Speech Therapy Services (Hansard, 12 March 1990)

§ Mrs. Ray Michie (Argyll and Bute)

I am grateful for this opportunity to raise the subject of speech therapy services. While I appreciate that the Under-Secretary of State for Health will only be able to answer primarily for England and Wales—and I would not have it otherwise, because Scotland is supposed to run its own Health Service—the generality pertains to the whole of the United Kingdom.

The Minister may be aware that my interest in the provision of speech therapy services stems from my membership of the College of Speech Therapists, and I have the honour to be one of its vice-presidents. Prior to entering the House, I was a practising speech therapist, and managed the service for the Argyll and Clyde health board.

The organisation of speech therapy services has evolved over the years. Prior to 1974 they were managed by local health and education authorities. After 1974, they came under the auspices of the National Health Service. That was a good move, because it provided an opportunity to develop a comprehensive and integrated service for both NHS patients and education departments. The latter was of prime importance to the thousands of children requiring help with their speech.

Between 1974 and 1980, speech therapy managers developed the service in each health authority or health board. Some had greater success than others, depending on available resources. But the model was there for allowing the employment and deployment of speech therapy manpower offering a variety of expertise and specialisms to meet the large number of different communication problems. They ranged from learning difficulties and stammering to patients suffering from strokes, head injuries, cleft palates, and Parkinson's disease, to name but a few examples.

The model also provided wide clinical opportunities for student training and the sharing of expensive equipment. Most important of all, it encouraged a team approach throughout an area, providing valuable support, in particular, to speech therapists who have to work on their own. Many still do so, particularly in rural areas.

Unfortunately, since 1980, the profession has been caught up in a series of NHS reorganisations and restructurings that have done nothing for continuity. On the contrary, they have led once again to fragmentation of management and of provision. No sooner had people adapted to one restructuring and tried to manage with it than they found themselves being overtaken by yet another.

I stress that this is a small profession. Even fully staffed, it will always be small in the context of the large numbers of people employed in the Health Service. It is therefore not sensible or cost-effective, nor is it an indication of good man or woman management, to allow the profession to be broken up into little bits and pieces at unit, sub-unit or locality level, each trying to do its own thing and still service the wide range of problems. It really is a very narrow and restricted outlook that leads to the belief that every service and profession in the National Health Service can or should be delivered in the same way.

131 The results of the most recent research—carried out by Enderby and Davies, and funded by the Department of Health—were published in the December 1989 issue of the "British Journal of Disorders of Communication." That research concerned, in the first place, the size of the speech and language impairment problem. The results indicated that in the United Kingdom there are 2..3 million people with a speech and/or language disorder. Of those, 800,000 have a severe communication difficulty; in other words, they have difficulty in making themselves understood by anyone other than their immediate family. Then there are 1.5 million who have a moderate communication disorder—that is, a speech and/or language problem that is noticeable to the lay person.

Enderby and Davies estimate that, under present patterns of speech therapy provision, 26 qualified speech therapists may be required per 100,000 of the population. This is four times as many therapists as are currently employed. There has certainly been growth in the numbers and service since 1972—most of it took place between 1974 and 1980—but the expansion has not kept pace with the need and with the realisation of what a comparatively young profession can do. The Minister will say that extra money has been put into the service, and that there has been an increase in the number of therapists. I appreciate that, but it does not meet the reality of the situation.

Services have developed very patchily. For example, Government figures indicate a variation in provision from 22 speech therapists per 100,000 in Hampstead to two per 100,000 in Hereford—to say nothing of the Greater Glasgow health board area, where 18 speech therapy posts have been frozen or are unfilled because of financial constraints. The average figure is 5.9 therapists per 100,000 people: no improvement on the Quirk report, which, in 1972, almost 20 years ago—on figures based on hospitals alone—suggested that it was necessary to have six speech therapists per 100,000 of the population.

Of course, recruitment and retention of staff are of fundamental importance. Success will depend to a large extent on the provision of decent salaries. The present salaries do not reflect the qualifications, knowledge, expertise and dedication of speech therapists. They remain significantly lower than those of other professionals requiring similar qualifications. I often wonder whether this is because 98 per cent. of the people in the profession are female. Of course, in so many occupations in this country females have traditionally been low paid. On 1 December 1989, a speech therapist wrote to me, stating: I hope we achieve something for the young therapists—too late for me at the end of my career. I qualified in 1956 and after 33 years earn the princely sum—£10,974!! Good job I have a husband!! What about all the therapists who cannot call on their husbands for help?

