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Commissioning highly specialist speech and language therapy services for children and young people who are deaf Table of contents 1. Purpose ............................................................................................................................. 3 2. Incidence and prevalence............................................................................................... 3 3. Any specific population groups covered by the guidance ......................................... 4 4. National policy context and guidance and implications for commissioning in England ..................................................................................................................................... 4 5. Specific risks facing this population group if communication needs are not met .. 5 6. Role of speech and language therapy in improving outcomes................................. 6 7. Key issues in relation to the care pathway .................................................................. 7 8. Workforce requirements.................................................................................................. 8 Appendix 1: Case study ....................................................................................................... 11 Appendix 1a ........................................................................................................................... 14 Appendix 1b ........................................................................................................................... 15 Appendix 1c............................................................................................................................ 16 References ............................................................................................................................. 18 Page 2 of 19 1. Purpose The purpose of this document is to support the commissioning of highly specialist speech and language therapy services for children and young people with severe to profound deafness and those with moderate hearing loss who are not making expected levels of progress despite receiving support from mainstream services. The commissioning of equitable, specialist speech and language therapy for children and young people who are deaf is problematic, particularly for those with bilateral severe to profound deafness (>70dB HL BATOD, 2006). This population includes those eligible for a cochlear implant; those who only hear sounds louder than 90 dB HL at frequencies of 2 and 4 kHz (NICE, 2009). The population has a low incidence and deafness is a long term, high need condition. The low incidence, complexity of need and expertise required from the speech and language therapist (SLT) presents commissioning challenges for its provision. This is because the service required is highly specialised and an integrated commissioning focus is required from Clinical Commissioning Groups (CCGs). Specialist speech and language therapy should complement and add to the ongoing support provided by audiological and specialist education services for deaf children, who also have a specific focus on and undertake ongoing interventions to promote the language and communication development of deaf children and young people. 2. Incidence and prevalence In the UK, there are more than 10 million people, including more than 45,000 children, with a hearing loss (Action Plan on Hearing Loss NHS England 2015, Hearing Matters 2015, actiononhearingloss.org.uk). The total number of permanently deaf children aged 0 to 19 years across the UK is at least 48,125. This figure is a 2% increase from 48,125 in 2014 and an 18% increase since 2011. It is difficult to be certain about the extent to which this increase is due to changes in demography or accuracy in reporting (The Consortium for Research in Deaf Education, CRIDE, 2015). There are 1:1,000 babies born with permanent hearing loss (over 40dBHL) in one or both ears in the UK increasing to 1:100 babies who have spent 48 hours in intensive care (www.nhs.uk, accessed 2016). Data from the newborn hearing screen supports this (Uus and Bamford, 2006); a rate of 1 per 1,000 babies screened. Of these, approximately 370 children in England are born with permanent severe to profound deafness each year and more than 900,000 people in the UK are severely or profoundly deaf (Action on Hearing Loss, 2016). However, hearing loss also develops throughout childhood, about 1 in every 1,000 children is severely or profoundly deaf at 3 years old (www.nhs.uk) and for hearing losses over 40dB, the incidence rises to 1.65:1,000 live births, presenting a possible 2.05:1,000 by 9 years of age and older (Fortnum, Summerfield, Bamford, 2001). In terms of the prevalence of severely/profoundly deaf children needing speech and language therapy input, the Cheshire & Merseyside Speech & Language Therapy Hearing Impairment Network (the Network) figures average 222 on the caseload from the 2.8 million total population. If representative, this equates to approximately 4,900 bilaterally severely to profoundly deaf children nationally in need of specialist SLT intervention. This figure increases with the inclusion of children with moderate to severe losses. The CRIDE survey report (2015), estimates that there are 9,700 severely to profoundly deaf school children in the UK. It also estimates that 10% of deaf children Page 3 of 19 use sign language in education in some form, either on its own or alongside spoken language (CRIDE UK wide survey report 2015). Twenty-six percent of the Network caseload (May 2016 spot analysis) used British Sign Language as a first or second language. Additionally, Emerson and Robertson (2010) estimate that there are 4,000 deafblind children (0-19) with ‘more severe’ co-occurring hearing and vision difficulties and up to 23,000 with co-occurring impairments. The ‘more severe’ group would face significant educational and development issues, requiring input from multi-agency services that include specialist speech and language therapy services. 