1.01 In considering the large volume of evidence submitted to us, we were impressed by the rapidity with which speech therapy has established itself as an indispensable service. Providing treatment virtually unknown in Great Britain sixty years ago, speech therapy is now very widely acknowledged as vitally important in a large range of conditions, and the demand for speech therapists has for long far exceeded the supply. It might be expected that a specialism of such acknowledged value would by now have attained a very strong professional position, but in fact this is not so. There is a striking contrast between the value attached to the speech therapist's work and the ignorance, in many quarters, of the complexity, range and difficulty of that work; between the eagerness of employers to recruit speech therapists and the poor working conditions offered; between the readiness to enlist the speech therapist's help and the reluctance, in some professions, to accept her as a colleague upon equal terms. Speech therapy has always been a numerically small profession, and in recent years its growth has not kept pace even with the overt demand from employers. This has meant that the profession has inevitably had to concentrate on the most obvious problems and the most immediate needs. The individual speech therapist, contending with a heavy burden of urgent treatment cases, has rarely been afforded the opportunity to extend either her theoretical knowledge or her practical experience into new fields. At the same time the leaders of the profession, similarly preoccupied, have been unable to define the present scope of the profession's concern or to reflect upon its future potential.

1.02 We gained the impression that the speech therapy services were in a similar position to one which can occur in business when, after a vigorous start, demand for a product increases faster than the capacity to produce and there is no reserve of capital from which to finance expansion. The successful product in this case is the speech therapist herself. Capital for expansion has been lacking not only in the most literal sense, but also in the sense that the profession has been without a full grasp of its present and future role or a clear conception of the proper direction for future development. This has caused a loss of confidence which the increasing public demand for speech therapy has worsened by making the profession even more aware of the inadequacy of present services.

1.03 We are in no doubt of this inadequacy. As a result of the shortage of speech therapists, services have developed very patchily. For example, while reasonable standards are maintained in such favoured regions as London and the south east, the story is very different in regions such as the north-east in which recruitment to posts is more difficult. Even where recruitment of speech therapists is comparatively easy, it has been possible to develop some aspects of their work only to a very limited extent. This applies even to fields where speech therapy already has the most widely acknowledged usefulness. For instance, while children below school age may be referred for speech therapy if their language development is markedly delayed or abnormal, there is no provision for systematic screening; as a result, less obvious difficulties may be

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overlooked until the child reaches school or even for longer. Again, old people may be treated in hospital for dysphasia following a stroke, but resources are rarely available to seek out and treat those in the community who are at risk of losing their powers of speech because of isolation or illness.

1.04 The place of speech therapy in the management of some other disorders has never yet been fully explored. It is probable that speech therapists, in co-operation with other professions, could offer a great deal more, for instance, to the mentally handicapped and those with a hearing impairment. The relevance of speech therapy to some other less understood problems affecting human communication, such as autism and learning difficulties, has yet to be studied. To explore these questions will require clinical and academic research, but neither their training nor the organisation of their work at present equips speech therapists to make a contribution to this.

1.05 Various specialised techniques of great value have been developed which no-one but speech therapists are equipped to apply. To give an obvious example, it falls to the speech therapists to teach the technique of using "oesophageal voice" to patients whose larynxes have been surgically removed. This skill is, however, a rare one, and while it is usually available in the centres where such operations are performed, it is more difficult for the patient to obtain continuing therapy and support once he has returned home. Other examples could be cited which reinforce our impression of a very imperfect service offered to those suffering from speech and language disorders, and a profession unable at present to attain its full usefulness and stature.

1.06 A major reason for this is, as we have made clear, the shortage of speech therapists: this causes too many immediate pressures on individuals and on the profession at large. In addition, we found very considerable uncertainty, both within the profession and outside it, about its basic orientation and the proper direction of future developments. The profession has over the years fought strongly - and in our view with justification - to establish and maintain its independence. Nevertheless, one of its most striking features is the extent to which it interrelates with other professions and other disciplines. Its theoretical basis is eclectic, deriving traditionally not only from psychology and phonetics but from various aspects of medicine and from education, and in the normal conduct of her day-to-day work the speech therapist employs on the one hand medical knowledge and on the other techniques which are akin to those of education. Again, while she must co-operate with a wide variety of other professions, she is most frequently and most closely involved with doctors and teachers. Indeed relations with these two professions have led to affiliations which tend actually to cut through the speech therapy profession itself. There are at present two distinct speech therapy services, one organised under educational and the other under medical auspices.

1.07 Thus while the speech therapy profession is independent, there are good reasons why it does not stand alone: poised as it is between education and medicine, there is a constant risk of its absorption by or annexation as an auxiliary to one or the other. We say "risk" since we regard continued independence as essential for vigorous development: speech therapy needs to maintain its integrity as a profession, while retaining and indeed strengthening links with other professions and services.

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1.08 Speech therapy is not assisted in maintaining a stable equilibrium independent of both education and medicine, by a system of training which, though exacting and detailed, does not adequately reflect the complexity of the material to be mastered or the academic level at which it must be understood. Therapists are forced to protest their right to be accepted on equal terms by colleagues in other professions, on the basis of a training which does not provide equal opportunities for further study and education.

1.09 We trust that the consideration we have given to these and other problems in this report, and the recommendations we make, will be of use firstly in improving the outlook for those suffering from disorders of speech and language, and secondly in assisting the speech therapy profession and individual speech therapists, who have, by their vitality and dedication, earned the esteem of us all.

2.01 Speech therapy is a comparatively young profession. In little more than 50 years it has developed in Great Britain as a separate profession specialising in the treatment of disorders of speech and language, with its own techniques, body of specialised knowledge and code of professional behaviour. Similar developments abroad led to the foundation in 1924 of the profession's own international learned society, the International Association of Logopedics and Phoniatrics.

2.02 The story of the profession's development in Great Britain consists of three closely interwoven strands. These are: firstly, the expansion of knowledge of the communication process and the realisation that speech therapy could be helpful in a wide range of communication disorders; secondly, the evolution of a specialised training for this work; and thirdly, the birth and development of professional identity and independence. These three lines of development interacted upon and influenced one another in a complex way, growth in one area leading to an advance in another. This process still continues today.

2.03 The complexity of the profession's growth, and the fact that growth is still continuing, make it difficult to disentangle and expound the three lines of development. We decided therefore not to make the attempt, but instead to give a chronological account. For convenience we have divided this into three main sections: from the origins of the profession to 1918; from 1918 to the foundation of the College of Speech Therapists in 1945, and from 1945 to the present day. We include a description of the work of the College and of the Union of Speech Therapists and we end with a brief account of the present system of training for speech therapy.

I BEFORE 1918

Origins

2.04 With the work of men like Bell, Ellis and Sweet, the latter part of the nineteenth century saw considerable advances in the physics of sound and in studying the nature and behaviour of the human speech organs. These studies were further developed in the early twentieth century by the work of Daniel Jones and other phoneticians and by linguists such as de Saussure, who examined the nature of language as a whole.

2.05 It is only gradually that the full influence of modern studies of linguistics is being felt in the practical clinical activities of speech therapists. Originally the theories on which speech therapy was based depended to a large extent upon the studies of contemporary phoneticians on the one hand and neurologists on the other. Charles Darwin included among his interests the development of speech in childhood. From the mid 1860s Hughlings Jackson published a

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series of writings on the problems of aphasia and loss of speech, which laid the foundation for much modern research (and influenced, in particular, the work of Henry Head). Jackson's work, however, took some time to become generally known, particularly on the Continent (for example, Freud in 1897 was unable to obtain copies of his papers though he was aware of their existence). Even in Great Britain Jackson's work was not well known until the early years of the twentieth century, by which time the pioneering work of H. C. Bastian had been published. Dr. John Wyllie of Edinburgh published his classic textbook The Disorders of Speech in 1894, and his work was followed by numerous publications in Great Britain and on the Continent on the subject of the development of speech in childhood, its disorders, and loss of speech in adult life. The First World War provided Henry Head, one of the leading neurologists of his time, with the opportunity to study large numbers of patients with head injuries causing impairment or loss of the ability to use spoken language. His work attracted a great deal of attention and inspired many teachers and nurses to try to assist him in his endeavours to improve the spoken language of brain injured patients. "Speech Correctionists" or "Vocal Therapists" were appointed to hospitals, though always on a part-time and honorary basis. Head's clinical experience resulted in his Aphasia and Kindred Disorders of Speech, published in 1926.

2.06 The nineteenth-century physicians, while interested in speech disorders, did not consider that the treatment of such conditions lay within their professional competence. They turned for help, in the first instance, to the only people with practical experience in a related field - the teachers of voice production, elocution and singing. Many of these, realising their lack of scientific background knowledge, began to work closely with doctors to build up a body of knowledge of speech disorders and to equip themselves to identify and treat a variety of conditions. This early association with training for the stage has, however, left speech therapy with the unfortunate legacy of being partially identified with elocution in the mind of the lay public.

2.07 Other recruits to the new profession came from the universities and teacher training colleges, and included some teachers of the handicapped, in particular of the deaf. These brought with them the theories of educationalists such as Piaget, Montessori and Froebel. As the treatment of speech disorders developed, and particularly as the range of patients widened to include not only those with functional disorders but also the psychiatrically disturbed and the mentally handicapped, there was considerable influence from educational theory. We have seen that the beginnings of the profession depended on stimuli from medicine while undergoing influence from the insights of phonetics and linguistics, psychology, psychiatry and education. It is natural that each of these should have come to have its place in schemes for training.

The Beginning of Organised Treatment for Speech Disorders

2.08 Systematic therapy for speech disorders in Britain began in 1906, when Manchester became the first local authority to provide classes for stammering children, an example soon followed by Glasgow. The classes were staffed by teachers who had undergone a short intensive training in a method of treatment based on a period of complete silence, followed by speech re-education. It is

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interesting that the first disorder for which organised therapy was provided should be one presenting problems which still produce controversy within speech therapy (see 6.39). The first clinic to offer speech therapy to adults as well as to children was opened in 1911 at St Bartholomew's Hospital, London, in the Ear, Nose and Throat Department. A second similar clinic was opened in 1913 in the Almoner's Department of St Thomas' Hospital. This became the first hospital centre to offer clinical training in the treatment of speech defects, and from 1919 onwards was associated in this capacity with the course of training for speech therapists at the Central School of Speech and Drama.

