Anna van der Gaag

The practice of complexity : Review, change and service improvement in an NHS department

PURPOSE In the last five years more and more scholars have drawn on insights from the complexity sciences as a way of understanding the process of managing and organising in the NHS differently. This paper aims to describe working methods derived from the theory of complex responsive processes, a more radical interpretation of these insights, used by a consultancy team in one NHS setting. DESIGN/METHODOLOGY/APPROACH The authors were invited to undertake this intervention over a two year period to bring about service improvement. The paper sets out a critique of systems theory, which underpins most management literature, as well as offering a critique of some of the ways that complexity theory gets taken up in the health literature. As an alternative it explores the theoretical underpinnings of complex responsive processes and gives practical examples of methods that the authors believe are more suitable for understanding the complex environment NHS staff work within. FINDINGS Working with ideas of ambiguity, paradox and complexity are not easy for staff educated in a Western tradition of linear cause and effect. However, as a result of this intervention managers and staff pointed to a much greater confidence and skill in dealing with the complex daily process of organising, which they attribute to the methods used. Although the authors make no claim that service improvement arose as a direct consequence of the methods employed, significant, observable improvements in service provision did occur during and after the consultancy intervention. ORIGINALITY/VALUE The description of working methods based on reflective and reflexive group processes, alongside more empirical data-gathering methods, is offered as a radical alternative to more orthodox ways of understanding, and attempting to work with change in the NHS.

An examination of the pattern of preschool referrals to speech and language therapy

This evaluation was undertaken as part of a UK-wide multidisciplinary audit of services to preschool children with speech and language difficulties. Information was collected via questionnaire from parents, health visitors and general practitioners from six districts in Britain. The results showed a discrepancy between the average age at which parents first noticed speech and language problems in their children (2;3) and the average age at which health visitors referred children to speech and language therapy (3;3). This is interesting in the light of new research on early communication that suggests that it should be possible to screen for communication difficulties as early as 12 months and that many language difficulties will be apparent by 2 years. The study also found that health visitor training by speech and language therapists was provided on an ad hoc basis. The paper recommends that more training should be available and it should support professionals in providing good practice based on current evidence.

How shall we be judged? Speech and language therapists in educational settings

Speech and language therapists are under ever-increasing pressure to demonstrate the value of their work, both in terms of cost to the pur chaser and benefit to the client. The work of these therapists in school settings differs significantly from their work in health-care settings, not least because of strong philosophical and organizational differences between health and education. This paper argues that the methods developed within the field of educational research are amongst the most productive in the investigation of effectiveness. It provides details of a multidimensional model which could be applied in educational settings.

Economic aspects of a therapy and support service for people with long‐term stroke and aphasia

BACKGROUND This paper considers some economic aspects of a therapy and support service for people with stroke and aphasia. This material was part of a broader evaluation of the service, which is reported elsewhere (van der Gaag et al. 2005, van der Gaag and Mowles 2005). AIMS The purpose of this part of the study was to investigate the feasibility of undertaking economic appraisal in a voluntary sector service providing therapy for people with aphasia and their families. METHODS & PROCEDURES The costs of delivering therapy and support services were calculated. These costs were compared with the costs of equivalent services in the National Health Service (NHS). The EQ-5D health-related quality of life instrument was used to calculate quality-adjusted life years (QALYs). OUTCOMES & RESULTS The cost of delivering therapy was lower than expected for a customized service of this nature. The study generated cost data for delivering therapy services, allowing some comparisons to be made with equivalent services in NHS settings. QALY data were generated for a sample of 25 clients on one of the programmes. CONCLUSIONS The economics of speech and language therapy service delivery have received scant attention in the published literature. The paper argues that decision-making about methods of service delivery can be aided by the explicit consideration of the costs and consequences of different programmes.

Speech and language therapy caseloads in seven districts in the UK

This paper provides managers and clinicians with an analysis of routine data collected by seven speech and language therapy services in the UK. Managers in seven districts in the UK of varying size and location were asked to provide information on referrals, waiting times and attendances during the six month period, and to give a breakdown of the types of intervention offered and type of clients seen. These data were aggregated and comparisons were made with existing data on speech and language therapy services. The results revealed considerable variations in prevalence, staffing ratios and client management practices. The implications for service planning are discussed.

AN AUDIT TOOL FOR HEALTH VISITORS AND SLTS WORKING WITH THE PRE-SCHOOL POPULATION

This paper will present the preliminary findings of a national Royal College of Speech and Language Therapists audit of speech and language therapy and health visiting services to the pre-school population. The audit was carried out in six districts of the United Kingdom, representing a broad range of locations and models of service delivery. The purpose of the audit was to evaluate specific aspects of the management of children with speech and language difficulties. Audit tools were applied to referral and selection procedures, inservice training and parent programmes. Preliminary findings and their implications are discussed.

What colour are the alligators?" A critical look at methods used to assess communication skills in adults with learning difficulties

This paper describes the assessment of communication skills in 120 adults with severe to moderate learning difficulties. Each subject was assessed on the Communication Assessment Profile (CASP), a new communication assessment procedure for use with this client group. Qualitative and quantitative comparisons were made between three different methods of assessment used in CASP. These included observational assessment, elicited conversation and a structured language task. The relative usefulness of each method was evaluated, and the implications for communication assessment outlined.

Reviewing the Review Process: Examining Decision-Making in Practice

A national multi-disciplinary audit showed variation in SLT practice on the decision to review pre-school children or place them on waiting lists following initial assessment. Audit evidence suggests some reasons for these differences and contributing factors are illustrated by case history examples. Current health-care policies encourage practitioners to make decision-making transparent to consumers but this process is problematic if there is a lack of evidence to support principled choice. An outline is presented to enable therapists to gather their own evidence for review outcomes in daily practice.