3. Any specific population groups covered by the guidance This guidance covers children and young people, primarily with bilateral severe to profound deafness (>71dB). However, the guidance is not designed to exclude the number of deaf children with communication needs, but with a lower degree of hearing loss, who would benefit from the expertise of the specialist SLT. The typical population includes those who are bilaterally, severely/profoundly deaf and who have implantable devices such as cochlear implant/s or other amplification, using speech or sign. It includes those who use British Sign Language as a first or preferred language, or sign as a support system and may not have English as a first language, which presents additional complexities for their specialist speech and language therapy provision. It may also include those who have specialised audiological disorders such as auditory neuropathy spectrum disorder and those with additional and complex needs. 4. National policy context and guidance and implications for commissioning in England For deaf children and young people in England, NHS England is driving the development of population-based integrated hearing networks, combining health, education, social care, and voluntary agencies in line with the ‘Five Year Forward View’. The aim is to ‘manage networks of care not just organisations’. This is an emerging national population system/community of care approach for children and young people with hearing loss working across service providers and commissioners for areas with an annual birth rate between 15-30K. These networks are envisaged across the whole of England and include an integrated network with an auditable standardised process of system specification. Specialist speech and language therapy is an essential part of this national specification. The integrated networks are informed by the following documents: • • • • • • • NHSP Quality Assurance (2006 – 2013) Integrated Care: Our Shared Commitment (May 2013). This is a framework that outlines ways to improve health and social care integration. Best practices in family-centred early intervention for children who are deaf or hard of hearing: an international consensus statement (October 2013) Atlas of Variation in Diagnostic Services (November 2013); Reducing unwarranted variation to increase value and improve quality. This highlights variation in the provision of healthcare services. NICE technology appraisal for cochlear implantation (January 2009) Children and Families Act (2014) Action Plan on Hearing Loss (NHS England, March 2015) Page 4 of 19 5. Specific risks facing this population group if communication needs are not met Deaf children and young people have the potential for high level speech, language and communication but can present with speech and language communication needs (SLCN) due to the effects of auditory deprivation from their development in the womb onwards. Acquired deafness in the early years presents equally important challenges to ensure age appropriate language development occurs and that communication needs are supported appropriately. Deafness and SLCN are linked. If speech and language therapy for deafness is not commissioned appropriately, the language development and communication needs of this population may not be met, potentially compromising their educational, social, economic and mental health outcomes for life. Such risks for children with SLCN include costs to both society and to the individual. There is more likelihood of unintelligible speech and delayed language development (spoken and sign language), leading to poor educational attainments (since age appropriate language skills are fundamental to the acquisition of literacy). There are increased risks of experiences of bullying, challenges to mental health, emotional and behaviour difficulties, later social exclusion, abuse and poorer employment prospects, and in some cases a descent into criminality (RNID, Opportunity Blocked, 2007; Bercow Report, 2008; Children’s Communication Coalition, 2010). Known factors affecting children and young people who are deaf: 90% of deaf children are born to hearing parents with little or no experience of deafness or knowledge of how to communicate with a deaf person (Moores, 2001, NDCS.org.uk). 