II 1918-1945

2.09 The period between the wars was one of rapid growth for speech therapy. In 1918, the London County Council opened four speech clinics for children who stammered: other local authorities followed suit, and a number of part-time "Remedial Teachers of Speech", "Curative Speech Trainers" and "Stammering Instructors" were appointed. Stammering continued to receive a large share of attention and a number of books on the subject were published in the 1920s and 1930s. These included Appelt's Stammering and its Permanent Cure (1920), St. John Rumsey's No Need to Stammer (1923), Dr. John Fletcher's The Problem of Stuttering (1928), and The Nature and Treatment of Stammering, by Boome and Richardson (1931). This was also a period of important development in linguistics, with the work of Sapir and Bloomfield in the United States, Trubetskoy, Jacobson and the Prague School in Europe, to mention no others. The work of such thinkers as Luria in the Soviet Union becomes important at this time, and we have the fruitful interaction between linguists and psychologists that was to result in the new field of study, psycho-linguistics.

The Beginning of Professional Identity

2.10 This growth of interest presented a problem for speech therapists. The posts that were available were part-time: no full-time LEA appointments were made before about 1930. Furthermore, as no criteria of qualification or competence existed, many authorities appointed poorly-qualified therapists to important positions. During the 1930s another problem was presented by the arrival from Europe of a number of refugees qualified as speech therapists in their own countries, and the question arose of their eligibility for appointment to school clinics in Great Britain.

2.11 Speech therapists realised that if recognised standards of qualification were to be established and the interests of the profession adequately promoted, professional organisation would be essential. Two professional associations were founded in the 1930s. In 1934 the Association of Speech Therapists was formed from what had previously been the Remedial Section of the Association of Teachers of Speech and Drama. This organisation, formed principally of those therapists whose interest and experience had originated in speech training and elocution, had no journal of its own, but the journal of the Association of Teachers of Speech and Drama printed articles on speech therapy. The British Society of Speech Therapists, founded in 1935, was more medically orientated. It was backed by a Medical Advisory Council of 33 members representing all

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parts of Great Britain and all relevant branches of medicine, and a General Advisory Council of eleven members of other related professions. Admission to the Society was at first by oral examination. Its journal, "Speech", published articles on every aspect of speech therapy, including contributions from surgeons, psychologists, phoneticians and dentists as well as speech therapists, and is a valuable source for the history and development of the profession. Shortly after their foundation, both associations realised that there was no room in so small a profession as speech therapy for two organisations. The first formal meetings to discuss amalgamation took place in 1939, but were interrupted by the outbreak of the Second World War.

The Beginning of Organised Professional Training

2.12 Professional organisation would have been largely ineffectual without some recognised form of professional training leading eventually to a qualification of established standard. Most of the earliest speech therapists in effect trained themselves (cf 2.06): people from a variety of backgrounds took up the work and evolved their own methods of treatment, working from their own experience with whatever further knowledge and insight they could glean from medicine and other professions. Later, private pupils were trained by individual speech therapists. Some remarkable individuals gathered around them a number of pupils and assistants. In London, Miss Elsie Fogerty provided specialised training in speech therapy at the Central School of Speech and Drama, in association with St Thomas' Hospital, from 1919. In Glasgow, Dr Anne McAllister did pioneer work in the study and treatment of speech disorders. Working in the Glasgow University Educational Clinic, she drew students and staff from the University and training colleges: her work provided the foundation for the Glasgow School of Speech Therapy, founded in 1935. It retained its links with the educational world and in 1964 became part of the Jordanhill College of Education.

2.13 As the potentialities of speech therapy were explored and extended, the need was felt for a broader curriculum covering aspects of medicine, education and psychology and for students to have some organised provision of clinical practice. The first School of Speech Therapy on these lines was founded in 1929 at the West End Hospital for Nervous Diseases under its speech therapist, Miss Kingdon-Ward: its honorary medical director, the late Dr C Worster-Drought, was keenly interested in disorders of speech and language and his influence on the profession was great. In 1932 another school was established by Miss Beryl Oldrey which later became the Oldrey-Fleming School of Speech Therapy. These two schools offered a two-year course of training which included most of the main ingredients of the present syllabus - General Psychology, Phoniatrics, Anatomy, Biology and Neurology.

2.14 By 1935, with the foundation of the Glasgow School of Speech Therapy and the introduction by the Central School of Speech and Drama of its formal qualification, the Certificate of Proficiency in Speech Therapy, there were four established schools of speech therapy offering two-year courses of training. Three of these were predominantly medical in background and orientation. The fourth, at the Central School, continued to associate speech therapy with drama, voice production and elocution. This difference in emphasis and curriculum was a major source of division in the profession and a prime source of

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difficulty when, in 1939, the Association of Speech Therapists and the Society of Speech Therapists began to discuss amalgamation. As the then Chairman of the Executive Council of the Society said

On first consideration, it would seem to be quite a straightforward task, merely to decide what subjects a student needs to study, and how much time should be allocated to each subject. But in practice, the position is quite different and more complicated. Speech therapy requires a wide field of knowledge, and in consequence the syllabus may include many subjects which need to be studied from a special angle; it is no easy matter to decide what to include and what to exclude within each subject.

Wartime developments

2.15 While the Second World War, unlike that of 1914-18, did not present speech therapists with a new range of case problems, it had a profound effect in demonstrating the indispensability of speech therapy and in strengthening its links with other professions. The desperate situation of young men severely handicapped in speech as a result of head injuries called forth every available resource to help them: speech therapists worked with neurologists and psychologists more closely on these cases than at any time previously. Tests developed by psychologists and neurologists to apply to these aphasic patients later formed the basis for assessment procedures used and further developed by speech therapists for children as well as adults.

2.16 The immediate effect of the war on services, training and professional development was disruption, as evacuation and emergency conditions took their effect. This was soon followed by the rebuilding of services, often in improvised settings. Training continued, and a fifth school of speech therapy, the London Hospitals School, was established in 1942 (renamed in 1950 The Kingdon-Ward School, and now the School for the Study of Disorders of Human Communication).

2.17 Initially there was a drop in the number of speech therapist appointments in hospitals, but by the end of the war this had been made good by the creation of posts in the neurological units of new hospitals for service casualties (and certain civilian ones) under the Emergency Medical Service. Professor Norman Dott, neurosurgeon at the Royal Infirmary, Edinburgh, established an effective rehabilitation team for neurosurgical cases at the Bangour Head Injuries Unit, near Edinburgh. The speech therapist appointed to this team was the first full-time speech therapist in the hospital service. Sir Hugh Cairns, in charge of a similar military unit at Oxford, also employed a speech therapist. Speech therapists in this type of post were granted affiliation to the Register of Medical Auxiliaries. This was extended, in 1945, to all fellows and licentiates of the newly-formed College of Speech Therapists. At the time this development was welcomed by the profession as a desirable step in growth of professional status, carrying a guarantee of recognition and protection. Hospital service was at

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this time considered decidedly preferable to LEA employment. Miss Kingdon-Ward, writing in Speech, advised therapists seeking employment that

no elementary school clinic, valuable as is the work, will ever give you the standing with the medical and speech therapy professions in general that tenure of office in a hospital clinic will do; chiefly by reason of the limitations in the field of work implied by the circumstances, and the fact that in most cases it is entirely with children, cutting out that with adults altogether.

Foundation of the College of Speech Therapists

2.18 The discussions on amalgamation between the Society of Speech Therapists and the Association of Speech Therapists were resumed during the war and finally resolved in 1943. The enrolment of members to the new College of Speech Therapists began in 1943 and a Founders' Meeting took place in 1945. The College's aims were

to encourage research into problems concerning defects or disorders of voice and speech, to improve the facilities for scientific training, to conduct examinations for those wishing to practise the art of Speech Therapy and to maintain a high standard of professional skill and conduct, so that a supply of suitable workers may be available as the need for speech therapy is more widely understood and the demand grows.

2.19 The new College made an early approach to the Association of Teachers of the Deaf with a view to union. The teachers of the deaf in Great Britain, however, preferred separate organisation because of the disparity which they considered to exist between the academic standards of the two professions and because they felt that each already provided a sufficient area of specialisation.

2.20 A common examination syllabus for the Licentiateship of the College was produced as a basis for study at the training schools: the first students to take examinations on this syllabus qualified in 1948. The course of training was extended from two years to three, with the first part of the examination being taken after two years: the first students to complete the three-year course qualified in 1949. The examination subjects for Part I were Normal Voice and Speech, Phonetics, Anatomy and Physiology, Speech Pathology and Therapeutics I; and for Part II, Psychology, Neurology, Speech Pathology and Therapeutics II. Candidates also had to satisfy the examiners orally of their

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ability to use English effectively, and to pass a test of clinical competence. In addition they followed, but were not examined upon, short courses in Physics, Social Science, Paediatrics, Diseases of the Ear, Nose and Throat, Orthodontics and Prosthetics, and Plastic Surgery in relation to speech therapy.

Post-war growth in demand and expansion of training facilities

2.21 The growth of demand for speech therapy foreseen by the College's founders came quickly. Section 48 of the Education Act, 1944 laid upon local education authorities the duty to make arrangements for the provision of comprehensive facilities for free medical treatment for their pupils, and posts within the School Health Service were created for many more speech therapists. The National Health Service Act, 1948, encouraged the establishment of speech therapy posts in hospitals. With the passing of these two Acts the demand for speech therapists for the first time exceeded the supply: a situation which persists to the present day.

2.22 In an effort to meet the increased demand, courses have been started in six further centres since the end of the war. A full list of the eleven courses of speech therapy training, with their foundation dates, brief historical notes where changes of name, etc. have taken place, and present student capacity is given below.

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The degree course at the University of Newcastle-upon-Tyne

2.23 The first (and so far the only) degree course which qualifies its holders to practise as speech therapists is conducted in the University of Newcastle-upon-Tyne. It was established as the result of initiative by members of King's College, University of Durham, as it then was: notably Dr. M. E. Morley, Lecturer in Speech and herself a speech therapist; Professor S. D. M. Court, the Professor of Child Health, who had a deep interest in speech and its problems; and Professor J. P. Tuck, the Professor of Education.

2.24 A plan was developed to establish a small research department in speech, with the object of expanding it when finance was available into a teaching department. Because there was initial reluctance on the part of the Senate to accept a professional training course as worthy of degree status, it was several years before the plan was implemented. By the time agreement was reached on the establishment of a three-year degree course recognised by the then Ministry of Health, the Department of Education and Science and the College of Speech Therapists, it was to the new University of Newcastle-upon-Tyne that the first students were admitted in 1964. Administration of the course was undertaken by a Sub-Department of Speech, the responsibility of the Departments of Education and Child Health jointly. The degree was initially called the Bachelor of Education (Speech) until the danger of confusion with the B.Ed. of the Colleges

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of Education made it advisable to change its name to B.Sc. in Speech. Since its inception the course has expanded gradually from its original intake of 4 students to an annual intake of 15.

