We are very grateful to Jessica for agreeing to share her reflections with us.
My time at Airedale was spent observing Steph conducting 2 online therapy sessions and having lots of discussions in the stammering centre. Being a first-year student from Leeds Beckett University and having not yet covered the stammering module today was a huge eye opener into the world of stammering in SLT. I learnt incredible amounts, but the following are some of a few key takeaways for me.
Providing therapy online. Personally, coming from a background of creative arts therapy (workshops), therapeutic interventions online weren’t something I had considered. I was impressed to see the benefits of providing therapy this way for individuals and was something Steph and I discussed. I gained a better understanding on how providing therapy this way can be a great way for individuals to access therapy from their own environments where they may even feel more comfortable. Giving some the opportunity to try the techniques and suggestions from Steph immediately, allowing there to be less of a separation between life and clinic or therapy. This is something that I could now see myself incorporating in the future.
Anatomical explanations. I was surprised to see the amount of depth Steph went into explaining the anatomical process of speech production for her clients who stammer. While it surprised me at first, I could really see the benefit of breaking down the process of speech to explain to those who struggle to show them how complicated speech actually is! This in turn helped them understand how the interventions directly benefitted them. For example, when we know how important and complex breath is to speech production, we can learn to think about how we control it. It was a brilliant insight into how to explain the workings of our bodies to others in a simpler way while also teaching me! I made many a note for my own medical science exams!
Challenging opinions. I discovered that part of a journey of stammering is one of challenging opinions – those of our own internal dialogue and those of others. Adopting the social model can help to provide others with an understanding of differences, of helping others to change their opinions and how others can help provide a more inclusive space. ‘Learn to accept’ over ‘learn to control’.
Decision making process. She also walked me through the importance of the decision-making process when working towards clients’ aims and goals. Listening to their hopes and taking a holistic client focused approach and teaching them how to become their own therapist.
Overall, I had a wonderful observation day and feel a little more understanding of the complicated world of stammering in SLT!
We come from a stammering-affirming stance. Our role is not curative or medical but supportive and enabling. We see ourselves as allies, not experts.
Our Beliefs
•Each person who stammers should have the right to access specialist support if they want it.
•Stammering is a valid and valuable way of talking. It is a difference, not a defect or disorder. It does not need fixing.
•The problems associated with stammering largely arise from a general lack of understanding and tolerance of stammering and from negative and unhelpful responses to it.
•A person who stammers is the expert in their own stammer and has the right to choose what their therapy journey looks like.
Our Aims
•To create a space for open, non-judgemental conversations, to dispel myths and encourage acceptance and understanding.
•To support children and adults who stammer to be themselves, to speak comfortably and spontaneously and to say what they want to when they want to.
Our Vision
A world in which nobody is judged negatively, excluded, laughed at, mocked or mimicked for the way they speak.
You’ll all have seen the headlines about record NHS waiting lists. But why are they so long? Well, it might seem complex, but in my view the answer is pretty simple. It’s to do with the policy of austerity which led to swingeing funding cuts to the NHS and an ideology which has seen the increasing marketisation and privatisation of the NHS. Over the last thirteen years, since George Osborne first introduced his disastrous ideology, all NHS services have seen their funding levels fall in real terms. Speech and Language Therapy (SLT) services have been particularly badly hit since they are often seen as a soft target. Some of this is down to a lack of understanding about the very vital and life-changing services we provide, and perhaps as a profession we have not always been good at shouting out about this and resisting the ongoing erosion of our services.
Here is my explanation for how that has badly affected services to children who stammer, but the same reasoning applies to other areas of SLT and indeed most areas of the NHS.
When austerity started to bite, SLT teams were asked to do their bit to find efficiency savings, which sounds so much nicer than cuts, doesn’t it? What this meant was that specialists in a particular area, including stammering, weren’t replaced if they left or retired. In some cases, specialists were downgraded and expected to do the same specialist role at a lower grade and salary. Not surprisingly, many SLTs chose to leave the profession to do other things or set up privately.
In the Trust I work for, I have protected stammering time because of my specialist role. I am grateful that I have a manager who values the service I provide and has fought with me to retain our specialist service. That allows me to attend training and keep up to date with the most recent research and practice which I can then pass on to the rest of the team. I am able to support and train my colleagues, meaning that they are confident and skilled in working with the families of children who stammer. Our stammering service pathway is regularly updated by myself and we have a consistent approach across the team, meaning families who need our services can be sure of the same high standard of service and rapid access to support.
However, the picture is very different in the increasing number of Trusts with no stammering specialist. The loss of protected specialist stammering time is a double whammy since it also then has a knock-on effect on the wider SLT team. It has to be said that many SLTs come out of their undergraduate training with little confidence or practical skills in working with children who stammer. Those skills are often acquired once they qualify and start practising. Generalist community SLTs (a bit like the GPs of the SLT world) have the incredibly difficult job of dealing with a vast array of speech, language and communication needs, which means they have to quickly acquire a breadth and depth of knowledge covering many different areas. If there is no specialist in a particular area, e.g. stammering, then it can be difficult to access advice or support for managing those cases and no straightforward way of developing the required skills. If a team has no SLTs with experience or confidence in the area of stammering, then referrals for stammering are unlikely to be prioritised. The lack of a specialist means that the team may not have an up to date service pathway for supporting families of children who stammer in a timely manner.
