BOUNDARY ISSUES (6)

An exceptional case?
Jan Broomfield considers the following scenario:
n these times of austerity, we are increasingly faced with limited resources to meet the needs of our clients. This means we must make challenging decisions. Do we offer less to all clients? Do we prioritise those requiring specialist services rather than targeted and universal, as per the triangle of need (Gascoigne, 2006)? Do we respond to demands to keep initial assessment waiting lists short, thereby opening up a duty of care for those cases requiring intervention (RCSLT, 2006, p.25) and being cognisant of the nature and needs of the caseload? Or do we instead prefer to remain nave about what awaits us and defer the initial appointments? We face these issues of prioritisation every day, whether managing a whole service, a specialist team or a personal caseload. We determine the acceptable standards for our service, including waiting lists, both from referral to initial assessment, and from assessment - which identifies a need for intervention - to the point at which that intervention can be offered. Whenever we have a staffing issue, whether covering annual leave, long term sickness, maternity leave or career break, there is juggling of resources to maximise the provision available. When this situation is short-term, it is demanding yet somehow achievable but, when it is longer term or even permanent, such as through a recruitment freeze or cuts, this is likely to result in a reduction of service standards and availability. We have a duty to conduct the assessment, as the only person who can identify a speech and language therapy clinical risk is a Speech and Language Therapist . Whether or not an individual can be helped by SLT will determine the existence of a clinical risk (RCSLT, 2006, p.25). There is a growing evidence-base which, in some cases, indicates that direct input from our services is required for effective interventions (Law et al., 2003). Further, there is emerging evidence suggesting that lengthy waiting lists may lead to less overall progress than offering intervention soon after referral and initial assessment (Broomfield & Dodd, in press). What then are the consequences of deferring initial assessment, or of delegating our directed intervention to others? These may be strategies we employ to enable us to manage increasing caseload demands within tightening resources. Where does that sit within an evidence based practice framework (RCSLT, 2009)? The Royal College of Speech & Language Therapists states that we must act in the best interests of individuals using speech and language therapy services and carry out all duties in a professional and ethical way. Further, it reminds us that we must recognise the eth-

The department you lead has a recruitment freeze and you are struggling to keep up standards of service, including waiting times. A referral comes in from a GP, and you realise the child concerned is the son of the Trusts Chief Executive Officer.
BOUNDARY ISSUES EXPLAINED The Health Professions Council Standards of Conduct, Performance and Ethics (2008) require us to behave with honesty and integrity at all times (p.14). We are reminded that poor conduct outside of your professional life may still affect someones confidence in you and your profession (p.9). Arguably, our clinical conversations and research literature do not focus sufficiently on moral principles, but they at least touch on the ethics around issues such as prioritisation and evidence-based practice. In this series we think through everyday events which receive much less attention but also need to be on our ethical radar. So, when you recognise a referral as being the son of your organisations Chief Executive Officer, and you have vacancies and are therefore not able to meet your contracts agreed waiting times from referral to assessment, what do you do? Have you already informed the Trust Board of the difficulties you are facing and the economic case for your service (Marsh et al., 2010)? You could take the view that the CEO ought to be treated like everyone else and made aware on a personal level of the impact your waiting list has on families in which case you simply add the name to the lengthy waiting list and they receive an assessment as time permits. Alternatively, perhaps falling outside of the contractual time may place the future of your service at risk. Is it ethical to prioritise this case over all others, in order to appear to be meeting the demands of the contract and the agreed service standards? As with all such ethical issues, there is not necessarily a right answer, but rather an argument to be had, and the best possible decision made, taking account of all the supporting evidence and pitfalls. Whatever you decide, it is an opportunity to raise the profile of your service in a positive way. For this reason you will wish to ensure you communicate well about the waiting time and send the appointment with lots of notice. You may also offer a short-notice cancellation, consider the likely urgency of the clients needs, or hand pick the therapist who will see the child. Any therapist who becomes aware of such a referral should consult their manager in the first instance. In the end the manager, as leader of the team, needs to be able to provide support, if challenged, to justify the decision SLTP you have jointly made. Jan Broomfield (jan@speechtherapy4kids.co.uk) is a consultant speech and language therapist and the RCSLT Councillor for Research & Development.
References Broomfield, J. & Dodd, B. (in press) Is speech and language therapy effective for children with primary speech and language impairment?, IJLCD. Gascoigne, M. (2006) Supporting children with speech, language and communication needs within integrated children's services. Position Paper. London: RCSLT. Law, J., Garrett, Z. & Nye, C. (2003) The effect of treatment for children with primary speech and language delay or disorder, The Cochrane Database of Systematic Reviews, 3. Marsh, K., Bertranou, E., Suominen, H. & Venkatachalam, M. (2010) An economic evaluation of speech and language therapy. London: Matrix Evidence. Royal College of Speech & Language Therapists (2006) Communicating Quality 3. London: RCSLT. Royal College of Speech & Language Therapists (2009) Research Strategy. London: RCSLT.

ical dimension that exists within every clinical decision taken (RCSLT, 2006, p.10). Much of the time we can adhere to our services protocols about length of waiting list and prioritisation, even though we may believe this is not ideal. Periodically, perhaps where we have a personal connection or a professional interest in a particular client, we will be faced with a dilemma do we adhere to the standard service provision, or do we make an exception? RCSLT (2006) recommends response times from referral to assessment for different client groups and clinical presentations. These go from 2 working days (extremely high risk of choking, inhaling food or inadequate nutritional intake), through 10 working days (individuals at risk of the above, or those at high psychosocial risk due to newly acquired communication difficulties or deteriorating communication skills), to within 13 weeks (at psychosocial or educational risk due to speech, language, communication difficulties) (p.199). Our contracts with funders, purchasers, commissioners and others who buy our services may stipulate different waiting times, usually shorter. When fully staffed we may manage to meet these demands but, when resources become limited, this may have to give to best meet the needs of the whole caseload.

26

SPEECH & LANGUAGE THERAPY IN PRACTICe AUTUMN 2011