An Independent Profession

2.25 The impetus given to speech therapy by post-war developments, and the gain in confidence and standing from the establishment of the College to govern and regulate the profession, led to a new mood of independence. Whereas in 1945 speech therapists welcomed the inclusion of licentiates and fellows of the College on the Register of Medical Auxiliaries, a very few years were sufficient to persuade speech therapists that they were capable of standing alone as a profession.

2.26 In 1951 the Cope Report on Medical Auxiliaries was presented to Parliament. This was a compendium of the reports of 8 committees set up by the Minister of Health, under the general chairmanship of Sir Zachary Cope, to consider the supply and demand, training and qualifications of certain professions employed in the National Health Service. Those reviewed were almoners, chiropodists, dietitians, medical laboratory technicians, occupational therapists, physiotherapists, remedial gymnasts and speech therapists. The Cope Report recommended the establishment of an overall Council for Medical Auxiliary Services to maintain statutory registers of persons qualified for employment in the National Health Service and to hold wide powers on training, examination and recruitment. A Minority Report, of which the sole speech therapist included in the Cope Committees was a joint author, stated among other points of disagreement that the term "medical auxiliary" was misapplied in connection with the profession of speech therapy, that a central controlling Council directing diverse professions would be stultifying to professional work, and that the Committee's assumption that doctors could satisfactorily plan and control the curricula of training and methods of work of the professions under review was contrary to the facts.

2.27 A Working Party on Statutory Registration, on which each of the 8 professions was represented, recommended the establishment of a Registration Board for each profession to hold the main powers. Members of the profession concerned were to form a substantial majority on the boards, and there was to be a Co-ordinating Council with limited powers. In a scheme put to the professions by the Minister in 1956 this proposal was modified to reduce the majority held by each profession on its Registration Board to only one. The College of Speech Therapists found this unacceptable, arguing that only a minority of speech therapists were employed in the National Health Service and that speech therapy was already a united profession with one portal of entry, whose registers were recognised by the Ministries of Health and Education. The profession decided in 1956 to withdraw from the National Health Service Whitley Council, though this decision was reversed in 1966.

2.28 In 1959 the Professions Supplementary to Medicine Bill was introduced "to provide for the establishment of a Council, boards, and disciplinary committees for certain professions supplementary to medicine, to provide for the registration of members of those professions and for regulating their professional education

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and professional conduct and for cancelling registration in cases of misconduct; and for purposes connected with the matters aforesaid".

Speech therapists were included in the Bill at its first Reading. Explaining the status of the professions involved to the House of Commons, the Minister said,

Broadly the position is that the doctor is responsible for the prescription of appropriate treatment and the general supervision of that treatment.

2.30 In requesting to be excluded, the College of Speech Therapists told the Minister that:

Speech Therapy has achieved and established an independent professional status. It is a fully organised, united profession with a single standard of entry. It is not solely related to medicine, but has equally close association with phonetics and psychology, as well as with education. ... The aims of the College are based on the principles that speech therapy is a special discipline in its own right, in the sense of being a body of knowledge with its own terminology, theories and hypotheses regarding the structure and nature of human beings inasmuch as they use a verbal means of communication. ... It is clear that speech therapy is an independent profession and not supplementary to medicine.

Inclusion should be regarded as a privilege, not as a penalty, and entry should be by way of conviction and not compulsion.

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THE PRESENT ROLE OF THE COLLEGE OF SPEECH THERAPISTS

2.32 While under the Regulations the Health Ministers are made responsible for approving courses of training, the College of Speech Therapists has the responsibility for examining students and issuing the Diploma which, subject to limited exceptions, provides the entry to the profession. (The exceptions cover those already in the profession at the time the Regulations were framed (1954) and a very few others who have since been admitted to the Minister's list or that of the Secretary of State for Scotland.) The College is thus able to exert a crucial influence over the examination system, and over clinical standards by means of the practical examination and the requirement in terms of "minimal hours" of clinical training during the course. Though there is some variation in the options and emphases pursued by individual schools (2.44-45), the examination syllabus followed at all of them is closely modelled on that recommended by the College.

2.33 The exception is the B.Sc. (Speech) of the University of Newcastle-upon-Tyne. Qualifications for entry, like the syllabus and examination requirements for this course, are naturally prescribed by the University, which also conducts the examinations and appoints the examiners. One of the College's practical examiners is usually appointed as an external examiner by the University, but on the invitation of the University rather than as the College's nominee. The College recognises the B.Sc. course as fulfilling their requirements.

2.34 Apart from the functions of examining, qualifying and registering new speech therapists, carried out by their Examinations Board, the College's Training and Registration Board also visits and inspects newly established courses leading to the LCST and makes formal and informal visits to established ones. It keeps the nature and scope of training under constant review and considers the proportion of time to be spent by students on observation, in lectures and in clinical work. Although the College provides no initial training directly, it arranges a number of short courses and conferences for qualified speech therapists, and would wish to do more if funds were available. Among its other functions are included the publication of the monthly Bulletin, which provides a forum for the exchange of view for College members and a medium for advertising posts, and the biannual British Journal of Disorders of Communication, the professional organ of speech therapy in Great Britain. It also maintains a small library of relevant books and theses at the premises of the Royal National Institute for the Deaf.

2.35 The College keeps a list of persons qualified to practise speech therapy: this includes those who have passed the College's own examination, those holding the degree of B.Sc. (Speech), and therapists from countries with which the College has made arrangements for reciprocal recognition of qualification and who are granted a licence to practise. Membership of the College is open to all those listed on payment of an annual subscription. There is thus a technical distinction between possessing the College's Diploma and being licensed by the College to practise speech therapy. Not all newly qualified speech therapists become members, nor do all practising speech therapists in Great Britain remain members: at present membership totals 2,210. The College's Register, which is revised every 2 years, lists only members of the College.

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2.36 The College is also the professional and disciplinary organisation for the profession. Its Council, an elected body consisting solely of members of the profession, is responsible for the profession's management, policies and development. Membership of the College can be ended by disciplinary action as a consequence of professional misconduct, imprisonment or failure to renew the subscription. The College Council, as guardian of professional standards, carries out enquiries when any member is alleged to have acted "in a manner detrimental to the reputation or interests of the Art and Science of Speech Therapy or in a manner calculated to bring the Art and Science of Speech Therapy into disrepute or has wilfully and persistently refused to comply with the regulations or bye-laws of the College". The Diploma, however, cannot be withdrawn, so that therapists whose membership of the College is terminated - an extremely rare occurrence - remain eligible for employment as speech therapists.

THE UNION OF SPEECH THERAPISTS

2.37 The College of Speech Therapists is not the negotiating body for the profession. This role is filled by the Union of Speech Therapists, which is registered as a trade union to deal with trade union matters for speech therapists. In October 1971, it had 586 paid-up members. Salaries and career structure for speech therapists are negotiated within the National Whitley Council with the participation of NALGO, to which some speech therapists belong. The division between Union and College of responsibility for the profession's working conditions is not clearly defined. It is for the Union to negotiate salaries, agreements: on working conditions, travel allowances and so on, and to represent any individual speech therapist who has a grievance against her employer in any of these respects. The College can, however, take a hand by refusing to advertise in the Bulletin posts with an authority which consistently provides poor working conditions. Broadly speaking it could be said that working conditions are the concern of the Union in so far as they affect the comfort or convenience of the individual speech therapist, and of the College in so far as they may hamper effective treatment or efficient organisation.

SPEECH THERAPY TRAINING TODAY

2.38 There are now 11 schools of speech therapy (2.22). Their output of trained speech therapists is in the region of 150 a year.

2.39 The pattern of basic training for speech therapy remains substantially the same as that established by the College's founders in 1945 (2.20). Schools of speech therapy are free to pursue their own interests and to emphasise whatever aspects of the subject they choose. But the examination syllabus laid down by the College must be covered and the schools' freedom is limited, since the greater part of the course is taken up with this.

2.40 Until recently, recruitment literature in use in the profession referred to a minimum requirement for entry to training of 5 'O' levels in the General Certificate of Education, or the equivalent Scottish qualification. It was however found that students with less than 2 'A' levels were in many instances unable to meet the academic demands of training, and entrants are now advised that at

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least 2 'A' levels are necessary in order to gain a place. Candidates for training must have passed English Language at 'O' level, and the schools usually suggest that other subjects should include a foreign language, mathematics or a science, preferably Zoology or Biology. At Newcastle the candidates must satisfy university requirements for admission, which means that they are required to have a minimum of six General Certificate of Education passes, at least two of them at 'A' level, one of these being Biology or Zoology.

2.41 All applicants for training are interviewed and some schools apply in addition various tests of aptitude: these may include tests of intelligence and of auditory discrimination. Good clear speech, without defects or marked idiosyncrasies, is of course considered of great importance. In addition, the schools look for the personal qualities required in a successful speech therapist. These include maturity, physical and mental stamina, and a sympathetic personality. As one school states in its prospectus

One of the main interests of this work lies in the fact that every case has to be assessed as an individual problem, because the personality of the individual can affect the results of treatment. For this reason, students should have a stable, well-balanced personality themselves, as well as a sympathetic and understanding attitude towards others. This work calls for patience, initiative and imagination: to the prospective student these qualities are as important as the necessary academic ability.

2.43 Though the syllabuses in individual subjects have been revised by the College's Examinations Board and are kept under review, the content of training remains very similar to that originally established by the College, save that a. much has been added to the syllabuses and, by way of additional subjects, to the training course as a whole, while b. the examination in the Effective Use of Spoken English has been abandoned, though candidates are still expected to follow a course of training in this subject and to reach an adequate standard,

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which is assessed within the schools. Panels of examiners appointed by the College of Speech Therapists set papers in each subject, while over 60 practical examiners are spread over the 11 schools to give external assessment of students' practical performance. The examination subjects now are:

Bases of Language, Voice, Speech and Hearing. (1 paper)
Speech Pathology, Assessment, and Therapeutics. (4 papers and 1 practical)
Anatomy and Physiology. (2 papers)
Phonetics and Linguistics. (1 paper, dictation and oral)
Clinical Neurology. (1 paper)

Psychology including Psychopathology. (2 papers)

2.45 Schools are also free to give the study of individual subjects whatever unifying theme seems appropriate. Perhaps the biggest change in training since 1949 is in the prominence now given to normal child development as the underlying subject to which the various academic disciplines are related, and on which the study of disorders and deviations from normal, in children or in adults, must be based.

