A therapist discusses the funding cuts and incessant policy changes that have exhausted NHS staff
“I’m a speech and language therapist, working in community services for a foundation trust. I specialise in working with children with autistic spectrum disorder, and have worked for the NHS for about 10 years.
My job involves assessing the communication and social skills of children with autism, and helping their families respond to the child’s unique strengths and needs. I also help school teaching staff adapt environments so that children can more easily access the curriculum and develop relationships with their peers.
My current department is based in a deprived area, with high demand for NHS services. Although the NHS budget recognises that such areas need more funding, our budget is too small for us to meet demand. It is also constantly changing: although the NHS budget as a whole is ring-fenced, our department has consistently seen its budgets squeezed.
Initially, there was a drive to improve efficiency locally through cost reduction. This involved cutting jobs – therapists who resigned were not replaced – and changing services: for example, closing the home-visiting service for children aged under three.
We have also had to explore new ways of working, such as group-based therapy approaches which enable us to see more patients. And we’ve pushed some clinical duties back to parents, who now need to commit to appointments and to the therapy programme of their child. We used to chase up non-attendance, but now we automatically discharge the client if they miss an appointment.
This saves money, but some of the parents we work with are affected by health or social issues that disturb their attendance at appointments. Their children are vulnerable, and need help to access services instead of being excluded.
As part of the Surestart programme, we used to work in children’s centres, which allocate free places to children over three: it was a brilliant way to identify children with communication needs and intervene early. But when Surestart funding changed, the centres stopped buying our services; and we lost another opportunity to help families with needy children whose parents were struggling to access our services.
We also had to change the way we work with schools, as our local education authority brought in new controls that limited eligibility to receive our services to children who have statements of special education needs. Schools were encouraged to allocate funds from their own money to buy extra provision for children who have no statements. This led to variation between neighbourhoods, as some schools were willing to spend the money and some were not. It also had knock-on effects on the SLT department: because schools employ us on short-term contracts, our department can only offer short contracts to therapists, limiting our ability to attract high-quality staff. On the plus side, our partnerships with schools that do find the money to pay for provision are more successful, as the schools have made an active decision to pay for our input.
Meanwhile, the government has altered its approach to the NHS – replacing performance targets with a focus on improving productivity and outcomes for clients. This has been a welcome change. We still have client contact targets to meet, but we’ve also now introduced a number of ways of measuring how much our interventions improve the client’s everyday life and how happy parents were with our service.
Around the same time, our specialised, clinical managers were replaced by general, corporate managers. This did move us towards more viable business models and create some positive effects: for example, we began measuring our outcomes, streamlining our pathways and working more efficiently, both through the packages we offered and in recording our activity. However, we often feel that non-clinical managers and commissioners don’t understand the nature and complexities of working with children. The new managers want us to create set programmes that can be applied to any client, but every child is different and needs their own package. Furthermore, managers want to reach specific, measurable outcomes, but our work involves supporting families and schools to understand a child and to come to terms with the child’s needs – making outcomes tricky to quantify.
We’ve been through the ‘Agenda for Change’, which streamlined our roles and responsibilities; the division of the old trusts into commissioners and providers; the merger with other local trusts in order to achieve foundation status; our more recent transformational phase, which is threatening to leave some people jobless; and the reality of open competition in provider services. Our department has become a more viable business and fought to maintain its focus on the quality of care, but we’ve had to drop some services to vulnerable groups of children, and therapists are on the brink of exhaustion. All this change has costs. It must result in a vision for the NHS that encapsulates our core goal: to provide an excellent service to our clients.”
Interview by Elysia Wright