picture
Vocabulary Scales
- Comprehension
- Test of Word Finding
- Test of Word Knowledge
GENERAL OBSERVATION
- secondary features: eye-blinking, tics.
- social skills, eye-contact
- avoidance
- fear, frustration, embarrassment
- type of stutter (prolongations / repetitions)
Administer appropriate type(s) of
therapy (relate to diagnosis).
Examples include
- fluency shaping 2 3
- stuttering modification 2 3
- interaction therapy 1 2 3 4
- brief therapy / client centred 2 3 4
- cognitive-behavioural therapy 3 4
- breathing and relaxation 3 4
- Lidcombe approach 1 2
- group therapy (where
applicable)
- social communication skills
approach 2 3 4
- general advice 1 2 3 4
REVIEW
- open review
system (telephone
review?)
- to contact us after
1 month for a
progress report
and re-evaluation
- formal review
periodically (3
month / 6 month)
JOINT
ASSESSMENT
CLINICS
- refer to joint
assessment
clinic if no real
progress has
been made or
if there is a
high level of
concern
- complete
referral form
FLUENCY
REPORT
fluency
format, plus
liaison with
relevant
parties THERAPY
referral to
specialist
centre via GP
DISCHARGE
- discuss relapse
- discuss re-referral procedures
DIAGNOSIS / PROFILE OF RISK
- complete profile of risk and share with
parents, discussing prognosis
- diagnosis:
1. BORDERLINE
2. BEGINNING
3. INTERMEDIATE
4. ADVANCED
contact parents prior
to assessment for
telephone discussion
to gather broad
information and to
reinforce advice;
possibly ask them to
tape the child
(see appendix 1)
}
- LANGUAGE ASSESSMENTS
- SCREENING ASSESSMENTS
(if appropriate)
CHILD ASSESSMENT
SCHOOL AGED CHILD
SCHOOL AGED SCREENING
ASSESSMENT
referral to the speech and language therapy service
send out initial appointment with standard
dysfluency leaflet
to
be seen within
6 weeks (as soon
as possible)

treatment - 2nd Ed. Lippincott, Williams & Wilkins.

Rustin, L. (1987) Assessment and Therapy programme for Dysfluent
Children. Windsor: NFER-Nelson.
Rustin, L., Botterill, W. & Kelman, E. (1996) Assessment and Therapy for
Young Dysfluent Children: Family Interaction. London: Whurr Publishers.
Resources
Renfrew Action Picture Test by Catherine Renfrew is available through
Speechmark or Taskmaster.
British Picture Vocabulary Scales, see www.nfer-nelson.co.uk
Germans Test of Word Finding and Wiig & Secords Test of Word Knowledge
from the Psychological Corporation (www.tpc-international.com).
For further information
Michael Palin Centre for Stammering Children www.stammeringcentre.org
British Stammering Association www.stammering.org
Lidcombe www3.fhs.usyd.edu.au/asrcwww/
McGuire www.mcguire-freedomsroad.com
Starfish www.starfishproject.freeserve.co.uk
The pack has been in community clinics for approximately one year. I now
need to look at its widespread use and effectiveness and whether or not
the speech and language therapy department is meeting its standards. The
pack is being audited to assess the appropriateness of the standards and to
ensure that they remain workable. The packs availability and use may also
be extended to therapists in the special needs team and not just commu-
nity clinic therapists. I will continue to monitor the information in the pack
to ensure that it remains in line with current theories and practice.
Overall, I am pleased with our progress over the last three years, and
look forward to continuing to develop the service for young children in the
Portsmouth area. From my recent work, I would strongly recommend a care
pathway approach when developing services.
References
Christie, E. (1999) Parental Awareness Campaign. British Stammering
Association.
Cook, F. & Botterill, W. (1999) A profile of risk for generalist therapists.
Paper presented at the Oxford Dysfluency Conference.
Guitar, B. (1998) Stuttering- an integrated approach to its Nature and
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 ;
how l
was familiar with the care path-
way approach from a previous
incarnation working for a bowel
cancer charity. There, I saw how
developing a common understanding of a framework and pathway for
treatment could bring real benefits in terms of service planning, sharing
good practice and making it easier for patients, carers and the voluntary
sector groups that supported them to shape service delivery.
My first brush with care pathways for aphasia came when I saw an item
by Lisa Hirst in the British Aphasiology Society newsletter (2001). Reading
Lisas article and examining the care pathway she had developed, some-
thing clicked.
At Speakability, my work involves a balance between the macro view
of monitoring and influencing changes in policy at a national level, and
taking the most extremely micro view in talking with people whose lives
have been turned upside down by aphasia. These are usually the children
or partners of people with aphasia who call the Speakability information
service. The onset of aphasia may have been very recent, sometimes
within the last week, or a long time ago, even ten years or more, and it
may have been due to a brain tumour, head injury or other neurological
damage, not only stroke. Sometimes my interaction is with people with
aphasia themselves, such as those confident enough to call the information
service or to take part in Speakability events, local groups, regional net-
work meetings, or one of the working parties that inform Speakabilitys
work. I am, for example, facilitating a working party to develop a
Patients Passport, a conversation support tool to enable people with
communication difficulties to maximise their consultations with their
healthcare team.