2.46 The degree course at Newcastle-upon-Tyne covers, in a form approved by the University, the basic subjects included in the College's syllabus. First-year students follow courses in Child Development (including an individual child study), Phonetics, Anatomy and Physiology. In the second year they study Speech and Speech Pathology, Applied Linguistics, Audiology and Psychology: all these subjects are continued in the third year with the addition of Neurology. Clinical work is included throughout the course, and continuous assessment adds to the final practical examination result.

Higher Qualifications

2.47 Qualified speech therapists may go on to take one of two higher qualifications administered by the College: the Diploma of Membership (MCST) and the Fellowship (FCST). Candidates for the MCST must normally have been qualified for at least three years. They are expected within a period of one year to

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pass a written and an oral examination and to submit an essay on a special subject chosen by the candidate and approved by the College's Higher Qualifications Committee. Work for both the examinations and the special study is under the guidance of a supervisor appointed by the College, who at the end of 6 months makes a brief report on whether the candidate is likely to reach the standard required in the given time. The FCST is awarded on the basis of an original thesis in the field of Speech Pathology and Therapeutics, which must be submitted not less than one year and not more than two years from the date of approval of candidature. Candidates must either have been qualified for not less than 5 years or must hold the MCST. An academic supervisor is appointed by the College.

2.48 The College's Higher Qualifications Committee, consisting of a total of 12 members half of whom are speech therapists, is responsible for the approval of applications and of the fields of special study chosen, the appointment of supervisors and examiners, and the final decision on the award or otherwise of Membership or Fellowship. To date there have been less than a dozen successful candidates for Membership and about 50 for the Fellowship.

2.49 As well as these internal qualifications, qualified speech therapists are eligible for a one-year Diploma course in the Teaching of Speech Therapy at the University of Reading Institute of Education, and for the Diploma in Audiology and Linguistics at the University of Manchester. A new M.Sc. course in Human Communications, for which LCSTs as well as members of other professions are eligible, was established in the medical faculty of the University of London in October 1971. The LCST is not otherwise acceptable to universities in itself as a qualification for advanced study or postgraduate research, although some universities are prepared to consider individual speech therapists on their merits for admission to appropriate courses of advanced study.

Training School Staff

2.50 As this chapter has made clear, the original schools of speech therapy were founded by gifted individuals who gathered a nucleus of students around them. The original principals of schools combined the roles of clinician, teacher of speech pathology and the theory and practice of speech therapy, clinical organiser and supervisor, registrar, bursar, administrator, welfare officer and domestic supervisor, and had also to find time to read the literature of the subject, devise curricula, and appoint and guide visiting lecturers in all subjects.

2.51 As the schools have developed, staffing has become more structured and specialised. A principal now has more than one assistant, and the ratio of full-time teaching staff to students has improved over the past 10 years. Full-time teaching staff are usually themselves speech therapists, but in the larger schools administration, registration, welfare and domestic arrangements are now often delegated to specialist staff who are not. Lecturers in subjects other than speech and speech pathology visit on a sessional basis: they are often University personnel.

2.52 The principal's role is increasingly an administrative one. It is generally felt, however, that this post must be held by someone with training in and experience of speech therapy, who understands and agrees with its professional

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concepts. Schools aim to recruit teaching staff of the calibre of a good university lecturer: that is, they must have sound understanding of the speech therapist's role in all circumstances and with all categories of patients, the ability to put forward their knowledge and ideas clearly and acceptably, and the ability to organise and manage academic and clinical programmes for their students. As noted in 2.49 there is at present one university course on the teaching of speech therapy.

3.01 In describing the origin and growth of the speech therapy profession we may already perhaps have given a slight indication of the range of disorders with which speech therapists may be confronted. The conditions which may give rise to disorders of speech or language are very numerous and many of them are in themselves extremely complex. An attempt to describe them briefly must unfortunately involve some medical and other technicalities: nevertheless, we considered that the attempt should be made, in order to demonstrate the breadth of theoretical knowledge which underlies the practice of speech therapy, and the depth to which the speech therapist must understand it. It is particularly important to emphasise these matters, since there is evidence that they are not well understood by the general public or, indeed, to the requisite extent by the other professions in contact with speech therapy.

3.02 We received evidence from several sources, including doctors and educationalists as well as speech therapists themselves, that the title "speech therapy" was in itself misleading. The head of one of the schools of speech therapy told us that "the commitments of speech therapists extend beyond the limitations of their title: the term 'speech' is wholly inadequate and 'therapist' wholly misleading", while the Royal College of Psychiatrists (then the Royal Medico-Psychological Association) said that "'speech therapy' is not a good term. It emphasises their therapeutic functions and ignores their diagnostic ones". The title suggests to many laymen that the speech therapist is little more than "an elocutionist in a white coat". There are two elements involved in this popular misconception of speech therapy: first the implication that the profession is concerned only with the administration of treatment (therapy), second that the treatment relates only to executive or motor functions of the vocal organs (speech). We shall show in this report that there are responsibilities far beyond these two limits which the profession is eager to accept and which no other profession is so centrally poised or so well equipped to undertake.

3.03 The College of Speech Therapist's official memorandum, Terminology for Speech Pathology indicates that speech therapists have a far wider role than the correction of articulatory defects. In this memorandum are considered a large number of disorders of language and speech, and it is clear that abnormalities of voice, articulation and of language itself are treated by speech therapists. The name of the College's official journal, The British Journal of Disorders of Communication, reflects the breadth of concern more accurately than the speech therapist's title as practitioner. We understand that attempts are being made within the profession to find a more apt title, such as "speech pathologist", "ortholinguist", or "logopedist", but we have not thought it appropriate ourselves to add to the discussion.

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SPEECH THERAPY: THE BASIC TERMS

3.04 The terms VOICE, ARTICULATION, RESONANCE and LANGUAGE are part of the basic vocabulary of speech therapists and since they are used extensively in this report, they require some clarification. VOICE is defined by the College as "sound originating in the larynx", ARTICULATION as concerned with "the sounds produced in speech by means of movement of the lips, jaw, tongue and palatopharyngeal mechanism in co-ordination with respiration and phonation", and RESONANCE as "the modification of the voice in contiguous cavities (by amplification and damping)". LANGUAGE is defined as "the acquired use of symbols, usually audible (speech) or visible (writing) for the purpose of communication".

3.05 The speech therapist's view of human communication can be summarised somewhat as follows:

I Receptive aspects

A person may be unable to understand what is said to him either a. because the signals do not reach his brain (e.g. through hearing loss) or b. because brain malfunction or slow development has affected his capacity to assign meaning to the sounds he hears.

II Executive aspects

Correspondingly a person may be hampered in expressing himself a. because a psychological or physical defect prevents him from making sounds properly or b. because brain malfunction or slow development has interfered with or prevented him from acquiring the capacity to express meaning intelligibly in words (or perhaps to express meaning at all).

3.06 For the speech therapist, "speech" relates to IIa. in the above scheme and "language" to lb. and IIb. The position is thus that "speech" is regarded as presupposing the existence of "language", whereas the existence of "language" does not necessarily presuppose the existence of "speech". But not all disorders of communication can be simply, authoritatively and uncontroversially assigned to one aspect of the communication function rather than the other: that is, it is not always possible to characterise a disorder as one of "speech" or "language" alone. A further difficulty in this complex situation is that the term "language" is often used more loosely to cover the whole communication process.

THE RANGE OF DISORDERS

3.07 There is at present no single satisfactory classification of the disorders of language ability, a situation reflecting the need for long-term research to which we draw attention in Chapter 10. In the presentation that follows we merely try

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to associate the complex and highly ramified conditions with, in the first place, some reference to common causation and, in the second place, with their distribution in specific age-groups. We now list the main heads, with paragraph references, for the fuller discussion which we attempt below for each group of conditions:

I DISORDERS OF VOICING

3.08 Hoarseness or impairment of voice (dysphonia) and total loss of voice (aphonia) are more common in adults than in children, among whom they occur infrequently. They may however occur in children suffering from multiple benign tumours (papillomata) and in very rare cases voice impairment may date from birth: it is then usually associated with paralysis of the vocal cords, the cause of which is obscure. Damage to the larynx may be caused by accidents in which caustic or corrosive liquids are swallowed.

3.09 There are many causes of impairment or loss of voice in adults, varying from inflammatory conditions which may be transient to the complete loss of voice resulting from, for example, total laryngectomy for cancer of the larynx. The commonest single cause of chronic hoarseness is probably misuse of the voice in individuals who have to shout or use their voices loudly in the course of their work: this may cause degenerative changes in the larynx, associated with nodules of the vocal cords. Chronic or recurrent infections of the larynx may also impair voice: for instance, recurrent severe respiratory tract infections may eventually cause chronic changes in the larynx, though these are more common in chronic infectious diseases. They may also occur in the course of certain diseases affecting other parts of the body, such as rheumatoid arthritis. Accidents or suicide attempts may cause permanent damage. There is in addition a condition known as "hysterical aphonia", in which the structure and innervation of the larynx are intact, but the ability to produce voice is lost as the result of an emotional disturbance or shock. It rarely occurs before puberty and most commonly affects young or middle-aged women.

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3.10 Examination by an otolaryngologist is essential in cases of loss or impairment of voice. The speech therapist, however, assesses the type and severity of the impairment and arranges for appropriate therapy in the light of the diagnosis made by the otolaryngologist and in association with him.

Resonance

3.11 Although the basic vibrations which make voice are produced within the larynx, their sound waves are amplified and modified as they pass into the resonators - principally the chest, pharynx, nose, mouth and sinuses. The size, shape and movements of these resonators influence what is called the "quality" of the voice. The most common disorder of resonance referred to the speech therapist is excessive nasal resonance: this is heard when, during speech, some of the air from the lungs is deflected fairly constantly into the nose. This occurs, for instance, when a cleft palate has been unsatisfactorily repaired or when an apparently normal soft palate has either insufficient length or insufficient mobility to shut off the stream of air to the nose when required. On the other hand the passage between the nose and the back of the mouth may be blocked by adenoids or catarrh, in which case the air cannot enter the nose and a different type of speech difficulty arises, the main characteristic of which is a defect of articulation involving a few frequently used consonants as well as a loss of the normal nasal resonance. In some cases both the conditions described exist together, in that a nasal consonant like "m" sounds like a "b", whereas vowels take on a nasal quality. Disorders of resonance may occur alone or in association with disorders of articulation.

