HC Deb 24 November 2000 vol 357 cc607-14

Motion made, and Question proposed, That this House do now adjourn.—[Mr. McNulty.]

1.54 pm
Ms Oona King (Bethnal Green and Bow)

I am delighted and relieved to have secured this debate on speech and language therapy provision, because, since my election in 1997, I have met many families who are waging a war with the system, trying to get their children the treatment that they need. I have asked for this debate to explain directly to the Minister the frustration and injustice that many of my constituents feel. They believe, and I agree, that their children's education and life chances are being irreparably damaged because they cannot access speech and language therapy.

I would like to set out the importance of speech and language therapy, which has a basic objective: to enable people to communicate. Without effective communication, people are excluded; not just from a social conversation, but from their families, their school environment and society. If children cannot communicate properly, they cannot be educated properly.

The right to education is enshrined in many UN charters, the new Human Rights Act 1998—which came into force on 2 October this year—and the Children Act 1989. On paper, all British children receive those rights. In practice, in some areas, they do not. Tower Hamlets is one of those areas. In Tower Hamlets, the speech and language therapy service is currently operating "beyond crisis point". Those are the words of the chief executive of the Tower Hamlets health care trust, Christine Carter. She states that this is due first, to the enormity of the case loads; secondly, to the management of cultural diversity and the challenges that it brings; and thirdly, to the level of deprivation in Tower Hamlets. Other relevant factors are recruitment and retention of speech and language therapists. The shortage of trained and experienced therapists is manifest, and that includes occupational therapists, speech and language therapists and physiotherapists.

In a recent survey, the Royal College of Speech and Language Therapists found that of 276 posts advertised, only 50 per cent. were filled. Recruitment and retention is a particular problem in Tower Hamlets. Could my hon. Friend the Minister explain whether any steps are being taken to improve the training for speech and language therapists and to encourage students to take up that training? I hope that the Government will include speech and language therapists among the key worker groups which will receive help with housing in areas such as Tower Hamlets and in central London, where it is virtually impossible to buy a property if one is not exceptionally wealthy.

The strain on SLT services in Tower Hamlets is evidenced by the high number of referrals; there are at least 40 new referrals every month. Tower Hamlets has four times the national average of children with hearing impairments. The number of children with complex medical and educational needs is rising. The number of children with autism in Tower Hamlets—and across the country—is rising. In Tower Hamlets, 40 to 50 per cent. of the children referred are bilingual. That requires assessment and therapy in two languages. A consultation takes 75 minutes with a therapist and an interpreter, compared with 35 minutes with a therapist alone.

Overall, Tower Hamlets has 14 funded therapists in post, but it should have 40. The waiting time is 12 to 18 months from referral to initial assessment appointment. That means inevitably that staff have no choice but to prioritise the needs of children under the age of five. That is obviously problematic because it means that older children with serious problems no longer have access to speech and language therapy. Following cuts in the 1996-97 financial year, Tower Hamlets had to restrict SLT provision to under-11s. Even those under the age of 11 in Tower Hamlets are not always receiving therapy. More astonishingly, even the under-fives in Tower Hamlets are having to wait for about a year for assessment.

In the summer, I received a letter from Dr. Gordon Craig, of the Globe Town surgery in Roman road, about a four-year-old patient who was waiting for SLT assessment. He wrote that her hearing is poor and she is doing poorly at school. As you can see the current waiting time for a 1st appointment is 11 months and I find this extraordinary. I think if I had children I would be up in arms against this sort of delay in something that may be so potentially detrimental to the child's education. I am sure you will agree. I do agree, and I am sure that my hon. Friend the Minister agrees that we must do everything in our power to enable such children to access services that are vital to their education and life chances.

Unfortunately, in many cases, parents have to resort to tribunals to obtain the right educational provision for their children. For parents who are not familiar with the ins and outs of the civil service and government bureaucracy, the matter is further complicated; while speech therapy is provided by the health authority, overall responsibility for provision of special educational needs remains with the Department for Education and Employment. As a result, the provision of SLT is patchy; unexplained variations create a postcode lottery.

