Our health, our care, our say: a new direction for community services

The health white paper and what it means for SLTs

Also available as a pdf

1. This paper aims to provide a summary of the key areas within the health white paper that relate to the work of speech and language therapists, highlighting many issues that SLTs need to be aware of or where they themselves need to take action locally.

2. In addition, RCSLT is working on behalf of members to support the profession at a national level by influencing the development and delivery of some of the white paper's key proposals. These actions include:

Holding a national conference that aims to inform the profession about 'Commissioning a Patient-led NHS' in London on 27 April 2006.
Hosting a seminar with the NHS Confederation on 28 March 2006 which will contribute to a joint leading edge briefing on commissioning.
Working with the Department of Health to try to influence the development of tariffs.
Working with the National Workforce Review team to inform the shift towards the new approach to planning and developing a workforce planning toolkit to support local practitioners in line with these developments.

A. Introduction

3. The new white paper and its determination to shift the resources and emphasis of health and care services from secondary to primary and community settings will result in fundamental changes to which speech and language therapists, along with the rest of the NHS, will take time to adjust.

4. ACTION/IMPLICATIONS FOR SLTs: SLTs need to think about how they can and do fit into the new environment and also how they can exploit its opportunities. There will be an increased commitment by the NHS and its commissioners to focus spending on prevention and public health and to do this with better value for money. SLTs should show how they are integral to the new approach through presenting a business case for their role. They need to show how their work and crucially its outcomes correspond with, and can help to deliver, the objectives set out in the white paper.

5. From 2007, primary care trusts will be expected to ensure that providers of community health services accord with the direction of the white paper in that service provision must be (a) equitable, fair and focused on the most vulnerable; (b) high-quality and designed around people's lives; and (c) value for taxpayers' money. ACTION: SLTs need to identify if this is the framework to be used to inform assessment of service provision (contestability). RCSLT will look at developing an audit tool to support SLT service providers and will work to try to influence commissioners to ask for evidence from the use of this audit tool.

6. ACTION: SLTs can make a good case for helping the NHS to achieve value for taxpayers' money. Faster interventions with personalised, high quality care are both a positive step for patients and mean less burden on the NHS over time. SLTs need to identify and develop outcome measures for their work (using RCSLT clinical guidelines, its publication 'Communicating Quality 3' and various position papers to inform this) but the following outcomes, endorsed by the white paper, will be used by the Department of Health (DH) as measures to structure its own goal-setting for health and social care in the Local Area Agreements (LAAs) negotiated over the next two years:

Improved health and emotional well-being
Improved quality of life
Making a positive contribution
Patient choice and control
Freedom from discrimination
Economic well-being
Personal dignity

7. ACTION: SLT services need to find out what local priorities are in the LAAs and how to influence them.

B. The white paper's context

8. Over the last few years, the Government has focused on improving hospitals: building new ones, repairing existing ones, improving standards and bringing down waiting lists. But because the large majority of people's contact with the NHS takes place outside of hospital, the next phase of its reforms will focus on improving primary care and community services. The new white paper has three key themes which fit closely with the holistic approach to social care taken by SLTs to maximise patients' communicating skills and quality of life:

Putting people more in control of their own health and care
Enabling and supporting health, independence and well-being
Rapid and convenient access to high-quality, cost-effective care closer to home

9. It also identifies three further challenges:

To meet the expectations of the public
To do so in an affordable, value-for-money way
To shift the system towards preventative and community-based care

C. Community based care

10. A new strategic direction: The Government's new direction applies to all care services provided in community settings. Specifically, these are social care, primary care (including all general practice, optician and pharmacy-based services available within the NHS) and community services provided outside hospitals by nurses and other health professionals (for example physiotherapists, chiropodists and SLTs).