II DISORDERS OF RHYTHM

3.12 Stammering (stuttering, speech dysrhythmia) is characterised by abnormal hesitation, blocking (the involuntary inability to begin or to continue utterance) or repetition of sounds, syllables or words. It occurs fairly frequently. There is evidence of a genetic predisposition to stammering in a high proportion of patients. Emotional stress may play a part in precipitating stammers, as may undue attention by parents to the lack of fluency typical of the 3-4 year old. The majority of adults who stammer have done so since childhood, usually with periods of relative remission and exacerbation. Acquired stammering occasionally occurs after brain damage, but in these circumstances it is almost always associated with articulatory disorders (dysarthria).

III DISORDERS OF ARTICULATION

(a) Specific Developmental Delay

3.13 The great majority of children referred to speech therapists suffer from a mild developmental disorder which affects their speech alone. In these cases comprehension of spoken language and use of vocabulary seem normal, but the child is slow to acquire speech sounds and may omit or substitute some: many of these cases used to be diagnosed under the name of "dyslalia". While a large proportion of these cases clear up spontaneously by the age of seven, a speech therapist's early assessment is necessary to ensure that there is no underlying disorder of language. It may also be necessary to offer treatment even for comparatively mild articulatory disorders, if there is any possibility that the

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child may be hampered in communicating at school. In addition, parents need advice and reassurance. Nor can it be assumed that a child whose disorder is one of articulation alone will necessarily be easy to treat. There are rare cases where no language disorder can be demonstrated, yet the child's speech is so badly affected as to be unintelligible, and these present very difficult problems for the speech therapist.

(b) Structural Dysarthria

3.14 Dysarthria may be "structural" in the sense that the lips, tongue, palate or neighbouring structures such as the jaws, the naso-pharyngeal aperture, or the teeth may be abnormally developed or damaged as a result of injury or disease. An example of a congenital structural abnormality is cleft palate, and an example of a structural abnormality caused by disease is the obstruction of the nasal airway caused by disease of the adenoids, commonly associated with chronic or recurrent upper respiratory tract infections. Abnormalities may also be caused by accidents, for instance when a child tears his soft palate by falling while holding a sharp pointed object such as a stick or pencil in his mouth.

3.15 Some structural abnormalities persist into adult life, but the majority of articulatory disorders among adults are acquired as a result of injury or disease causing structural damage to the lips, tongue and palate. These may include traumatic lesions, as in industrial or traffic accidents, which are frequently associated with fractures of the upper and lower jaw, sometimes resulting in permanent deformity. They may also include chronic diseases causing loss of tissue, including cancer and like disorders, which invade and replace the articulatory structures.

(c) Neurological Dysarthria

3.16 Neurological lesions may affect the function of the lips, tongue, palate and related organs, and these conditions may be congenital or acquired: the nuclei of the cranial nerves may fail to develop, or these nerves may be damaged by infection or injury. Some congenital abnormalities of the innervation of the articulatory organs, and some of those acquired in childhood, persist into adult life. There are however a large number of acquired neurological disorders which may cause articulatory disorders in adults, for example tumours, thrombosis and haemorrhage in various parts of the brain, and chronic disorders such as multiple sclerosis and Parkinson's disease.

IV DISORDERS OF LANGUAGE

(a) Specific Developmental Delay

3.17 Developmental disorders of language occur in healthy children of all levels of intelligence. They can occur in the presence of normal hearing and without any evidence of environmental deprivation (though hearing impairment or social deprivation may be complicating factors). More boys than girls are affected and many of them have a family history of slow speech development. Evidence of relatively weak cerebral dominance is often found.

3.18 In considering these disorders it is important to bear in mind the distinction between speech and language which we attempted to explain in 3.05-06.

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Developmental disorders may affect speech alone, and there are some cases where language alone is affected. In many cases, however, both are affected: retardation in the development of language may be accompanied by, or may manifest itself as, a disturbance of articulation. The disorders vary considerably both in kind and in severity and there is no constant relationship between the nature of the disorder and its degree of severity. In the comparatively rare cases where retardation of language development is unassociated with articulatory abnormalities, there is a risk that, because their speech is ostensibly normal, children may be overlooked until they reach school age and even then their condition may be wrongly assessed.

3.19 A proportion of those suffering from developmental speech disorder (3.13) are retarded in the development of language. Where spoken language alone is affected the acquisition of sounds is severely delayed, many consonants or consonant clusters are omitted or substituted, and in a proportion of 4 and 5 year olds spoken language may be unintelligible. Those still more severely affected show not only failure or partial failure to develop spoken language, but also impaired comprehension of spoken language. Their articulatory disturbance may be worse, their grammatical structures even more imperfect and their vocabularies still smaller and less precisely used.

3.20 In the most severe, and rarest, variety of developmental disorder, children have difficulty not only in comprehending and using spoken language but also in responding appropriately to non-speech sounds. These children may be 2 or 3 years of age before they look towards the sound of a radio set or aeroplane or pay attention to a door shutting or opening. Until this time they are often believed to be deaf, and indeed it is relatively common to find evidence of a severe impairment of the function of the brain (receptive dysphasia) combined with some hearing loss. Even when they begin to show a response to sound it is often only intermittent. They may not begin to comprehend spoken language until four or five or sometimes even later, and a minority may never do so. Such children are very difficult to diagnose and the nature of their apparent hearing impairment, their great delay in the comprehension of spoken language and their inability to make themselves understood by using speech tax the combined diagnostic resources of the speech therapist, the audiologist, the paediatrician, the psychologist and the child psychiatrist. As a result the nature of their underlying disorder is a matter of considerable controversy. A number of these children are likely to be multiply handicapped.

(b) Acquired Brain Damage

3.21 The great majority of language disorders in the adult are the result of acquired disease. Brain lesions often cause associated paralysis of one side of the body and other neurological defects. The common causes of brain damage among adults are cerebral thrombosis, haemorrhage and infections, brain tumours, degenerative diseases of the brain, and head injuries.

3.22 There are many different and complex classifications of these language disorders, (distinguishing, for example, executive, receptive and global dysphasias), but for our purposes we need only point out some of the chief types of disability. Some patients have auditory comprehension difficulties, others do not. Speech may be slow and limited, there may be difficulty in "word-finding",

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or words may be used inappropriately. Certain patients produce fluent streams of nonsensical words, while others express themselves by circumlocutions. Written expression and reading ability are frequently affected.

3.23 Thrombosis, haemorrhage, and degenerative conditions of the brain are particularly common in the elderly. The assessment of their impaired language ability can be difficult because of other associated disabilities, for example, deafness or a loss of intellectual function. Acquired dysphasia among children may follow such conditions as head injury or resuscitation after cardiac arrest, or illness such as encephalitis. The clinical picture is complicated by the fact that there will not only be a loss of language ability already acquired but usually a delay in further development as well.

(c) Associated With Hearing Impairment

3.24 Impairment of hearing present from birth or early infancy will affect the development of speech and language to a degree dependent not only on the severity of such impairment but on the presence of additional handicaps such as the structural and neurological disorders referred to in 3.14-16, intellectual impairment and social deprivation. Specific developmental disorders (3.13; 3.17-20) may also accompany hearing impairment. Acquired hearing loss in the older child or adult is a different problem, but, unless specific efforts are made to maintain spoken language, it may be lost or severely impaired.

(d) Associated With Mental Handicap

3.25 Among mentally handicapped children* the major finding tends to be one of backwardness in the development of language ability. These children are almost invariably slower than normal children to learn to understand speech, their vocabularies are smaller, and their grammatical structures are imperfect. Mental handicap may persist into adult life, and may in addition be acquired in adult life as a result of any of a wide variety of diseases (dementia), involving a variety of communication disorders: physical handicaps often occur as well.

(e) Associated With Autism or Psychosis

3.26 In infantile autism (a condition in which children withdraw from or fail to establish normal social contact and become obsessed in simple and repetitive activities) there is a marked limitation of verbal output. In autism of early onset there is variable generalised retardation of the development of language ability. Spoken language is often grossly reduced in amount, and the degree to which the developing ability to understand spoken language is affected varies greatly and may in very withdrawn children be extremely difficult to assess.

3.27 Both children and adults with psychotic disorders may show a wide variety of disorders of language ability. In addition we may mention an uncommon childhood disorder known as elective mutism, in which the child may talk normally in some circumstances but refuse to talk at all in others. This is, how-

*The term "mentally handicapped" is used here as a general one to cover all children with a significant degree of retardation. While it is normally used in this sense in Scotland, it is usually applied in England and Wales not to the educationally subnormal but only to those severely mentally handicapped children responsibility for whom was transferred from Health to Education on 1/4/71.

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ever, a matter for the Child Guidance Clinic or the psychiatrist rather than the speech therapist.

(f) Associated With Severe Social Deprivation

3.28 Where there is severe environmental deprivation, as in non-talking families or in some institutions, there is usually retardation of the development of language ability in children. The problems of such children need to be carefully unravelled, as there is a danger that their speech difficulties may be put down to social deprivation when other factors are also present. Adults living in institutional conditions can rapidly suffer deterioration of language. This problem affects in particular older patients and those with additional handicaps.

V MIXED DISORDERS

3.29 The group of mixed disorders is a comparatively large one, and many speech therapists and doctors would assert that a very high proportion of those suffering from disorders of spoken language show multiple problems. The classification we set out in paragraph 6 relies upon diagnosis being made by the major communicative function which is disturbed, but we recognise that some patients have multiple disabilities, all of which are important in determining the nature of the disorder of spoken language, and that it is not always possible to classify these patients according to the major linguistic function which is impaired. For example, hearing impairment is relatively commoner in children who are mentally retarded than in those of average intelligence. To classify such children as suffering from "a secondary speech disorder" does not give much indication of the nature of the disability. Since even the most skilled doctors and speech therapists may be hard put to it to assess the relative importance of the two causative agents, it is probably better to refer to such children as suffering from "secondary retardation of linguistic development attributable to mental retardation and hearing loss". To take another example, a patient suffering from cerebral palsy characterised by excessive involuntary movement (athetoid cerebral palsy) might show disorders of voicing, rhythm and articulation as well as retarded language development, and it might well be impossible to determine the extent to which his difficulties were due to involuntary movements of the larynx and respiratory muscles, incoordination of the articulatory organs, mental handicap, and hearing loss. Equally complex problems may occur among elderly patients, for example the socially deprived, demented individual with hearing impairment who has suffered a stroke.

3.30 Specific difficulties in learning to read and to spell (so-called "developmental dyslexia") occur particularly frequently in children suffering from retardation of the development of language ability, and are perhaps most obvious in intelligent children with mild or moderately severe types of specific developmental speech disorders. The particular disabilities encountered vary widely and may include unusually severe difficulty in correlating the written and the spoken language symbol, word-sound problems in which there is difficulty in sounding written syllables correctly and in synthesising them into meaningful words, and visuo-spatial difficulties in analysing the shapes of written symbols, their sequence and their orientation.