I am exceptionally pleased, however, that the DFEE and the Department of Health established a working group on SLT. The group made its report this week. It quotes the special educational needs programme of action, published in November 1998, which noted that there are difficulties in securing therapy services for children with SEN, which partly result from the different statutory responsibilities and priorities of health authorities and LEAs, and from lack of clarity over funding. The difficulties are most pronounced in speech and language therapy but similar issues apply to occupational therapy and physiotherapy. There was clear agreement on the nature of the problem but not on possible solutions. The working group did its utmost to find possible solutions. Currently, however, even where solutions are forthcoming from the Government, they sometimes do not solve the problem in the way that one might expect. For example, Stewart Harris, the head teacher of Phoenix secondary and primary school in my constituency, wrote to me stating: Phoenix … receives Standards Fund (education support, matched funding from DfEE) which enables us to theoretically employ a Speech Therapist on two days a week to work with children with speech and language difficulties who are on the autistic spectrum. The Health Authority has been unable to provide consistent staffing to enable us to develop the project properly. For instance, over a period of eighteen weeks, we have received speech and language support for only eight of these and are currently again without speech therapy for this project. That is the situation today. Mr. Harris continued: Feedback at a recent meeting with the Health Commissioner was of the view that the setting of priorities within Health depends on G.Ps. G.Ps see children with speech and language difficulties as being dealt with by health visitors and schools…It may be that greater emphasis needs to be given centrally by the Department of Health to the importance of early language development in preventing more severe difficulties emerging. Will my hon. Friend consider specifically that point about the importance of early language development within the Department's own framework and priorities?

My constituent, Mohammed Nazmul Islam, received speech therapy until three years ago. Since then, his parents have fought a protracted and sometimes desperate battle to get the speech therapy that he needs. He is an 11-year-old child with Down's syndrome. After intervention from Tower Hamlets health care trust and with the help of the chief executive and after making inquiries myself, he is now receiving speech and language therapy, but not from a trained SLT therapist. That returns me to the problem of recruitment.

To solve that problem, we need to consider the emphasis that the Department of Health places on SLT. Historically—since 1974—SLT has been regarded as either education or non-education provision. If the provision of SLT is deemed to be educational and included in part 3 of a child's statement, responsibility lies with the local education authority if the health authority is unable to provide it. In this case, the NHS is not under a statutory duty to provide SLT.

The experience of many parents is that their children's statements do not specify the level of provision and support necessary for the children to receive an appropriate education. That risks leaving the provision open to interpretation, reduction and, in the worst cases, misinterpretation. If statements are unclear, they are unenforceable. There is an incentive for hard-worked, over-stretched and cash-strapped LEAs not to specify provision, because if they do, they will bind themselves to long-term financial commitments. So I should like to know whether the Government will issue LEAs with clear guidance on good practice that goes beyond the existing SEN code of practice, which includes guidelines on the provision of speech therapy.

Currently, the link between health authorities and education legislation is somewhat tenuous, partly because of the fundamental differences in principles and access. We know that, in health care, there has to be rationing. However, in education, everyone is, in theory, supposed to have an automatic entitlement. The chief executive of Tower Hamlets health care trust believes that her department and the LEA work well together in endeavouring to provide SLT to children. But she would be the first to say that the shortage of speech therapists makes it impossible for them to fulfil the statements.

The Government are taking the problem very seriously. They need to close what might be described as the co-operation gap in SLT provision. I warmly congratulate the DFEE on this week's announcement that extra support will be made available to help LEAs enhance their SLT services in partnership with the NHS and the voluntary sector. Some £10 million is being made available under the standards fund to support pilot SLT projects.

I hope that what the headmaster of Phoenix school said illustrates the problems that we face in practice and that the Government's excellent initiatives—which put money where our mouth is—help to solve the problems that children experience. I urge the Minister to take forward those initiatives.

Mr. Deputy Speaker (Mr. Michael Lord)

Order. I gently remind the hon. Lady that she should address the Chair.

Ms King

Thank you for that instruction, Mr. Deputy Speaker.

I should be most grateful to the Department of Health if it would look at the problems that exist between its provision for children and the provision made available by LEAs so that children in areas such as Tower Hamlets, where there are multiple indices of deprivation, can receive the speech and language therapy that will give them a fair chance in life.

2.10 pm
The Minister of State, Department of Health (Mr. John Denham)

I congratulate my hon. Friend the Member for Bethnal Green and Bow (Ms King) on securing this debate on the important issue of speech and language therapy services.

More than 1 million children in this country have speech and language difficulties, and adults who had no difficulties at an early age may encounter problems later in life, after strokes or other accidents. We think of speech and language therapists as working mainly with children, and it is important that intervention occurs as soon as a problem is identified, but we should not forget that older people may also need help.