Another consequence of funding cuts is that it has become increasingly difficult for NHS SLTs to access high quality training. A decade ago, SLTs were routinely given time and funding to attend training courses and be part of clinical networks, but training is one of the areas which often got cut (sorry, efficiently saved) from departmental budgets. This means that SLTs who qualified many years ago may still be using outdated and discredited approaches to stammering because they haven’t been able to keep their skills up to date.
Wider social factors, including a huge increase in child poverty and the removal of families’ safety nets and support networks (also caused by austerity) mean that there is a greater demand on SLT services than ever before. Couple this with NHS services being badly stretched across the board because of the aforementioned funding cuts and the exodus of demoralised and burnt-out staff, and you have a perfect storm. This means that those SLTs who remain within the NHS have many more children on their caseload than they can reasonably manage. It’s incredibly depressing for highly skilled professionals not to be able to offer the service they’re trained for and which they know is needed, but that is the situation NHS SLTs now find themselves in. As a consequence, more and more are leaving the NHS and the situation continues to deteriorate.
All of these factors lead to a postcode lottery, with families in some areas facing waits of up to two years to be seen, which means missing a crucial window of opportunity to prevent the stammer from developing into a problem. Here at Airedale NHS Foundation Trust, we have been trying to address this dire situation by offering low-cost training and supervision opportunities to enable NHS SLTs across the UK to develop their skills in the area, but there is a limit to what we as a small team can do.
The only proper solution to these problems is if NHS funding is fully restored to the levels of a decade ago, when the NHS was ranked number one healthcare system in the world. What a depressing comparison with the unacceptable situation we see now, created by ideological decisions from politicians whose only interest in the NHS seems to be how to profit from it.
I feel deeply for desperate families left with no help and support because of this situation. Often they are left with no choice but to go private if they can afford it (many can’t of course), but that is no guarantee of a high quality service. The private sector is generally less well regulated than the NHS, and while there are some excellent private therapists, there is nothing to stop a private provider from saying they offer a specialist service, even if their skills and experience fall far short of what an NHS stammering specialist would be expected to have. I would urge any families of children who stammer facing unacceptably long waits for support from their local NHS service to contact their local MP and complain. Please bear in mind that none of this is the fault of NHS SLTs, most of whom are doing their very best in incredibly difficult circumstances.
HCPC standard of performance and ethics states, “You must work in partnership with colleagues, sharing your skills, knowledge and experience where appropriate, for the benefit of service users and carers.” We are delighted to share our experience of diversifying into clinical training and hope that our learning can benefit SLTs working in other areas. With thanks to Ayesha Bibi, Leeds Beckett University SLT student, who helped to collate the data, and to all our course participants for generously sharing their feedback.
Many SLTs enter the profession with little or no placement experience in stammering. An informal audit by our department showed that about 10% of paediatric referrals are stammering-related, and yet even experienced SLTs may lack confidence in this area.
Cuts to services have meant that in many areas specialist stammering therapists have left and not been replaced. Reductions to training budgets have also made it increasingly difficult for therapists to access high-quality training. As a result, there is an inequity in services for people who stammer, which has been exacerbated by the pandemic. We know of families who have waited over a year for any kind of support and other areas where no support is available at all.
Within our specialist stammering service, we have many years’ experience in delivering services digitally. We decided to apply this experience to offering accessible and affordable online training to SLTs. Our aim was to increase the confidence of SLTs and develop their skills, enabling other NHS Trusts to standardise their dysfluency service. We hoped this would help to address the variance in service quality across regions.
Adopting a PDSA (Plan, Do, Study, Act) model, in October 2020 we piloted a free half day course for NHS SLTs – Introduction to Working with Children who Stammer. We chose to use Zoom for its reliability, ease of use and features such as break out rooms, screen sharing and instant polling. 280 SLTs from every region of the UK applied. The first 100 applicants attended free of charge, and we then repeated the course twice more with a small charge to cover our costs. Following the initial free course, we asked attendees, “If there had been a charge for the course, what difference would that have made?”
My Trust would have paid
I would have paid (what is the maximum you would be willing to pay?)
I would not have attended
Only a third of respondents said their Trust might have paid, and a third said they would not have been able to attend. The average amount SLTs were prepared to pay themselves was £20-£25. Although we would have liked to continue to offer the training free of charge, that was sadly not possible. We calculated that for £20 per person, we could cover the costs of running future courses. We also decided to offer the training to final year SLT students at a cost of £10 and to open it up to independent (non-NHS) therapists at a comparable rate to that charged by other training providers.
We received 223 responses to our post-course evaluation, which we administered and collated using Survey Monkey.