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THE SCOPE OF THE SPEECH THERAPIST'S WORK

3.31 Speech therapy has been involved, to a greater or lesser extent, in the management of all the foregoing conditions. In Chapter 6 we shall review the role of the speech therapist in the light of what we consider to be desirable. But it would clearly be impossible to describe in detail the part that the speech therapist may now play in each of these disorders. Instead we attempt a general account of the work undertaken by a speech therapist with some typical patients, in the hope that it will illustrate the extent of her present responsibilities and the variety of knowledge, techniques and skills on which she draws in the course of her work. Each individual speech therapist approaches her work in her own way, and in context of the particular circumstances in which she has to work, and the pattern we describe will not be applicable in detail to all. It should nevertheless give a broadly true picture of the therapist's method of work.

Assessment

3.32 A patient is usually referred for speech therapy through a doctor, though arrangements may vary from locality to locality. In some cases the referral is accompanied by a medical case-history, clinical findings at a recent examination and a firm diagnosis. Often, however, the referral is made on a small printed slip bearing the patient's name and address with the barest indication: "Speech defective. For speech therapy". It is usual for a speech therapist working in hospital to have access to medical notes from which she can obtain further relevant information, but a therapist working in schools needs the help of a school medical officer to obtain this background medical information. In all cases, however, it is necessary for the speech therapist to make her own assessment of the patient's "speech", "voice" or "language".

3.33 This assessment is in three parts:

(a) the case history;
(b) the examination of presenting symptoms;
(c) search for underlying causes.

3.35 (b) Examination Many standardised tests are used in British clinics, including tests of understanding of speech as well as of use of speech, articulation, grammar, vocabulary, etc. Some of them are appropriate for the child with slow or abnormal development of spoken language while others - unstandardised - are for adults whose language has become impaired. These tests are mainly for measuring attainment and from their results profiles can be drawn showing the variation in performance in the different areas of language

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ability. In dysphasic patients account can be taken, using appropriate tests, of their educational, occupational and social background, and their previous intelligence. Their articulation, comprehension and ability to use spoken language can also be tested. With stammering, it is more difficult to quantify and describe, though this has been attempted; and with voice disorders lengthy descriptions have to be made in terms that have no clear or agreed definition but are meaningful to the individual therapist.

3.36 (c) Causes The results of the attainment tests help the speech therapist to know which of many possible underlying causes should be investigated. She is guided not only by the low score in certain tests but also by the type of errors made. She may test, for example, auditory memory span, auditory discrimination, the ability to imitate, the speed and precision of the movements of the articulatory mechanism. She will often be involved with others concerned in the case to instigate investigations by radiologist, audiologist, psychologist, dentist, orthodontist and others (but see 6.08-09). Speech therapists in hospital are usually more fortunate in obtaining additional diagnostic information from these investigations promptly than their colleagues working in schools.

3.37 In cases of cleft palate, the plastic surgeon depends on the speech therapist for an analysis of the nature of the patient's speech difficulty; this is necessary to help him assess whether further surgery, after the initial repair, has a chance of improving the condition. Sometimes, where a cleft palate has not been repaired in babyhood, he may want the speech therapist's assessment before operating at all. Similarly, the laryngologist in many cases relies on the speech therapist's examination to bring to light personal problems which may be causing the physical tension resulting in a voice disorder: such patients may prove to require psychiatric treatment.

Treatment

3.38 As a result of the assessment the speech therapist has guidelines to plan her course of action. This may involve no more than giving information and advice to the parents of a retarded child who uses speech and language consistent with his mental development, or to relatives of a dysphasic patient who is senile and confused and would not respond to therapy. It is often possible to predict from the tests if a child is likely to improve quickly when he starts at nursery or infant school and the parents can be reassured accordingly.

3.39 When regular treatment has been decided upon, it usually takes place in a speech clinic. Few therapists, however, work in the same clinic each day: it is more usual to travel from one to another. Patients are usually seen individually for half an hour once a week, but many therapists treat certain patients in groups of four to six once or twice a week, while a few (for example those working in rehabilitation units or special schools) treat their patients daily. Hospital in-patients who have had strokes or laryngectomies are wherever possible seen daily.

3.40 Speech therapists normally spend about six sessions weekly in treating patients and a further four in assessing new patients, attending joint clinics with other specialists, and visiting patients' homes or schools. They also need time for regular meetings with colleagues, not only to discuss general principles

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but to obtain the help and advice of experienced therapists in difficult cases (5.17-18). Time also has to be found for record-keeping, writing reports, making appointments, maintaining equipment, etc. (5.25).

3.41 The techniques used in treatment vary according to the nature of the patient's disorder as well as his age and, sometimes, his level of intelligence.

3.42 (a) Children The speech therapist, with her knowledge of the sequence of language development, selects appropriate material for speech stimulation. For example, with a three-year-old using only about a dozen barely intelligible words, she will demonstrate to the mother how to encourage babbling to develop new speech sounds. Using pictures representing words he has the competence to articulate she can increase his noun vocabulary as well as his confidence in being able to name things intelligibly. She will draw attention in play to contrasts that require the use of predicates, such as "big", "hot", "gone", to prepare for the construction of phrases. Above all she will know various ways to provoke the child into making more use of speech, such as when to employ some judicious misunderstanding. In some cases the speech therapist will show the mother how to practise tongue and lip movements with the child and will demonstrate chewing exercises combined with the introduction of an increasing amount of hard food into the diet.

3.43 Treatment with older children is more formal. Choice of techniques depends on whether the child's speech difficulty is mainly due to being unable (in spite of normal bearing) to detect differences between sounds and words that are similar, or whether he can hear the difference but cannot organise and control the movements of his speech organs into the correct positions at the right time to make these sounds and words. One way in the first case may be a carefully programmed system of auditory training by which his sound discrimination ability will be trained to the limits of his potential. This has to be supplemented by drawing attention to the movements of the mouth while speaking and similarly to the shapes and order of letters in written material. Such children usually have some difficulty in understanding speech and in acquiring a large vocabulary. Regular practice in reading aloud, conversation and story telling gives the therapist constant opportunities for comments, questions and explanations that can help resolve confusions in meaning. Many therapists work from stores of colourful pictures which illustrate activities interesting to the child. These, graded in order of difficulty, are a means of helping the child to learn how to formulate his ideas explicitly.

3.44 In the case of children suffering from difficulties in controlling the sequence of movements of tongue, lip and palate a careful study of their speech reveals apparent inconsistencies which can be grouped by their phonetic contexts, of which some are acquired earlier than others. The speech therapist, using her training in phonetics, can devise an individual programme based on the pattern the child has already learned and show him how to make adjustments in tongue movements to produce different English sounds.

3.45 Therapists use a variety of situations to encourage older children to practise their newly acquired speech skills. Playing tape recordings of their speech helps them to hear and judge their degree of success.

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3.46 When a child has speech therapy away from school the mother usually accompanies him. She is usually, but not always, invited to come into the treatment room for at least the first few sessions so that she can see how the therapist works with her child, and at the end of each session the therapist will tell the mother what she would like her to practise with the child during the following week or discuss any other problem that has arisen. Frequently the child is given a note book with the practice material written in it. When a child is treated on the school premises, contact with the mother is usually lost but the teacher's co-operation is often gained. This is highly desirable but not so easy to secure consistently on a long term basis. However, speech therapists in schools usually have the advantage of close contact with the School Psychological Service (or its Scottish analogue) whose help is invaluable.

3.47 Important as are the specialised techniques of speech therapy, much success in treating children with late and poor talking comes from the therapist's relationship with the child, her interest in him, "drawing him out", her enthusiasm for speech, her ability to demonstrate how desirable it is to be a ready and entertaining talker.

3.48 (b) Adults Treatment of adults with a voice disorder is dependent very specifically on the findings of the otolaryngologist at his examination. If paralysis of a vocal cord has been diagnosed the speech therapist may use methods including breath control, pressure exercises, vowel glides, humming and strongly articulated syllables. On the other hand, if the laryngologist described the cords as moving together normally but, before quite articulating, separating quickly, the loss of voice is likely to be of hysterical origin. In this case the therapist would apply her knowledge of psychology and vocal pathology. She is unlikely to give any voice exercises but instead will concentrate on getting the patient to talk out the problems he finds at home or at work in such a way that insight is gained into the reason for withholding voice. In most cases normal voice is produced within the first few interviews but if the therapist fails to gain the patient's confidence and confidences fairly quickly she will refer him to the psychiatrist.

3.49 The principles of speech therapy for the dysphasic patient have been described by such terms as "substitutions" and "re-education". Examples are seen in the re-training of a patient who has lost the ability to recognise individual letter outlines. The method used to compensate for the disability is a series of exercises leading eventually to recognition of letters by minute eye movements. Similarly a patient with severe receptive dysphasia can be aided to comprehend auditory information by fragmenting messages, repeating and noting each point as it is retained. Re-education is linked with re-training of patients suffering from reading, writing and calculation disorders. A more apposite description for general speech therapy is possibly "the methods by which the patient is helped to re-acquire language mechanisms and functions". This is particularly true for disorders of reception and expression of the spoken word as these abilities result from an interaction of innate features and environmental influences. In addition the etiology has to be taken into consideration with concomitant physical disorders since individual programmes have to be structured. The adverse emotional reactions of the patients and their relatives have to be modified and co-operation with other members of the rehabilitation team organised (4.28 ff).

REGULATIONS GOVERNING EMPLOYMENT

4.01 The employment of speech therapists in the National Health Service in England and Wales is governed by The National Health Service (Speech Therapists) Regulations 1964. While legally these apply only to speech therapists employed by the N.H.S., in practice local education authorities almost always require speech therapists to be qualified in terms of the Regulations. There is, however, no legal bar to the employment by a local education authority or an independent school of a person not thus qualified, or to the establishment of such a person in private practice. The public's safeguard against dilution of the profession by unqualified people therefore rests, in England and Wales, on established custom rather than on a legal provision and we were aware of some uneasiness among our witnesses lest the shortage of qualified speech therapists might lead to employment of unqualified people. The situation in Scotland is different, as The National Health Service (Speech Therapists) (Scotland) Regulations 1964 cover the employment of speech therapists by an education authority as well as in the N.H.S.

CAREER STRUCTURE

4.02 The present grading structure for the profession is set out in the Whitley Councils' Professional and Technical Council "A" Circular No. 145, dated January 1970. The grades are defined as follows:

(a) Assistant Speech Therapist

A speech therapist under the supervision of a speech therapist in a higher grade working throughout each day on the same premises.