11. Protecting and including the vulnerable: It is hoped that the more people have the right to choose, the more their preferences will improve services but that this will not be at the expense of those with high levels of need, for whom high-quality services must be in place and protected. ACTION: SLTs have a clear role here in supporting advocacy for, and in enabling others to work with, people with communication difficulties and this includes support in accessing to GP and other primary care services.

12. Making the vision a reality: For the NHS, between now and 2008 there will be a major continued focus on improving access to hospital care through the 18-week maximum wait target. With the quality of secondary care assured in this way, the white paper moves on to the opportunities opened up in primary care by Practice Based Commissioning (PBC) and the new tariff (Payment by Results).

13. New freedoms in primary care: Under PBC, GPs and primary care professionals - working closely with Primary Care Trusts (PCTs) - will have greater freedoms than ever before to commission health and social care services for the individual person. The AHPF is aware of concerns from members that it is not yet sufficiently clear how GPs and others will work together to identify needs and to commission services. ACTION: SLTs need to inform this process and participate in structures and systems locally if they exist.

14. The white paper goes on to say that commissioning must be centred on the person using the service. Local authorities and PCTs together will focus on community well-being, with much more extensive involvement of people who use services. They will take action when services do not deliver what local people need or if there are inequalities in quantity or quality of care.

15. From hospital to home: Staff will increasingly need to bridge hospital and community settings in their work and DH will work with staff organisations to make sure the changes are implemented in a way that is consistent with good employment practice. ACTION: SLTs are well placed to help achieve this as they are already used to working flexibly and outreaching into homes and community settings.

D. Health, independence and well-being

16. The new direction - putting the patient first, shifting care from hospital to home, and making primary care more accessible - will begin at pre-birth, through infancy and childhood, and will extend throughout people's lives into old age. Making sure that from the beginning we give our children the right start in life is particularly important to achievements.

17. Childhood: Communication difficulties can greatly affect the formation of relationships and can often lead to behavioural problems and so the recognition in the white paper both that health later in life is influenced by factors right at the start of life and that early relationships may affect later resilience and mental well-being, are welcome.

18. Disabled children: Children with severe disabilities and their families will be given improved support where they have long-term health needs and/or nursing care needs as well as improved advice and support for disabled young people making the transition to adult services. ACTION: SLTs, as professionals who already do much to smooth this transition, should seek the opportunity here to develop their role further, ensuring they highlight their role locally.

19. People of working age: Health conditions and disabilities, if not appropriately managed and supported, can lead to job loss and long-term benefit dependency. SLTs play an important role in supporting people to stay in employment or return to work. ACTION: As GP practices evolve and expand, there may be new opportunities for SLTs to become involved in advising about back-to-work strategies and supporting those returning to work.

20. Two 'demonstration sites' will be set up, focusing on people of working age who have mild to moderate mental health problems. The sites will aim to keep them in work or encourage them to return, and will produce an evidence base of effective treatment. In time, they will expand to look at people of non-working age and those with more severe mental health problems.

21. People with learning disabilities: People with learning disabilities face particular health inequalities and the NHS has not historically served them well. The best way to deliver on previous commitments to introduce regular, comprehensive health checks for learning disabled people, and so direct them into the system, will be reviewed.

22. Older people: A perennial concern is how best to meet the needs of older people, particularly those with dementia. The National Clinical director for Older People will soon be publishing plans to improve services for people with strokes, falls, dementia, multiple conditions and complex needs and for promoting healthy active life and independence for older people. If they live alone they are particularly vulnerable to isolation and loneliness and a number of pilots are currently testing approaches to support for older people, including promoting good mental health.

23. In working with both older people and those with learning disabilities, AHPs and SLTs are already adding value. Furthermore, RCSLT has an ALD network and has developed position papers on both ALD and dementia. ACTION: These can be found at www.rcslt.org and SLT services need to reference them when developing their business case.

24. Mental health: Emotional well-being and resilience are fundamental to people's capacity to get the most out of life. The variety of services provided by AHPs can all have a positive outcome on a patient's mental health. For people who are clearly exhibiting signs of mild depression or anxiety, psychological ('talking') therapies offer a real alternative to medication and SLTs can make a valuable contribution where they are supporting those with communication difficulties.