Speech and language therapists work with people of all ages who have communication difficulties, and children and adults with eating and drinking problems. Children make up more than 70 per cent. of their work load, as there are about 1.2 million children with speech and language difficulties in the United Kingdom.

There are many reasons why children need speech and language therapy. Speech and language delay is one of the commonest forms of developmental delay. Some children need help because of the limited opportunities in their home environment. The links between deprivation and delayed development are well documented. Some children are born with difficulties that require the attention of a speech and language therapist, such as cerebral palsy, a hearing impairment, learning disability or cleft palate.

The therapists also work with disabled babies and children who have difficulties in sucking, chewing and swallowing and those who, through accident or illness, have acquired communication or eating and drinking problems. Children with autistic spectrum disorder and specific speech and language disorder require intensive help. Other children need assistance because of delayed or disordered articulation or speech patterns, or problems with fluency, such as stammering. The demand for speech and language therapy has grown because of a combination of factors. The therapists educate and train other professionals working with children and adults who may have speech and language difficulties, and public awareness of their skills is also greater than it once was, so referrals to them have increased and are often made earlier in the child's life or, in the case of adults, sooner after the onset of their illness or condition.

Speech and language therapists increasingly work in a preventive capacity in new inter-agency initiatives, such as sure start and on track, and their role in the school setting has expanded in both mainstream and specialist schools. My hon. Friend referred to the report of the working group set up as a joint initiative by my Department and the Department for Education and Employment. The group has recommended some constructive ways of developing the links between education and health services, to improve provision for the children who need it. She will know that Tower Hamlets is among the local education authorities already receiving direct support from the DFEE's standards fund. All English LEAs will be able to use their standards fund allocation next year to enhance speech and language therapy.

A research project was carried out under the aegis of the working group, under the direction of Dr. James Law. It provided a comprehensive overview of the nature and extent of speech and language therapy in England and Wales, identifying the factors that promote effective provision. The key messages were that there was a relatively healthy level of collaboration between local education authorities and speech and language therapy services in NHS trusts and that about 60 per cent. of the children receiving the services in primary and secondary schools have a statement of special educational needs.

The research also uncovered significant variations in the provision across England and Wales, in the first instance attributable to issues within the speech and language therapy service, including problems with recruiting and retaining staff and variations in case load. I shall come in a moment to the measures that can be taken to tackle the shortage of therapists.

The effectiveness of the therapy has been demonstrated in various ways, which has led to the professional input of the therapists being more valued, again adding to the pressure on the service. Some children also now present with more complex health needs, as a consequence of improvements and changes in medical technology that have substantially improved the life chances of premature and low-birthweight babies. Many of those children experience a degree of functional impairment in childhood and beyond, and some are severely disabled with very complex health needs. It is thus likely that a speech and language therapist will be a member of the multidisciplinary team that those children require.

In Tower Hamlets—a borough with high levels of deprivation—we would anticipate a high incidence of children with speech and language difficulties. There is also a large black and minority ethnic community, which poses additional challenges to the speech and language therapists working in the borough. Speech and language therapy with bilingual children must involve interpreters and, where possible, co-workers fluent in the children's languages and familiar with their culture. At best, the speech and language therapist would be competent in their first language.

The number of therapists currently from black and ethnic minority communities is small, so the Royal College of Speech and Language Therapists will draw up a recruitment and retention strategy to tackle the issue. Work with bilingual children is, of necessity, consuming of time and resources.

I want to discuss some of the measures that can be taken locally and nationally to deal with some of the issues that my hon. Friend has raised. It is fair for me to point out that the problems that she described did not begin in the past two or three years. The failure of the previous Administration to invest sufficiently in training places led to the shortage of speech and language therapists. Although we are expanding the training capacity, it is a skilled and professional job. I am afraid that it will take time to put right the years of under-investment in this part of the national health service, as in others.

It is right and proper that decisions on local services are taken locally. We want to encourage everyone who has an interest in improving health—patients and carers, organisations representing them and the local community in general—to have an input at local level to make the changes that make a real difference to people's lives. Vulnerable people are less likely to demand provision of services. We ask all with an interest in the subject to make sure that there are programmes to improve the health of the local population.

As a Government, we have placed a requirement on every health authority to lead the local development of a health improvement programme—HIMP. The first HIMPs came into effect in April 1999. They have developed to cover a three-year rolling time frame, with part of the programme reviewed in depth each year. They articulate national priorities in a local context.