21% of deaf children have an additional special educational need (CRIDE report on 2015 survey). More than 40% of deaf children are estimated to have mental health difficulties in childhood/early adulthood compared with an average of about 25% for the general population (Hindley et al, 1994; Hindley, 2000, www.actiononhearingloss.org.uk) Deaf children with permanent hearing loss have been twice as likely to experience abuse as hearing children (Deaf Children at Risk: NDCS briefing paper, 2010). Between 15% and 26% of deaf children in England have a statement of special educational needs or an Education, Health and Care plan (CRIDE, 2015). Data from the Department for Education (England) in 2015 shows that nearly three quarters of deaf children (72%) started school having failed to achieve a good level of development in the early years’ foundation stage assessment. Similarly, data shows that only 41% of deaf children in England have left secondary school having achieved the government’s expected national GCSE benchmarks. This compares with 64% of children with no identified special educational need. Hearing loss can impact on the development of language in children, reduce chances of employment, restrict aspirations and life chances, increase the risk of mental health problems and interfere with peoples’ ability to care for their own and their families’ long term health conditions. This can lead to low achievement, low self-esteem, isolation, loneliness and depression (Shield, 2006). Page 5 of 19 Pre lingually deaf people are more likely to be diagnosed with a mood, anxiety, personality or developmental disorder (Black and Glickman, 2006). In the Netherlands, De Graaf and Bijl (2002) found indication of mental distress amongst 28% post-lingually deaf men and 43% amongst postlingually deaf women, compared with 22% and 27% in the general population. 6. Role of speech and language therapy in improving outcomes The deaf population is heterogeneous in aetiology and presentation, with multifactorial influences on expected outcomes for an individual child. The documented research evidence for speech and language therapy intervention for this population reflects this complexity with the existence of many small, pre and post intervention research studies indicating positive outcomes as the result of intervention. The expertise of the specialist SLT is in choosing and implementing appropriate intervention for an individual child taking into account their profile and implementing therapy in the context of the wider multi-agency team. The role of the specialist SLT for deaf children is as part of this multidisciplinary team: to optimise the child’s speech, language and communication abilities to their maximum potential including social and educational outcomes. The role supports the identification of the many factors contributing to a differential diagnosis and delivers care with a range of people in the child’s environment supporting access to a biopsychosocial model of care. It is a holistic model improving communication in the context of the family, nursery and school. An example of this is that specialist SLTs working in the field of deafness may carry out joint assessments of deaf clients' communication skills, for example, with a Deaf practitioner, for clients who use British Sign Language. This care supports children’s health and wellbeing. If the child’s communication needs are not supported, there is a risk of isolation and bullying. The effectiveness and efficiency of the specialist SLT provides a return on health investment by ensuring that care is given by the right person with the right skills. There are many well-documented variables that can affect the outcomes for deaf children. These include age of diagnosis, degree of hearing loss, age of amplification, use of amplification, co-morbidities, and family support and additional speech and language disorders (systematic literature review, 2016). The therapist needs to understand normal speech, language and communication development in a hearing child, understand the known factors that may affect outcomes for the individual child who is deaf, have the knowledge of different conditions in order to support or make a differential diagnosis and then design an individual programme alongside other members of the team to maximise the child’s potential for effective communication in the context of their own environment. Evidence of prevalence of these risk factors among children identified as needing speech and language intervention is provided from a spot analysis by the Network in May 2016 (further information in Appendix 1). These figures are likely to reflect statistics from other specialist speech and language therapy services. The size of the Network provides a critical mass to support the evidence in this low incidence condition. In May 2016, with a population base of 2.8 million, there were 215 severely to profoundly deaf children on the caseloads of the network specialist SLTs in the Page 6 of 19 Network. Of these, 21% were diagnosed later than the Newborn Hearing screen. Fifteen percent were referred to speech and language therapy later than 5-6 months old, 19% were amplified later than three months old. Seventeen percent had a specific language impairment (SLI), 33% had additional and complex needs, 14% did not wear amplification consistently, 22% did not have good family support and 17% had a home language that was not English. These are all factors known to affect outcomes and requiring individualised specialised care for the child from the specialist SLT. Network discharge information provides evidence of specialist speech and language therapy intervention outcomes. Discharges occur when the child’s needs have been met and the child achieves ‘age appropriate speech, language and communication skills or skills in line with the child’s other skills’, or ‘the child’s further needs are more appropriately met by other members of the wider multidisciplinary team’ or the child ‘moved area’. When the network first began there were few discharges. By 2010/11, this had increased to 18% of the caseloads who were discharged on this basis and 32% by 2015/16. Special Educational Needs tribunal decisions have supported network decisions to cease intervention due to met need without exception. This is as important as appropriate continued intervention for efficiency and effectiveness for the service and also for the children to achieve optimal outcomes. 