25. Prevention - NHS 'Life Check': A new, personalised service to help people assess their own risk of Ill-health will be developed incorporating, where appropriate, follow-up from more specialist services and the development of a personal health plan. The service will be developed from 2007 and will take account of the changing needs of people in their early years, childhood, early adulthood, working and later years. ACTION: SLTs will play a role in advising in an individual's health plan and in providing training and education for others. It is important that SLTs inform the Life Check process and ensure it identifies key needs, highlighting to others involved in developing a health plan the difference between purely medical and other social healthcare needs. It is also important to highlight that there will still be a significant number of individuals who will require input from an SLT and a good outcome of the Life Checks would be early identification.

E. Better access to General Practice

26. New practice models, new primary care providers: Increasingly GP practices will involve nurse practitioners and practice nurses and may include other healthcare professionals, such as therapists, and specialists to give advice on employment aspects of being sick or disabled. New models of practice are also developing including NHS Walk-in Centres and primary care practices led by nurse practitioners. New providers, including social enterprises or commercial companies, may be encouraged to offer services alongside traditional general practice. ACTION: SLTs need to be aware of these different providers and models and consider the costs and benefits of each. These and other issues will be discussed at the RCSLT Conference 'Commissioning a Patient-led NHS: what does it mean for you?' in London on 27 April 2006.

27. More choice: People give a high priority to convenient access to social and primary care that they can choose and influence. The white paper aims to give people more choice by, for instance, giving patients a guarantee of registration onto a GP practice list in their locality, and introducing incentives to GP practices to offer more convenient opening times and appointments.

28. Responsive and accessible services: Public satisfaction with primary care services is high but sometimes they are not sufficiently responsive or accessible to local communities or groups, for example in providing services to black and minority ethnic groups or in areas of high deprivation. This is a challenge for all AHPs. ACTION: SLTs need to refer to CQ3 and also to National SIG Bilingualism to develop services for BME communities and show how they support improving access to hard to reach groups.

F. Better access to community services

29. Direct payments and individual budgets: A key aim of the white paper is to give people greater say in the services they receive through better information and publicity and the introduction of individual budgets. Direct payments - which give individuals a sum of money to purchase the social care services they feel they need - will be extended to currently excluded groups and the introduction of individual budgets will be piloted. A risk management framework will be developed to enable people using services to take greater control over decisions about the way they want to live their lives. ACTION: It is important that both SLTs and the patients with longer-term conditions with whom they work are aware of these developments.

30. Access to AHPs' therapy services: Self-referral to therapist services has the potential to increase patient satisfaction and save valuable GP time. In order to provide better access to a wider range of services, DH will pilot and evaluate self-referral to physiotherapy and will consider the potential benefits of offering self-referral for additional direct access for other therapy services. RCSLT would welcome these developments in self-referral and the ability for other therapy services to refer direct to their colleagues, for instance in the stroke care pathway.

G. Support for people with longer-term needs

31. Workforce implications of higher numbers of people with LTCs: There are over 15 million people (in England) with longer-term health needs. They are a large and growing group and it is estimated that every decade, from ageing of the population alone, the number of those with long-term conditions will increase by over a million. This vision of the future is crucially important for forward planning in the AHP sector. There are important issues around workforce numbers over the medium-term and the capacity of the existing levels of AHPs to cope with the projected increase in demand on their services. ACTION: Local SLT services need to use this information to support their own workforce planning and RCSLT is developing a toolkit designed to assist the SLT profession with this.