(b) Speech Therapist

A speech therapist who is:

(i) in sole charge of a speech clinic, or
(ii) in charge of a speech clinic without an assistant, but under the supervision of a speech therapist not working on the same premises throughout each day, or
(iii) responsible for a clinic or clinics requiring one other speech therapist working on the same premises or elsewhere.

(c) Senior Speech Therapist

A speech therapist with not less than 3 years' experience after qualification, who is responsible for a clinic or clinics where 2 or more other speech therapists are employed.

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nor does it allow recognition for responsibilities beyond those of Senior Speech Therapist; this is borne out by the number of authorities which have created special posts of Chief or Principal Speech Therapist for the head of their services.

ADMINISTRATIVE STRUCTURE OF SERVICES

4.03 Speech therapy services in Great Britain are organised in two main ways. There is an education service organised, under Section 48 of the Education Act 1944 and Section 58 of the Education (Scotland) Act 1962, as part of the School Health Service, and a hospital-based service forming part of the National Health Service. About three times as many speech therapists are at present in L.E.A. employment as in the hospital service.

I THE EDUCATION SERVICE

Patterns of Organisation

4.04 As part of the School Health Service, speech therapy services in Great Britain normally fall within the responsibility of the Principal School Medical Officer, who is, in all but two cases, also the Medical Officer of Health for the authority. He has ultimate responsibility for the efficiency and adequacy of the service and answers for it in the event of any complaint. It is for him, in consultation with the Chief Education Officer, to decide what number and level of speech therapist appointments to recommend to the Education Committee. The working accommodation made available and the authority's policy on the provision of travel allowances and car loans (in so far as these are not provided for by regulations covering local government employees) will be worked out by him in consultation with the Chief Education Officer for ratification by the local authority committees concerned. (For the extent to which speech therapists are expected to travel in the course of their duties see 5.19, 22, 24.)

4.05 There are some variations in overall responsibility, notably in Scotland, where several speech therapy services are organised as a part of the local education authority's Child Guidance Service and the overall organiser is a psychologist responsible to the Director of Education. In Aberdeen and a number of other Scottish services the speech therapy service is the responsibility of the Director of Education.

4.06 The day-to-day responsibility for the running of the service is normally in the hands of the speech therapists themselves. Where a Senior Speech Therapist has been appointed to be in charge of a service, she is responsible not only for her share of clinical work but also for deploying the therapists in her charge, overseeing their work and advising them on difficult cases, and for liaison with the employing authority and consultation with medical and psychiatric opinion. This is an onerous position: as one of our witnesses said:

The position of Senior in a large area is an impossible one. Too often they are tied by heavy case loads and are unable to give appropriate time to administration, public relations, and in-service training and co-ordination. They feel unable to delegate much of their work since no financial recognition is made for a deputy.

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But the situation may be still worse. In many cases there is no hierarchical structure at all within the speech therapy service, either because the authority makes all its appointments at senior level or, conversely, because there is no provision for a senior appointment or because no Senior Speech Therapist has been recruited. The latter situation can produce serious problems, which we describe in 5.16-17. In other authorities a special post has been created, outside the Whitley Council agreement, for the administrative and clinical head of the service. These appointments go by various names: Chief Speech Therapist, Director of Speech Therapy Services and Regional Speech Therapist are some examples. In Aberdeen administrative responsibility lies with a Principal Speech Therapist who co-ordinates the work in schools and hospitals in the city and reports to the Director of Education. In the City of Leicester the Education Committee maintains a Department of Speech, under a Chief Speech Therapist, which organises speech therapy services for schools and hospitals in the town and has also been responsible for organising the authority's School of Speech Therapy, and speech therapists of the Department undertake lecturing and tutorial work there. The fact that the School of Speech Therapy forms a department of the College of Education enables the authority to pay their Chief and Senior Speech Therapists on the Pelham Scale for lecturers in colleges of education.

Patients and Treatment

4.07 There are three main categories of children seen by speech therapists in the educational service: those at ordinary schools, those of pre-school age, and handicapped children in special schools.

4.08 Children in ordinary schools School children are normally referred for speech therapy by their teachers, usually through the school medical officer, sometimes by parents through their general practitioners. In some areas, notably Kent, children may be referred direct by their parents or teachers, or other interested parties, without the need for prior medical examination. Children who have undergone a cleft palate repair or other hospital treatment or surgery affecting their speech may if there is no hospital speech therapist be referred by the consultant to the education service therapist. In other cases speech therapy may be started by the hospital speech therapist, who later refers the child to the education service therapist if this is a more convenient means of continuing treatment after the child's discharge from hospital. School children may be treated either at a clinic or at their school or occasionally at home. The choice will depend on mutual convenience but will aim to minimise interruption of the child's education.

4.09 Children at ordinary schools commonly need treatment for defects of articulation, often associated with language difficulties, for stammering or for voice problems. The varying conditions which may give rise to these disorders, and the ways in which the speech therapist approaches them, are indicated in Chapter 3. The extent to which the therapist needs to deploy her skills of assessment, treatment and advice varies from patient to patient, according to the nature and severity of the disorder. A very young child with a simple defect of articulation, unaccompanied by language difficulties, may need only initial assessment and some advice to his parents and teachers. However, the therapist

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will probably arrange to review the case so that direct therapy may be given later should the defect persist. A child with delayed or disordered language development will on the other hand require early treatment as well as very careful assessment.

4.10 Pre-school children Children of pre-school age may be referred for speech therapy by the local authority child health services, by general practitioners, by parents, or, as in the case of older children, after medical investigation or treatment in hospital. Some referrals may come from nursery classes or units, and in these cases the speech therapist needs to visit the class, so that she can advise the staff how to approach the child's particular difficulties. Most other children of pre-school age are seen at a clinic. These very young children are usually referred to the speech therapist either because the development of language ability appears to be delayed or abnormal, or because some handicapping condition has been diagnosed which is having or is likely to have an effect on speech or language. The speech therapist's function in these cases is very often confined to assessment, advice or reassurance to parents, and perhaps arranging for later review.

4.11 Handicapped children in special schools or classes Good progress has been made in the early detection of handicapping conditions and many of these children will be seen by a speech therapist in their pre-school years. In some cases, however, either the need or the readiness for speech therapy may come or may be recognised later. The assessment of these children may present particular problems, since many suffer from multiple handicaps and in others, as we have shown in Chapter 3, similar problems may stem from a variety of causes. Receptive aphasia, for instance, is sometimes mistaken for deafness and may co-exist with a degree of hearing loss. Furthermore, assessment needs to continue as the children develop and the problems change, and since continuous observation can best be carried out in the educational setting the education speech therapist can make an important contribution to it in co-operation with teachers and medical staff.

4.12 Handicapped children in special schools and classes present a wide variety of speech and language problems including, for instance, severely delayed speech and language development in mentally handicapped children, and the special problems associated with language learning in the deaf or partially hearing child or the child with cerebral palsy. Handicapped children, particularly those with a mental handicap or delayed language development, often have subsidiary problems such as poor concentration and short memory span. This means that frequent therapy is usually particularly helpful for these children. This is most readily available in those special schools which appoint a full-time speech therapist, to be involved with the teaching staff in joint planning of teaching and treatment and to work closely with hospital consultants and other medical staff in charge of children at the school. Schools making these appointments may be run by a local education authority or by a voluntary body such as the Spastics Society or the Invalid Children's Aid Association, and the children concerned are usually those with severe specific developmental defects of communication or with cerebral palsy. One school for hearing-impaired children employs a full-time speech therapist. Elsewhere in special schools, the great majority of children receive at most periodic treatment from a visiting speech therapist if there is one available.

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Referrals

4.13 As has been said in the preceding paragraphs, there is a wide range of possible sources of referrals to the speech therapist in the education service. The referrals themselves, from whatever source, are frequently unsatisfactory, either because the therapist is given insufficient information, or because the condition underlying the speech or language disorder has not been properly assessed, or because the condition is one which speech therapy cannot help. Several witnesses spoke of "blanket referrals of cases in 'need of speech therapy'," the treatment of minor articulatory defects which were merely the effect of slow development (though we recognised that even a minor defect might if untreated slow down education progress) and referrals on a symptomatic basis of children with underlying disorders for whom speech therapy merely aggravated their distress, as may be the case with certain stammerers. On the other hand, there was also evidence that patients in need were not being referred. There was apparently a tendency, particularly on the part of general practitioners, not to refer children for speech therapy, on the grounds that they would eventually outgrow their speech difficulties. Since the majority of general practitioners lack the knowledge and training to make judgments of this kind, witnesses stressed to us that children should be referred to a speech therapist for assessment. The Kent system of open referral, which we mentioned in 4.8, ensures access to a speech therapist for any child whose speech or language is causing concern, but it leaves the speech therapist with the responsibility of ensuring that the child is examined by a doctor to detect any medical condition underlying the speech disorder.

Relations with other services

4.14 The education speech therapy service needs close working relations with a wide range of other professions, not only to ensure that patients are referred in as helpful a way as possible, but also so that speech therapists are enabled to work constructively with others. The therapist must work with a variety of other services, depending on the nature of the service being given - assessment or treatment - and the individual child concerned. In the assessment of a young mentally handicapped child, for instance, the Child Health Service, the educational psychologist and nursery or special nursery teachers will need to be involved, as well as the hospital specialist. When a child is referred with a problem which the speech therapist thinks may be the result of hearing loss, she will need the help of local authority or hospital audiological services. Speech therapists very often enlist the help of teachers in reinforcing their work, and they must work in close co-operation with teachers in ordinary schools and with a wide variety of teachers in special education, including particularly teachers of the E.S.N. and teachers of the deaf. The service also needs to work in close liaison with the hospital speech therapy services and may from time to time need to obtain, via the hospital therapist where there is one, the advice or assistance of other hospital personnel including paediatricians, neurologists, medical social workers, psychiatrists and clinical psychologists. The flow of advice or information is not all in one direction, since there are many occasions on which the observations and insights of the speech therapist, and her ability to gauge a child's stage of development of language ability, can be of great assistance to other professions.

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4.15 There are, however, frequently grave defects or gaps in this system of relationships. Many of our witnesses commented on the speech therapist's "tendency to function in a vacuum rather than in a team" as one put it. Some of the reasons for this tendency are examined in chapters 5 and 6.

II THE HOSPITAL SERVICE

Patterns of Organisation

4.16 Speech therapists working in hospitals normally come under the aegis of one department, headed by a consultant. Our evidence showed that the responsible department might be Rehabilitation, Paediatrics, E.N.T. or Neurology. Referrals came from all these departments and from the Geriatric, Surgical, Orthodontic and Psychiatric departments as well.