7. Key issues in relation to the care pathway Currently, speech and language support for deaf children and young people is commissioned through different pathways such as health, education, sensory support services, individual schools or a combination of these services. Furthermore, there is little consistency as to whether the provision is generic or of a specialist nature. However, the specialist SLT is able to provide an expert contribution to the differential diagnosis between deafness and other conditions such as autism spectrum disorder, auditory neuropathy spectrum disorder, and auditory processing disorder. Part of the role is to ensure that the hearing technology provided is enabling the child or young person to sufficiently hear speech intelligibly and functionally, compared to their audiological assessments. The specialist SLT will be able to recognise the need to liaise with the audiological physician where there is a mismatch with the child, young person or adult’s actual functional hearing to enable optimum communication development, taking into account the diagnosis and/or family communication preference. This may include supplementing spoken communication with visual support, such as, for example, through sign or Cued Speech. Without this highly specialist speech and language therapy intervention, language outcomes for deaf children who may be optimally amplified, but unable to access speech effectively, will be suboptimal. An integrated care pathway for this population would help achieve quality and consistency. It should also have input from parents, service users, administrative staff, audiological scientists and audiologists, Teachers of the Deaf, Deaf practitioners, auditory implant team personnel, social care provision, mental health services and link to voluntary/charitable organisations. Key contributors to the care pathway include: • • Newborn hearing screen Multiagency Children’s Hearing Services Working Groups (CHSWGS) including Local Health Service, Local Specialist Education Service, Local Page 7 of 19 • Social Care Services, Support Group and Voluntary/charitable organisations, Deaf CAMHS Regional integrated hearing networks driven by the Department of Health Key elements of the integrated specialist care pathway include: Referral: expectation of receipt of referral as soon as identification of deafness is made to maximise the benefits of early intervention and optimise outcomes. A suggested response to referral is within 13 weeks from the date of referral. At this stage, referral is on the basis of the condition of severe or profound deafness and not on symptoms. The aim is to provide a preventative service with intervention beginning before language and communication difficulties have become established. This may be separate from the existing speech and language therapy care pathways but will need to interlink, e.g. for those who are deaf with additional complex needs. Furthermore, referrals for those deaf children with a moderate loss but who are not achieving the anticipated progress can be integrated into the pathway. Assessment: to include differential diagnosis, and ensuring inter-agency communication. Intervention: setting goals, review of progress and outcomes. Accountability: ensuring productivity, supervision, discharge and complaints processes are in place. 8. Workforce requirements Given the high needs and low incidence of this population group, the skills and expertise required are best provided by a specialist SLT. The specialist SLT is required to have additional post qualification training, skills and experience to deal competently with the severe to profoundly deaf client group as described below. The additional attributes required from an SLT who specialises in supporting deaf children and young people include: Knowledge Ongoing continued professional development evidenced by attendance at and learning from short, specialist postgraduate courses/ independent learning activities to maintain and develop own specialist knowledge and expertise in deafness. For example in phonology assessment, working with deaf people, specific conditions associated with deafness such as auditory neuropathy, amplification devices. Essential training in the area of audiology. Skills Non-verbal communication (including use of sign to equivalent of Signature level 2). Practical management of hearing aids/cochlear implants. Experience A minimum of five years post graduate experience working as an SLT, at least three of which should be working with deaf clients. Practical logistics of