32. More support: The white paper outlines more support for people with long-term needs to manage their conditions themselves with the right help from health and social care services. It states that if people have a clear understanding of their condition and what they can do, they are more likely to take control themselves. There will be new initiatives to support carers - including a new helpline, new respite support measures, and the creation of an Expert Carers Programme - as well as those they care for. To assist people to take more control of their own care, investment in the Expert Patient Programme will be trebled, 'information prescription' for people with long-term health and social care needs and for their carers will be developed, and assistive technologies to support people in their own homes will be developed. ACTION: SLTs work to deliver a social model of care and are therefore already well placed to support individuals to manage their care.

33. Helping individuals manage their care better: The Expert Patients Programme (EPP) provides training for people with a chronic condition to develop the skills they need to take effective control of their lives. Training is led by people who have personal experience of living with a long-term illness. The white paper announces an increase in EPP capacity from 12,000 course places a year to over 100,000 by 2012 and states that the EPP course needs to be able to diversify and respond better to the needs of its participants. The EPP also needs a sustainable financial future in the context of a developing market place and Practice Based Commissioning. ACTION: SLTs need to show how they already work to support self-care.

34. More co-ordination of health and social care: An integrated health and social care plan that will follow a person as they move through the care system, will be devised for every person who needs one by 2008. By then, all PCTs will be expected to have established joint health and social care managed networks or teams to support those with the most complex needs. ACTION: As these plans are still in the development stage and as the concept will have a significant impact on the way that SLTs work, they should engage in and inform the process leading to both the implementation of the shared health and social care plan and the establishment of managed networks.

H. Care closer to home

35. The shift from secondary to primary and community care: In the future, far more care will be provided in more local and convenient settings. People today want a service that does not force them to plan their lives around multiple hospital visits. Better technology means that treatments can now increasingly be undertaken locally and safely. The ageing population means a community-focused strategy of prevention is more efficient and affordable than relying on high-cost hospitals. Not only do AHPs provide many of the services that would be affected by this proposed shift in focus and resources but they also need to work as part of the team to appraise services that could be provided by outside of hospital settings.

36. The white paper says that in shifting more care into people's homes, over the next 12 months DH will work with the Royal Colleges to define clinically safe pathways within primary care for a range of specialties including ear, nose and throat medicine - an area where SLTs have a role working with both children (who are hearing impaired) and adults (with cancer and voice related needs). ACTION: The RCSLT and AHPF have asked to be formally engaged.

37. New care pathways: A number of new models for redesigning care pathways are being investigated and demonstration sites will be established, involving trained professionals like speech therapists, which will consider issues such as clinical governance and infrastructure requirements. DH will examine the workforce implications of receiving care closer to home as it is likely to mean a different role for many specialist staff based in hospitals. ACTION: SLTs should inform RCSLT if their service is chosen as a demonstration site. The demonstrations will also seek to determine suitable clinical protocols to eliminate unnecessary patient attendances. RCSLT welcomes these demonstrations as a very important step. AHPF is working at a national level to influence and develop the demonstrations further.

38. Intermediate care: The white paper intends to build on the progress that has been made so far to help more people benefit from supported early discharge from acute hospitals, and to ensure that opportunities for rehabilitation (among others) are explored before a decision is made about placement in residential or nursing home care. ACTION: As SLTs play an essential role in rehabilitation in intermediate care it is important that they identify the added value they create here.

39. New community hospitals: The Government's manifesto commitment to create a new generation of modern NHS community hospitals is another important development. They will provide integrated health and social care services to the local community. ACTION: SLTs should engage and try to exert influence over the shape of new services Some community hospitals are currently under threat of closure as PCTs reconfigure local services but SLTs should cite the white paper when trying to influence their PCT - it says closure should not happen in response to budgetary pressures that are not related to the viability of a facility itself.

40. Patient transport: Transport can be an enabler to accessing care and there will be improvements in transport to health and social care services. Eligibility for the patient transport service will be extended to procedures that were traditionally provided in hospital but which are now available in a community setting. The hospital travel costs scheme will also be extended.