I understand that the HIMP for the East London and the City health authority deals with learning disabilities and better services for vulnerable people. There may be scope to add more about speech and language therapy specifically. We would expect HIMPs to refer to investment in speech and language therapy services if there is a local need.

I reassure my hon. Friend about her constituents' fears. Not all local priorities are set by general practitioners. It is true that we have devolved considerable responsibility for commissioning the detail of services to primary care groups and primary care trusts, but the commissioning of services must be carried out in line with the HIMP set locally. That is a process in which all the stakeholders participate and to which they must be signed up. The partners involved in drawing up a HIMP include the NHS trust, the primary care trust and the local authority—and not just its social services department. The process also involves the voluntary sector and local communities.

I expect the focus of the development of a local strategy to improve learning disability services, including speech and language therapy, to be the HIMP process. I am sure that my hon. Friend will take a close interest in that strategic process, which creates the ability to tackle local needs for services such as speech therapy if they are judged to be a priority locally. With such services, it is not possible to prescribe uniform provision nationally, because the extent and nature of local needs and existing local provision can vary widely.

When there is a health action zone, it should act as a catalyst for organisations and the local community to work together in cutting across geographical and structural barriers to speed up the process of improving health. I know that in east London the HIMP draws heavily on the work of the health action zone partnership. Improving access to services is an important priority for the health action zone and one of its early achievements can be seen in Newham where, working with Newham community trust and social services, a speech and language service is now up and running at the Shrewsbury family resource centre. That includes a drop-in service to provide direct access to speech therapy staff.

We are committed to sensible and, I hope, more dynamic ways of working for people who are more vulnerable than most. The successful development and implementation of HIMPs is critical if the goals of reducing inequality, improving health and delivering better health and social care are to be achieved. We want to secure equal opportunity of access for people who are at risk. We have made it clear that the health care needs of populations, including the impact of deprivation, will be a driving force in determining where cash goes. For example, the East London and the City health authority has received one of the best financial allocations for 1999-2000 and for 2000-01—in percentage terms, the second highest increase in England.

Although there are many pressures on the NHS, the unprecedented increase in investment that it is enjoying enables us to be more confident that, as the staff are trained and become available, we will be able to address the issues raised by my hon. Friend. Reducing inequalities will be a key criterion for allocating NHS resources to different parts of the country by 2003-04. The NHS reiterates our commitment to that.

The White Paper "Saving Lives: Our Healthier Nation" required local targets to be set for reducing health inequalities. The NHS plan makes it clear that for the first time local targets will be reinforced by the creation of national health inequalities targets to narrow the health gap in childhood and throughout life between socio-economic groups and between the most deprived groups and the rest of the country.

We need to ensure that trained staff are available to fill funded posts. The problem in many parts of the health service is increasingly not so much the lack of funding for those posts but the lack of people to fill them. The Department of Health and the NHS are now responsible for determining the number of training places in speech therapy. Responsibility and funding for that was transferred from the Department for Education and Employment in 1998. Since then, there has been an increase of 15 per cent. in training commissions. A further £21 million will be spent in the current financial year to provide additional training places for up to 490 key professionals. That figure includes funding to commission extra speech and language therapist training places. This year, we have already increased and funded 50 places over and above the NHS's commissions.

Increases in therapy and other key health professionals' training places have recently been announced in the NHS plan and there will be 4,450 more places by 2004. Work is in hand to determine how many additional speech and language therapy training places will be commissioned as a result, taking account of increased demand arising from national service frameworks and other Government initiatives. Consultants have been commissioned to carry out a labour market analysis of speech and language therapists. The results of that project will be used to inform recommendations on future commissioning numbers.

We do not want children or older people to wait to receive the services that they need. My hon. Friend will be aware of the targets on waiting times that we have set in the NHS plan. Our ultimate objective, provided we can recruit the extra staff and the NHS makes the necessary reforms, is to have a maximum three-month wait for any stage of treatment by the end of 2008. My hon. Friend will know that the NHS plan sets interim targets across the service that will lead to improvements. We have enabled people to influence the provision of local services and it is important that they exercise that capacity. We are determined to make the new systems for improving health care work in practice.

My hon. Friend made specific points about the relationship between health funding and school standards funding. I will draw them to the attention of appropriate colleagues to see whether more needs to be done. I hope she will recognise that we acknowledge the issues that she and her constituents face, but we have set in place the resources, extra training and new investment that is needed to enable us to deliver the NHS plan.

Question put and agreed to.

Adjourned accordingly at twenty-four minutes past Two o'clock.