I could see a real synergy between what Speakability was doing and what
Lisa was working on. Her outline care pathway charted the integration of
many different agents for change that take part in the aphasia journey.
Here, I could see the role of voluntary organisations like Speakability,
Headway, the Stroke Association, Connect and the independent local
groups that exist around the country. A care pathway approach could
make it easier for all of us to contribute to the person with aphasias recov-
ery, long-term rehabilitation and growth. So, I invited Lisa to speak at the
2002 Mary Law Lecture, and am delighted that she accepted.
The lecture is an annual event hosted by Speakability in London and outside
the capital. In 2002 we also held the lecture in Manchester and Edinburgh.
Named after the mother of Diana Law (the founder of Action for Dysphasic
Adults, the organisation that grew into Speakability), the lectures have
come to be a litmus test for the driving issues within the charity at a given
point in time. So, in 2000, the year Speakability relaunched under its new
name, we had a visionary presentation from Professor Steven Small of the
Department of Neurology, University of Chicago entitled The Future of
Aphasia Therapy - is it just a dream? The 2001 lecture was given by
Professor David Howard of the University of Newcastle-upon-Tyne. Under
the title The Role Of Randomised Controlled Trials In Aphasia, David argued
very convincingly that to get the resources for aphasia therapy services we
have to be able to engage critics (who often hold the purse-strings) as well
as supporters of therapy. He tackled some of the ground that underpins the
care pathway: does aphasia therapy work?; what sort of interventions
work with whom?
For Speakability, these questions about the efficacy of any particular
form of treatment, therapy or intervention are absolutely critical. The
organisation has no vested interest other than to see that people affected
by aphasia - principally the person with the condition, but also their families
as their main supporters - get the best deal. We take a broad, holistic
approach, as outlined in our campaign document, Joined Up Talking,
Joined Up Working. We are obviously concerned with speech and lan-
guage therapy, but also with earning potential, leisure activities, wider
healthcare, education and personal relationships - in fact the whole
gamut of things that keeps a person with aphasia human - not just a
patient or a tragic victim.
Space to transfer skills
As a campaigning organisation attempting to influence policy-makers and
service providers, we have to identify and understand what it is that delivers
benefit. Clearly, the overwhelming feedback we receive from people with
aphasia is that their speech and language therapy sessions were pivotal to

l
vhch way now'
Dssatsacton wth the tme, resources and evdence avaabe
or therapy or peope wth aphasa s wdespread. Reectng on
Speakabtys oo Nary law lecture, eca Yardey argues
that, when speced wthn a care pathway, communcaton
dcutes such as aphasa become measurabe and can thereore
attract resources and provde consumers wth ammunton to
press or mproved servces.
their recovery of a sense of self and their ability to rebuild communication.
But with the shortage of therapists, we need to identify components of the
therapy experience that can be replicated by family members, friends or
paid workers who are not speech and language therapy specialists. As part
of an aphasia care pathway, Speakability would press for assessment,
review and monitoring to be undertaken by speech and language therapists,
who would also consistently have space in their schedules to pass on their
approaches and transfer skills to family members. The family could then
maximise the many hours outside the therapy session and feel confident to
disseminate effective communication strategies throughout the person
with aphasias wider environment.
The audience discussions at the 2002 lectures reconfirmed what we hear
from people with aphasia and their carers, how language problems can be
sidelined and subsumed by wider issues of stroke care. Stroke care path-
ways can be quite massive, and aphasia may only get a very small mention;
and then, of course, aphasia is caused by other conditions too. But without
getting demoralised, I think that care pathways offer an opportunity to
concretise the needs of people with aphasia. Within a care pathway, aphasia
becomes something to be measured. What is measured can attract
resources. What is unmentioned lacks attention.
Many of the calls my colleagues and I take on the Speakability helpline
are about how to access speech and language therapy services. We often
hear the client end of the problem expressed so frequently by therapists -
no time, no resources. In some cases, we explain to callers how to use the
health authoritys complaints procedure in their area, to draw attention to
the lack of provision. Explicit mentions of aphasia in care pathways could
be ammunition for the would-be service user, enabling them to apply con-
sumer pressure for more resources.
The publication of the long anticipated Royal College of Speech &
Language Therapists aphasia guidelines will also help very much in this
way. Speakability will be taking part in discussions to frame the new guide-
lines, and we look forward to feeding into the process the many comments
elicited from the lecture audiences during the post-talk discussion and
post-it exercise. For this, we stuck up three large sheets with identical
generic care pathway grids divided into the phases acute, inpatient, first
few months after onset, first year after onset, long-term. The three sheets
were labelled: What do you do now? What is your ideal service? and What
stops you delivering your ideal service? The audience responded by sticking
post-its with their comments onto the grids.