conducting speech and language assessments with deaf children and making necessary adaptations for hearing children. Use of family-centred intervention techniques, including making necessary adaptations to those Page 8 of 19 Detailed knowledge of the different types of hearing loss, aetiology and possible implications for individuals. Detailed knowledge of audiological tests available and understanding of the findings and implications for the individual. An understanding of how hearing technology works and the effects of environmental noise on hearing/listening. Detailed knowledge of acoustic phonetics to inform intervention and management decisions. designed for hearing children. Differential diagnosis between deafness and specific language impairment, autistic spectrum disorder, auditory neuropathy Adaptation of speech and language expectations and objectives in the context of the type and degree of hearing loss. Advanced transcription of atypical speech patterns, including on segmental features. Knowledge of spoken language (English or language of the home), Sign (British Sign Language), Sign Supported English and bilingualism. Knowledge of augmentative communication systems such as Cued Speech, Sign Supported English, Signed English. Knowledge of communication strategies that support communication between deaf and hearing people. Knowledge of typical developmental patterns for deaf children (as well as knowledge of patterns for hearing children). Knowledge of D/deaf culture. Ability to sign to equivalent of Signature level 2. Knowledge of current research evidence for this population and its application for service improvement. Page 9 of 19 If a specialist speech and language therapy service is in place, specialist advice and training can be provided for generalist SLTs, parents and families, schools, further education colleges, nursing or residential homes. This includes support to deaf children and young people who are in specialist schools that meet needs that are additional to deafness. Some deaf children and young people have severe communication needs but may have a moderate or severe hearing loss and the expertise of a specialist SLT may be needed for these deaf children and young people. In order for this to work efficiently and effectively, this tier of specialist resource needs to be in place in the first instance with referral to an integrated specialist provision. Specialists are not easy to recruit or retain. To minimise these difficulties, a local training provision within the services is recommended with access to ongoing specialist training and peer support. Appendix 1 contains a case study illustrating a network approach to service provision, which is representative of an integrated model of specialist practice and includes a pathway example. Page 10 of 19 Appendix 1: Case study What could good practice look like? How can speech and language therapy be commissioned for this population: a description of the award winning Cheshire & Merseyside Speech & Language Therapy Hearing impairment network, a current successful commissioning model. Speech and language therapy services for deaf children and young people in Cheshire and Merseyside have been successfully provided on a regional footprint for 13 years: a regional network hosted by Liverpool NHS Community Trust, and commissioned by the regional CCGs. It was runner up in the NHS Network Awards 2005 as a network fit for purpose and shortlisted for the Health Service Journal Awards 2014, winner of Liverpool Community Health Trust creativity and innovation award and leader of the year award 2014. It is currently shortlisted for the trust creativity and innovation award 2016. The specialist speech and language therapy network is a consultant-led service provided as part of the service models in each NHS Trust in Cheshire and Merseyside, supported by local health, education and social care provision. The Cheshire & Merseyside Speech & Language Therapy Hearing Impairment Network is the regional, specialist, community provider for speech and language therapy for deaf paediatric, adolescent and adult clients in Cheshire and Merseyside. The mixed urban/rural population covered is 2.8 million with an average total of 222 clients on the caseload in 2015/16. The model provides some of the most accurate long term national speech and language therapy intervention statistics for a mixed urban/rural population. Caseload expectations are 40 clients per full time specialist. The model for a 2.8 million population. It includes 1 regional consultant SLT, 1 regional advanced clinician to cover for absences (fully employed covering long term absences for 13 years), 5 specialist SLTs (equivalent), 0.5 wte admin post The network was established in 2002/3, as a result of an evidence based needs assessment carried out by the North West Specialised Commissioning Team (NWSCT). Initially, the intention was to improve the cost effectiveness of cochlear implants by providing local specialist speech and language therapy rehabilitation and equity of access where there was previously inequity of access to specialist local speech and language therapy. This remit was then extended to incorporate rehabilitation for all severely/profoundly deaf people in the region who need speech and language therapy. a) Reducing inequalities, reducing barriers, access There