It is vital to retain an open self-referral system. That does not mean writing a blank cheque. The system is already restricted by the number of therapists available and the size of the budget allocated. Sadly, there is still a great deal of ignorance, which is not confined to the general public but is evident also in the medical profession where, if it were left to people in the profession to refer, many patients would be missed or ignored. That will continue unless the therapist can continue accepting open referrals and retains the right to assess, treat and discharge 132 his or her patients. Too often those who think that they should refer patients to speech therapists say, "Oh, they will grow out of it", or, "Nothing can be done."

I am deeply worried about a proposal to meet the need on the cheap by introducing a three-tier profession. It will not work and will mean a downgrading of the profession and the service available. I shall try to explain why. At present, there is a speech therapy helper or assistant grade, but it has never been successful on an extensive basis because there are not enough qualified therapists to supervise. An assistant tends to be allocated to a speech therapist who works at a number of different locations, such as schools and health centres, and if that therapist leaves the post and it is not filled the assistant is on her own and is unable to work because there is no direction or supervision. One could argue that he or she could be deployed elsewhere, but that is unlikely to happen if the management of the service has been fragmented. To introduce a second tier of therapists, half-trained for 18 months, is certainly not the answer. I know that schools and education authorities in particular have already said that they will not accept second best for their children.

I wonder whether the Minister knows that increased secretarial help would go a considerable way towards freeing therapists to concentrate almost entirely on hands-on patient and client care. That option should be seriously considered before we travel down the dead-end road of a second tier. Whatever plans are afoot, I hope that the Minister will first consult and involve those responsible in the College of Speech Therapists. They are more than willing to help. With respect, all the civil servants in the world, excellent as they may be, cannot and should not be asked to come up with a solution, because they do not know what happens.

I am aware that members of the college met the Minister of State on 28 February and that there are to be further meetings with Department of Health officials in April. The college officials are delighted that these meetings are taking place.

The achievement of a better service must surely be treated as a separate exercise because the NHS reforms and the National Health Service and Community Care Bill, which is going through the House at the moment, do not give the answer. Speech therapy is part of the National Health Service, but which reform will increase the number of therapists? And precisely which reform will equalise the service to patients throughout the country or see to it that speech therapists are paid a salary that reflects their qualifications and expertise so that health authorities can attract and recruit women and men to the profession and retain them once they are there?

Sometimes I think that little will be achieved until there is greater understanding of the problem among the general public. The profession has certainly tried to do something about that—for example, by its excellent "Speak Week" last week, which publicised the problems of communication handicapped people.

There needs to be greater understanding by the Government and the health authorities, too, because there remains a great deal of ignorance. Ministers keep saying that the level of speech therapy service to be provided will, as now, be a matter for determination by the district health authorities, in the light of local circumstances and of their assessment of priorities and available resources. But too often health authorities and health boards tend to treat speech therapy as a Cinderella service that is of no great 133 importance because the inability to communicate is not a life-threatening disorder. Matters will not improve unless the Government demand of the health authorities that they face up to their responsibilities to the communication handicapped and provide a decent service.

No one except those affected can fully appreciate the terrible sense of isolation—the deep psychological trauma—of those who have lost the ability to communicate. No one can understand the embarrassment and turning in on themselves and hurt—what has been described by many patients as an inner death—that patients suffer when they can no longer talk even to their own families. A speech and language problem is not visible to the world outside. Dysphasia is not supported by a zimmer; a stammer is not held in a sling; a laryngectomy is not in a plaster cast.

I am grateful to the Minister for having listened. I dare to say that I am optimistic that he will have a greater understanding of the needs of the communication impaired and the speech therapy profession than any of his predecessors.

§ The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)

I congratulate the hon. Member for Argyll and Bute (Mrs. Michie), who is an expert in the field, having been a practising speech therapist, on initiating the debate. I apologise to you, Mr. Deputy Speaker, and to the hon. Lady if my voice is not what it normally should be.

This has been a valuable debate. Not only has it provided a valuable education for me—there is nothing like an Adjournment debate to focus one's attention and encourage one to learn what one can with the benefit of advice from officials—but it has given the Government the opportunity to put on record for the first time for a number of years the valuable contribution that speech therapists make. It is not a Cinderella service; it is an important service.

I would not dissociate myself from the hon. Lady's estimate of the number of people with a communication problem. She said that the figure was 2.3 million, of whom perhaps 800,000 suffer some form of severe disability. That is the order of magnitude of the problem. That is very much greater than the estimate that was made 20 years ago by the Quirk committee. The service is important, and it is increasingly recognised by the Department of Health and by the NHS.