There were no real surprises in response to What stops you delivering
your ideal service? Time, lack of financial and human resources and the
conflict with dysphagia work all featured very heavily. This is, of course,
grist to Speakabilitys campaigning mill, and we will take forward these
and other points raised to the Royal College of Speech & Language
Therapists guideline development discussion and to a parliamentary event
scheduled for June as part of Speak About Aphasia Month.
Thriving generic group
One of the questions raised in the discussion in Edinburgh is whether ther-
apists need to start thinking more about the generic problems raised by
language loss. A member of our Scottish audience described a thriving
generic communication problems support group. This approach has also
been successful elsewhere. Where numbers of people with any particular
condition are low, and many of their problems are shared with people with
other medical labels, this approach seems to make sense. Certainly,
Speakability is aware of a great deal of common ground between people
affected by communication difficulties whatever their cause. As a friend of
mine who has had a laryngectomy commented, Being on the edge of a
conversation is the loneliest place in the world. The people with aphasia
whom I meet seem to back that up.
One of the central points for Speakability to arise from the lecture dis-
cussion is the role of the person with aphasia in developing a care pathway.
Several participants pointed out that the whole concept of a care pathway
is alien to many patients and their carers. They commented that the way
we frame care pathways may not match the key beneficiaries ways of
viewing things at all. Interventions may not be what the person wanted at
a given time - or ever - but we tend to offer what we are able to provide
(not necessarily what, in our professional judgement, the client really
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003 8
how l
needs) and to design tick box services, perhaps more to show how active
we have been than to respond to the clients individual needs.
Various members of the audience suggested that the care pathway concept
for aphasia needed to be less prescriptively linear, and more iterative and
organic. It should be designed to allow a person to return as necessary to
earlier types of intervention, and the stages should not be delineated in
terms of passing time but according to stages of psychological readiness.
Certainly, it seemed that many of the audience felt that the main push for
language therapy sessions should often be delayed for several months
longer than is currently the standard until the person with aphasia has had
enough opportunity to adjust to their new life and reach a state of readi-
ness and receptiveness for therapy. Clearly, there is pressure from relatives
in some cases - I hear it on the Speakability helpline - for therapy to start as
soon as possible so that no time is lost and as much is salvaged as pos-
sible. But if experience in many cases shows that it is more efficacious to
wait a while, perhaps six months post-onset, why not do it that way?
And the issue about the shape of the care pathway - whether it is best
modelled as a timeline or as a more iterative structure, such as a waterfall
with opportunities to return to earlier steps - also forces us to think about
the entry points to the process. Speakabilitys caseload includes people at
all times and phases along their aphasia journey. Some people contact
Speakability within days of their relative entering hospital, others some
years after discharge or if their loved one has never been in the system.
The post-it exercise revealed that, after the flurry of activity in the first few
months, the involvement of therapists trailed off significantly. I would be
interested to explore ways of achieving slow release of the therapists
expertise over the long haul of the patient getting on with their life.
Certainly one way in which this would be possible, as many of the audience
noted, would be for the care pathway to incorporate more opportunities for
speech and language therapists to share and exchange skills with other
professionals including members of the multidisciplinary team and adult
educationalists, with whom a person with aphasia might have long-term contact.
One approach to therapy that may be particularly attractive from the
patients perspective was the practice described by some members of the
audience who offer their clients a menu of therapy options to pick from,
so that their personal care pathway is negotiated with them and cus-
tomised (as much as possible) to their specific situation. As a lay person, not
a speech and language therapist, I listened with interest. What I would
take forward from that discussion is the need to research, establish and
implement what works in the issue of timing, content and mode of deliv-
ery of therapy. In my work for the Speakability information service, I would
aim to put power back into the hands of people with aphasia and their
families by adding this angle to the briefing we provide (through literature
and over the phone) about the sorts of questions they can ask about ther-
apy options. I would use aphasia care pathways on both the macro level -
to press for more resources to be devoted to interventions that work - and
on the micro level, to discuss with people what options they have for getting
the best out of the system that they can actively shape.
I think the advantage of going through a formal process of developing a
care pathway is the opportunity to have some protected time to think
about and discuss how best to provide services for people with aphasia that
match their needs and priorities. I am delighted that Lisa Hirsts example
pathway showed voluntary sector groups as partners alongside therapists.
That is how we think of ourselves at Speakability. If you would like to
explore ways in which we can work together, please give us a call!
References
Hirst, L. (2001) Pathway of care for aphasia? British Aphasiology Society
Newsletter. May.
Useful websites
Speakability (includes how to get hold of reports from the annual Mary
Law Lecture and Joined up talking, joined up working)
www.speakability.org.uk
Royal College of Speech & Language Therapists www.rcslt.org
Connect www.ukconnect.org
Headway www.headway.org.uk
Stroke Association www.stroke.org.uk