is access to the service for all people who are severe to profoundly deaf who live or have a GP in the area. Each network specialist SLT is based in and employed by their local NHS trust and has a flexible job description allowing them to work across the NHS Trust boundaries in Cheshire and Merseyside to meet changing needs. The flexibility across trust boundaries results in a service valued by patients with equity of access and provision. Families moving out of the area have reported provision in other areas to be more patchy and more like the provision in Cheshire and Merseyside before the network was established (see Appendix 1a). Page 11 of 19 All network specialist SLTs are required to have achieved, or are supported in working towards British Sign Language level 2 sign or above and use interpreters for British Sign Language and other languages where needed. b) Quality and performance indicators: Improving service user and carer experience and improving productivity There are three levels of intervention used in the network (outlined in the Appendix 1c), that are applied according to need and are reviewed after an episode of care. c) Outcomes The network designed a simple outcomes model using ‘Liberating the NHS: transparency in outcomes - a framework for the NHS 2012’ (now updated as NHS Outcomes Framework 2016 to 2017), highlighting domain 2 (enhancing quality of care for people with long term conditions) and domain 4 (ensuring that people have a positive experience of care). Most participating network trusts were using frameworks such as ‘Care Aims’ to inform the clinical decision-making processes underpinning the delivery of better outcomes for their service users. The network outcomes model was designed to work with and complement the principles and variations of all these existing models, using communication effectiveness targets to improve quality of life for the client and family. Parents expressed a preference to be included in discussions about identifying the desired, or ultimate, outcomes for the child or young person. The SLT assesses the child/young person’s speech, language and communication as normal and decides which of these skills need to be targeted and the appropriate interventions required to achieve the desired outcome(s). To monitor the attainment of communication effectiveness targets, progress against the target is recorded as achieved or not achieved with a simple ‘yes’ or ‘no’. The percent of the total gives commissioners percentage number of targets achieved. The data is collected as a network and can be viewed from different perspectives. In 2014, the Royal College of Speech and Language Therapists (RCSLT) carried out an appraisal of more than 60 outcome measures and frameworks against 11 criteria compiled by RCSLT members. These key criteria included the ability of the outcome measure to be used across a range of client groups, compatibility with existing tools, accessibility and ease of use. The RCSLT Board of Trustees considered the findings and the measure identified as the ‘best fit’ against these agreed criteria is Therapy Outcome Measures (TOMs) (Enderby and John, 2015). The RCSLT is developing a national database to collect and collate TOMs data from speech and language therapy services across the UK. It is not expected that TOMs will be used as a standalone outcome measure, but will be used alongside other measures and frameworks. d) Finance There is an agreement between NHS Liverpool Community Health Trust and Cheshire and Merseyside CCGs for full service costs: salary, travel, specialist resources, training to develop and maintain skills in hearing impairment. e) Activity Activity in terms of adults and children contacts and referral to treatment times are reported to CCGs monthly. Page 12 of 19 Calculating the speech and language therapy resource needed for the severely to profoundly deaf population if a network model is used (based on the Cheshire & Merseyside Speech & Language Therapy Hearing Impairment Network figures for 2015/16 to date). Area Population Current caseload Caseload per f/t SLT No. of specialist SLTs needed Additional staff included Expected contacts per annum Cheshire and Merseyside 2.8 million 222 40 5.5wte Consultant lead 1.0 wte Specialist SLT cover f/t Admin 0.5 4224 Page 13 of 19 Appendix 1a Number of specialist speech and language therapy sessions provided across Cheshire and Merseyside pre network in 2002 Page 14 of 19 Appendix 1b Cheshire & Merseyside Hearing Impairment Network Therapy Care Pathway Referral received Contact other agencies for information if required Referral accepted Initial contact within 13 weeks from date of referral (possibly with ToD) at mutually agreed time and place Decision about intervention made and discussed with parents Transfer to other SLT service Report written to family and relevant professionals Sign post to other services Discharge with information on how to re-refer Targets / programme to home / HSS / school Indirect intervention, eg training parents/setting staff development Review of speech and language development Direct intervention with child Page 15 of 19 Appendix 1c Levels of network intervention The network SLTs assess a child or adult’s communication needs and identify where there is a risk that communication is not or may not develop optimally. Appropriate intervention