41. Commissioning: Payment by Results creates incentives for providers to offer services in the most cost-effective manner but it needs to be possible to apply the tariff to activity outside of hospital settings. The tariff will also be 'unbundled' - current tariffs include several stages of a procedure, for example the follow-up outpatient appointments after an operation as well as the operation itself. Unbundling will break down the tariff into its constituent parts, allowing the secondary/primary care split. ACTION: The AHPF and RCSLT are working to try to influence the development of tariffs at a national level. They will require input and support from members.

I. Ensuring reforms put patients in control

42. Commissioning for those with LTCs: DH will work with partners from health and social services and their users to develop and disseminate good-practice models of commissioning for people with long-term conditions/disabled people. This will help PCTs to commission services for their whole communities and to help reduce health inequalities. ACTION: SLTs need to identify where to get this information and how it will inform local developments.

43. Practice-based commissioning (PBC): As a result of Payment by Results and patient choice, finance is increasingly flowing to where clinical activity takes place. Under PBC, where GPs have direct responsibility for managing the funds that the PCT has to pay for hospital and other care, primary health care teams will get real freedoms and incentives to work more effectively, including developing models of joined-up support within communities. PCTs will in future be expected to support health care practices that are innovative, working with them to redesign clinical pathways and secure the services that are needed locally. But where practices are unwilling or unable to make good use of PBC, PCTs will need to intervene appropriately.

44. Assessing commissioning: By 2008, the performance management systems for both PCTs and local authorities (which have thus far not adequately facilitated joint commissioning) will be synchronised. ACTION: SLTs need to identify who is responsible locally for developing the new system for performance management.

J. Making sure change happens

45. Enabling patient choice: To make sure change happens, people must be able to exercise choice and access services on the basis of high-quality information. Most of this information is already available online but these sources are not always accessible to all. During 2006 DH will review the provision of this information so that service users have what they need, when they need it and in the format most accessible to them. ACTION: RCSLT will need to raise awareness of people with communication difficulties.

46. Assessment of quality: The white paper proposes a new national scheme of accreditation for new and existing providers of specialist care in the community, ensuring safe, high-quality standards. DH will discuss further with the Healthcare Commission, the Royal College of General Practitioners and other interested parties the best means of doing this.

47. It also considers the wider need for quality assessment of primary care practices and providers. Again, DH will work with the Healthcare Commission to develop an appropriate scheme. This may well involve the Healthcare Commission in assessing and approving the professions' own accreditation schemes, where it believes these: provide a strong framework for service improvement, including holding to account poorer providers; are effective but non-bureaucratic; and meet the Commission's move towards more risk-based regulation. ACTION: RCSLT needs to ensure that it influences the Healthcare Commission to accept its professional standards and audit tools to inform this national scheme for the accreditation of provision for services. (See also paragraph 5 above)

48. Regulation: A review of the regulation of non-medical health and social care professionals has been carried out by DH and will be published in the spring. ACTION: RCSLT is working closely with the Health Professions Council in developing appropriate Continuing Professional Development tools to inform and support this work for its members. In addition RCSLT will ensure it maintains an overview of the revised arrangements for regulation to be published by DH in the summer.

49. Stronger local leadership: To improve commissioning and joint working and provide local leadership in well-being, the roles of Directors of Public Health (DPHs) and Directors of Adult Social Services (DASSs) will be strengthened. The DASS and the DPH will play key roles, with directors of children's services, in advising on how local authorities and PCTs will jointly promote the health of their local communities.

50. Developing the workforce: The white paper will mean changes for all staff working in the NHS and in social care and a fundamental shift will see better integration between the two. Increasingly, employers will plan around competence rather than staff group or profession and career pathways will be created across health and social care with staff expected more and more to have the skills to operate in a multi-agency environment, using common tools and processes. ACTION: RCSLT is working with the National Workforce Review team to inform this shift in approach to planning. The AHPF will raise concerns with ministers on workforce planning issues. The RCSLT is developing a workforce planning toolkit to support local practitioners in line with these developments.