I want briefly to refer to the expansion in the service over the past 10 years. The hon. Lady reminded the House that there has been an expansion. The record should show that expenditure on the speech therapy service in England has increased by more than 120 per cent. in real terms since 1979. That is a phenomenal increase. Between 1979 and 1988, the number of speech therapists employed in England increased by 80 per cent., and for Great Britain as a whole by 65 per cent. Those are impressive numbers, although I accept the thrust of the hon. Lady's argument that more needs to be done.

Since 1979, speech therapists have benefited from an increase in pay of 20 per cent. in real terms. It is interesting to note that the profession has recently accepted a 9 per cent. pay settlement for the 18-month period from 1 April 1989 to 30 September 1990. I appreciate the hon. Lady's 134 comments about that increase in relation to other professions, but it includes the benefit of that 9 per cent. pay rise.

I assure the hon. Lady that we are committed to a proper review of the grading structure for speech therapists towards the end of the year. We have brought that review forward at the request of the profession, and we are committed to it. I understand that, between 1989 and 1990, regional health authority plans in England suggest that the profession will be expanded by a further 5 per cent.

So much for the past. The hon. Lady rightly said that a recent study by Enderby and Davies recommended the need for a fourfold expansion of the service. She poured a little cold water on the idea of a three-tier profession, and I can understand why she did so. However, it is important for the House to appreciate that demographic factors alone will make it very difficult for us to expand the service to the extent to which she referred, a fourfold increase.

There are two things that we can and should do in relation to the expansion of the profession. First, to meet the hon. Lady's point about clerical assistance, there is a good case for expanding the number of assistants available to qualified speech therapists. There were only 40 assistants available at the most recent count, which I believe was in 1987. We can and should expand the use of assistants to relieve some of the relatively mundane and clerical tasks of the profession.

Secondly, we should discuss further with the College of Speech Therapists the introduction of another grade, perhaps less qualified than the fully qualified speech therapist, to provide appropriate assistance for the qualified members of the profession. We must be flexible in our approach, because we must further expand the service, and, without looking at other ways of increasing numbers, we shall not succeed as we all wish.

I now consider the main burden of the hon. Lady's comments, which concern the NHS reforms and the White Paper. The hon. Lady is concerned about the fragmentation of the profession. Those fears were repeated when representatives of the profession recently met my hon. Friend the Minister for Health. I do not share those concerns because we are placing on district health authorities the responsibility to plan for all aspects of the health care needs of all who live within the district boundary, and that includes the need for speech therapy.

For the first time we have placed on health authorities a clear responsibility to plan. Incidentally, we have preserved the right to local access where NHS trusts might be established. Speech therapy, like many other services, can—and I am sure will—be designated as core, or necessary, services for a local community and therefore must be provided by NHS trusts.

In most cases, when preparing a contract for speech therapy, a district health authority will be able to deal with speech therapists—the professional group to the district—as a whole. From consultations with occupational therapists, I am well aware of the fears about fragmentation. I made it plain in another debate that there is no reason for such fears. The professional group within the district can and should remain intact. It seems only sensible that contracts written by the purchasers of health care should respect that integration and cohesion necessary for planning, recruitment, morale and retention in the writing of contracts.

135 The hon. Lady referred to open referral. I assure her that we have no plans to change that. The figures show that 40 per cent. of referrals come from consultants or GPs, but the majority come from those working in the community such as health visitors, local education authorities or from individuals referring themselves for treatment. We have no plans to change that. Open referral is an important principle that should and will remain.

We have no plans to cloud or affect the clinical autonomy of the profession and the professional group operating within a particular district health authority. It is important that that should be maintained. Very often, professional groups are concerned that there is nothing specifically in the White Paper, "Working for Patients", referring to them, so they fear that they are being neglected or forgotten. The White Paper was all about introducing a new structure for the organisation of health care. It 136 contained no reference to speech therapists, and the same is true for many other professional groups, but I can offer the hon. Lady two assurances.

First, nothing in the White Paper would prejudice the provision of services by speech therapists. They are an important group, their services are needed and they will expand. Secondly, the hon. Lady laid great stress on consultation. I assure her that the Department will work closely with the College of Speech Therapists in planning the future expansion and provision of services.

It is our intention to work in true partnership and co-operation with that most important professional body to achieve what the hon. Lady and the Government seek to achieve—the expansion of the service within available resources and within the constraints of the demographic trough and to provide the best quality of speech therapy services for the greatest number of people.