is then implemented at Level 1, 2 or 3. Level 1 - Advice/ information is given and the child discharged from network therapy. Example: Intervention for babies and young children as sign and/or speech are developing is usually provided through play activities but not necessarily always by the network SLT. If this support is already provided, eg by the Teacher of the Deaf, network SLT input may not be necessary and the child may be discharged. The network SLT may re-open the case following re-referral and assessment, for instance if a gap was widening rather than closing between actual speech, language and communication (SLC) development and normal SLC development. Level 2 - Intervention is delivered via others who support the child/adult in their environment, usually on a more frequent basis with guidance from the network SLT. Example: For a school child the network SLT may set a functional target and subgoals with the supporting team, train the team if appropriate, write a programme for others to follow and monitor progress after an agreed time. At this stage, a formal or informal assessment will be carried out and a new level of intervention - 1, 2 or 3 agreed with a new time frame for achievement of a functional communication target. Level 3 - The child/client needs direct, one-to-one intervention with the network SLT. Example: For a child or adult who needs to develop a new communication skill, the network SLT will set a functional target and sub-goal, provide one-to-one intervention for an agreed period of time, and monitor progress after a specified time. At this stage, a formal or informal assessment will be carried out and a new level of intervention - 1, 2 or 3 - agreed with a new time frame for achievement of the functional communication target. Supporting Evidence 1 A manager’s view is given by a former SLT service manager who wrote at the time, "SLTs acquire a wide range of transferrable skills during their training. They are equipped to manage all client groups, but require specialist support to develop their skills in each area and to give clients the best service. This applies to all client groups, especially to those which require post-graduate training in addition to experience and support, eg dysphagia and hearing impairment. The provision of speech and language therapy without specialist support in a particular area presents risks to the patient and an ineffective service both clinically and financially. SLTs have much to offer clients with HI, but are not in a position to differentially diagnose which HI clients will benefit from their input or how to help complex clients. HI is an area which requires additional specialist knowledge and skills in assessment, diagnosis and management. These skills are acquired through Page 16 of 19 extensive post-graduate training and experience. It is my view that every speech and language therapy department requires a specialist in HI, whose role is to train and support SLTs to manage less complex HI clients as well as to personally manage more complex clients. This ensures a safe and effective service for the client and a cost-effective service for the commissioner." Supporting Historical Evidence 2: Written by the Mersey Deanery We are writing as a group of Community Paediatricians in Audiology in Mersey Deanery. Most of us have been in post since the early 1990s or before, and remember the very difficult and unsatisfactory times that our deaf children experienced because of an absence of Specialist SLTs for the hearing impaired. The children received the continuing support of the Advisory Teachers of the Deaf, but these very committed professionals did not have the training, nor the resources to offer speech and language therapy. The SLTs in our individual districts had not received specialist training for deaf children, and so most would not take these children onto their caseload. Thus there was no specialist speech and language therapy provision for our deaf children. In individual cases where the services of such a professional was paramount, we were obliged to buy in these services on an individual basis. Our professional group of paediatricians felt that the situation was most unsatisfactory. We were approached as a Mersey Deanery Group in the 1990s by the Cheshire & Merseyside Specialised Commissioning Team to ask how we could improve the services for our children, who were receiving cochlear implants. With one voice, we indicated the need for Specialist SLTs for the hearing impaired, working locally in our own districts. We were most fortunate in that the Permanent Hearing Impaired Network for Cheshire and Merseyside was set up and we have been receiving the input of the Specialist SLTs for the hearing impaired from 2003. These skilled professionals have been supporting our children who have significant sensorineural hearing losses, many of whom have subsequently received cochlear implants. They also liaise closely with the Manchester Paediatric Cochlear Implant Centre*, and share the information with the multidisciplinary team including Paediatrician in Audiology, Advisory Teacher of the Deaf, and Social Worker for the Deaf. *Now known as the Manchester Auditory Implant Centre This is a pilot version of this guidance and as such is open to comment and subsequent change. 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