“Dysfluency CPD in my Trust has been pretty much non-existent. This is the training I’ve been asking for! Thank you.”
“I’m leaving this session feeling so much more confident about my work with families, which I feel will help me be a better therapist.”
“A great mix of reassurance / fresh ideas and discussion – for the first time in a long time it has reminded me that I do actually love my job and am a good SLT! That is huge.”
“It’s really had a huge impact on my practise.”
97% of respondents agreed with the statement, “As a result of the training, I feel more confident in working with children who stammer.” At the beginning and end of each of our courses, we conduct an instant poll around levels of confidence. Participants’ confidence levels have always increased by the end.
We worked collaboratively with service-users, inviting people who stammer and parents of children who stammer to contribute to our courses. This aspect of the training is one of the most valued by attendees.
“It was amazing to hear parents’ stories as well as it opened up the side of the speech and language experience that we often don’t ever see or hear about.”
“Brilliant presentations from parents – not often you can have such an open discussion with people that have already been/going through the same journey as the family we encounter at work.”
We asked participants how they felt online training compares to face to face training.
“It was excellent – the breakout rooms are really effective and it still felt like a cohesive group who were happy to share and discuss. The management of the technology was outstanding – everything worked smoothly.”
All respondents felt online worked just as well as if not better than face to face training, citing advantages such as comfort, accessibility, affordability, no travel time or expense, easier for childcare, less time out of clinic. Many participants said they would not have been able to attend had it been face to face. The main disadvantage cited was the lack of interaction and networking opportunities, although most people felt the breakout rooms helped to address this and give some time for discussion.
Several months later, we asked participants, “What are you doing differently as a result of the training?” Common themes included use of language, incorporating the social model and acceptance of stammering, the importance of supporting parents and teachers, and knowing where to signpost.
“I’ve changed the way I talk about stammering with parents. I have changed the way I talk about the communication chain. I’ve changed my approach to taking a case history.”
“I am very much thinking about the language that I use with parents. I have been more aware of trying to think about how parents must be feeling and the importance of not rushing to give them all the facts, but walking with them through the journey of acceptance and responding to how they are thinking and feeling at that time.”
“Really thinking about reducing parental anxieties. Not assuming that teachers know about stammering. Being flexible is key and family-centred I think, but care pathways don’t always allow this so it is thinking about care pathways and what is really beneficial.”
“Practise has changed – aim of therapy is now for the stammer to never be a problem for the child / young person and that whilst therapy at a young age (if deemed necessary) may reduce stammering, it is all about making stammering ‘easier’.”
“Since my colleague and I attended the ‘Introduction….’ refresher course, we have revised/improved our Dysfluency Pathway, and from next year this will include an annual 5-session summer course for children and parents, that can be accessed year on year if required.”
41 out of 44 SLT students who attended the course agreed with the statement: “The training has increased my interest in wanting to work with children who stammer.”
Hanka, SLT student from City University, told us,
“The workshops added a great value and insight to the stammering module that I participated in as a part of the Uni course. It allowed me to extend my knowledge from the lectures by learning about real experiences of children who stammer and their parents and teachers.”
We have provided follow-up individual and group clinical supervision sessions, during which we’ve discussed management of tricky cases and issues such as working with anxious parents and educating teachers.
Lowri, SLT from South Wales, told us,
“At a time when I felt isolated working within dysfluency, clinical supervision was limited and the training budget was reduced, these very reasonably priced training sessions were priceless! The clinical supervision sessions and training have truly been ‘life changing’ for me. At 46 for the first time in my life I feel like a great therapist, with sound theoretical knowledge. I now have a plan on how to move forward with my own complex cases with additional strategies and knowledge on how to approach others which may come my way. I feel empowered, reassured and confident to provide a specialist service for pupils who stammer.”
Building on our learning, we have continuously improved the content and technical delivery of our training offer. As a result of feedback about what further training would be useful, we developed several follow-up courses, including working with teenagers and adults who stammer.
15 months after first trialling our online training, approximately 550 SLTs and SLT students from every region of the UK have attended a training or supervision event. We now have an annual timetable of courses and are also providing bespoke training to whole teams.
Feedback following each course has been overwhelmingly positive, and we now have robust evidence that this online training is helping to increase the confidence of SLTs working with people who stammer and improve their practice.
“an excellent way of sharing knowledge and helping professionals to feel enthusiastic and more competent in this area.”
Key Learning Points
High-quality training can be successfully delivered online.
Follow-up supervision can help to embed the learning.
Learning from this initiative is easily transferable. The same model could be adopted by specialist SLTs with expertise in other areas to upskill our current and future workforce, helping to reduce postcode lotteries and improve the lives of the populations we serve.
We welcome feedback and comments. Please get in touch if you would like to discuss any of the above.
Steph Burgess, Clinical Lead for Dysfluency, Airedale NHS Foundation Trust airedale.stammeringtherapy@nhs.net
Airedale Stammering Centre 