4.17 The number of speech therapists' posts created depends to a very large extent upon the interests of the consultant concerned and the importance he attaches to speech therapy. Since he may represent the speech therapists' interests on the Hospital Management Committee, or on the Board of Management in Scotland, his attitudes are likely to affect not only establishments but also the accommodation allocated to speech therapists and the equipment provided for them. When resources are limited, he may be reluctant to put the need for another speech therapist above the need for further assistance in his own specialism. Where he is not on the H.M.C., speech therapists' interests are not represented at all. This is a frequent source of frustration not only to speech therapists but to other interested consultants who might wish to see the service more fully developed.

4.18 There are a very few distinct departments of speech therapy. These rank equally with other hospital departments, such as Social Work, which provide a service for a number of specialisms. Such departments usually have no representation on the Hospital Management Committee or Board of Management. An example is Oxford, where a post of Chief Speech Therapist has been created for the head of department. Consultants in other departments refer patients to the Speech Therapy Department for treatment which thereafter is organised and supervised by the head of department, though she will work closely with the consultant concerned and will normally inform him before terminating treatment of a case.

4.19 Referrals may come not only from within the hospital but also from the education speech therapy service. A pre-school child, for example, may initially be referred to the education service, but may then be referred on to a hospital if the education speech therapist suspects the existence of an underlying handicapping condition which can be better assessed and treated with the range of skills available in hospital. School-children may be referred for similar reasons, or occasionally because treatment can be given in the hospital clinic more conveniently and with less loss of time in travelling than in that of the education speech therapist.

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4.20 Speech therapy is often organised on a hospital group basis rather than within individual hospitals. Hospital speech therapists do not necessarily, therefore, do all their work in the setting of a single hospital but may travel from one to another. Some hospital regions report an establishment without anyone in post, and others an establishment for one full-time speech therapist with only a part-timer in post. Thus it is clear that a substantial proportion of hospital speech therapists work single-handed, often isolated from other speech therapist colleagues.

Referrals

4.21 Our evidence showed that, despite the range of specialised medical knowledge available in hospitals, referrals were a source of dissatisfaction in the hospital as in the education service. Some of our witnesses felt that they were too often based on a misapprehension of the nature of the speech therapist's skill, or supplied her with too little information about the underlying condition. This was considered to reflect a general lack of knowledge of speech and language disorders in the medical profession. We return to this in 6.28-29.

Patients and Treatment

4.22 The patients seen by hospital speech therapists include:

(i) Pre-school children, particularly those suspected of late or abnormal language development;

(ii) children who are or have been under the care of a consultant in the hospital, or occasionally those who have been referred from the education service, including those with congenital neurological defect, cerebral palsy, or brain damage following an accident or illness, as well as those who have undergone mouth or throat surgery;

(iii) adults, including those who

(a) have undergone mouth or throat surgery, accidents, or strokes,
(b) are suffering from progressive neurological disorders,
(c) have voice disorders,
(d) are stammerers.

4.24 While the basic constituents of the hospital speech therapist's work - assessment, treatment, and advisory work - are the same as those of the speech therapist in the education service, the emphasis may differ. The hospital speech therapist is likely to be involved more often and more closely in the assessment

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of disorders, since in addition to the assessment which she makes of speech and language disorders in the patients referred to her, she may also be called in by a consultant to contribute her observation and evaluation of a patient's speech to his diagnosis of the overall condition. For example, the speech therapist's observations can be of assistance to the neurologist in assessing the amount of damage inflicted by a stroke or head injury, or by progressive neurological disease. As well as its therapeutic purpose, the treatment the speech therapist gives often has an assessment function.

4.25 One aspect of the speech therapist's advisory function is less prominent in hospital work than it is in the education service, since although the hospital therapist may from time to time enlist the help of nurses, occupational therapists, or physiotherapists, there is no-one in the hospital who stands in the same relation to the patient as the teacher does to the school-child with a defect of speech. The element of what could be termed personal counselling in the speech therapist's work is, however, more prominent in the hospital service, since the problems are more varied and complex. It falls to the hospital speech therapist not only to assist parents in managing their children's speech disorders, but to help adults who have suffered, for example, strokes or head injuries to come to terms with what may well be profoundly frustrating, irremediable defects in their ability to communicate and to make the most of impaired powers of speech, and also to prepare their families for the difficulties that will be encountered, enabling them to give help and support to the patient.

PRIVATE PRACTICE

4.26 Many speech therapists are prepared to undertake some private work in addition to their employment with an L.E.A. or in the National Health Service. There are also nearly 300 therapists listed in the College's directory as engaged only in private practice, although as we note in 5.5 the majority of these are in effect working part-time and do not make a large contribution to speech therapy as a whole. The College of Speech Therapists offers guidelines for sessional fees to private patients. It is possible that some married women have found that a little private work can more easily be accommodated with the demands of family life than employment, even part-time, with an authority which cannot allow the same degree of flexibility.

EFFECT OF VARIED ORGANISATION

4.27 Within the two broad categories of the education and hospital services, there is at present a variety of patterns of detailed organisation. The centralised hierarchical structure which works well in a densely populated, relatively compact urban area such as Leicester would be totally inapplicable to a scattered rural area where the population does not warrant a large service and hospital and other supporting facilities may be at a distance. Local arrangements have to be made with regard to local circumstances and the availability of existing resources. But there is little doubt that the diversity of patterns of organisation - most of which differ in everything save the fact that the speech therapy service is subordinate to another organisation - has helped to increase the sense of isolation and diffusion of effort which affects individual speech therapists and

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the profession as a whole. The resultant feeling of bewilderment and of being at the mercy of events was expressed by one speech therapist as follows:

There is no consistency of organisation ... each employing authority having its own methods. Speech therapists, therefore, can find themselves directly responsible to a Director of Education, Medical Officer of Health, Educational Psychologist, Child Guidance Department, E.N.T. Specialist, Neurologist or Paediatrician. Needless to say, it depends on these people's concept of Speech Therapy how much freedom of choice the Therapist has in choosing her cases and there is, naturally, a bias towards disorders of special interest to the person in charge.

THE TEAM CONCEPT

4.28 The concept of an inter-disciplinary team, working together particularly in assessment but also in the treatment of the whole patient, was put to us both as established good practice and as a desideratum by numerous witnesses. It can most clearly be seen in operation in the hospital, where the physical proximity of a range of disciplines makes constant consultation and shared responsibility easier, if by no means always achieved in practice. In the education service there are inevitably some geographical constraints on the development of a team approach, since the speech therapist may have to work for all or much of her time at a distance from colleagues in other disciplines. Nevertheless a team approach to assessment and treatment is being successfully employed, by means of regular meetings and case conferences, in several local education authority services.

4.29 The purposes and membership of the team varied with the setting and with the nature of the disorder being treated. Essentially, however, it was seen as a flexible instrument for continuous assessment, coordination of treatment, and discussion of progress. In the hospital it typically consisted of the consultant responsible (paediatrician, neurologist, plastic surgeon, as appropriate), the speech therapist, clinical psychologist and medical social worker. Other specialists, and the patient's family, were involved as necessary. In the education service, the rather more loosely-knit team might include the Child Health or Child Guidance Service, the educational psychologist, school medical officer, speech therapist and the child's teachers and family.

4.30 As the functions of assessment and treatment cannot be precisely divided from one another, it is not possible to specify exactly who might need to be involved in a given case. Assessment, particularly of young handicapped children, is often best carried out in an educational setting over a period of time: in these circumstances the class-room or nursery teacher has to be regarded as an integral part of the team.

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DUAL ALLEGIANCE OF THE PROFESSION

4.31 Speech therapy in Great Britain, in contrast with some other countries where there are consultant speech pathologists who are medical specialists, has not developed as a purely medical specialism. One reason for this is the close connection it maintains with education. This dual allegiance has its root in the history of the profession (2.06-07). It appears, however, to be more than an historical accident. The underlying causes of speech and language disorders are medical and psychological, and to assess and understand them the therapist needs a knowledge of anatomy, physiology, neurology and psychology. On the other hand, if her treatment is to be effective, she must understand learning processes and must possess the teaching ability to impart skills, arouse interest and encourage progress.

4.32 Considering speech therapy treatment as objectively as we could, and certainly without the accumulation of detail and associations that perhaps may sometimes obscure the individual speech therapist's view, we could see little difference in the skills needed, or the approach used, by speech therapists employed by a local education authority to work with children and those employed in a hospital to work with a wide age-range of patients. However, we saw some evidence of differences in attitude among speech therapists themselves. It is natural for the hospital speech therapist, whose work brings her into close contact with medical consultants and lays emphasis on the assessment function, to think primarily of the medical aspects of her work. The speech therapist in the education service, on the other hand, sees the intimate connection of speech and language with general development, social and educational factors and the application of her work to the teaching situation, and sometimes considers herself as almost another kind of teacher of handicapped children. To this extent, the present dual pattern is reinforcing a dichotomy within the profession.

5.01 What kind of people become speech therapists? How many of them are there? Are there enough to maintain the services described in the previous chapter? What sort of conditions are they working in, and what are the problems they face? The answers to these questions were in our view necessary to understand the present state of the speech therapy services and the anxieties of those concerned with them, whether speech therapists, patients, employers, or members of other related professions.

ACADEMIC AND PERSONAL QUALITIES

5.02 Most speech therapists embark on their training after leaving school at the age of eighteen, though a few older recruits are accepted by the schools of speech therapy every year. Entrants are nearly all girls - the College told us that in 1968-69 only 15 out of 764 applications for training were from men, and in the event only two of these were offered and accepted places; the 1971 intake included 5 men. As pointed out in 2.40 the effective minimum qualification for entry to training is 2 "A" levels, though 5 "O" levels was traditionally regarded as the formal minimum qualification: the careers leaflet "Speech Therapy", issued by the Youth Employment Executive, now states that students with less than 2 "A" levels are unlikely to be accepted. While in 1967 just under 15 per cent of students in training (excluding mature students) had less than 2 "A" levels, by 1971 the percentage had fallen to 4 per cent. Entrants to the B.Sc. course at Newcastle have to satisfy the university matriculation requirements: that is, they need a minimum of 2 "A" and 4 "O" level passes, and the Sub-Department of Speech requires one "A" level to be in either Biology or Zoology, with "O" level Chemistry or General Science. Speech therapy students therefore have academic qualifications equal in most cases to those of undergraduates, and the proportion of applicants for speech therapy training who withdraw on being offered places elsewhere shows that the speech therapy schools are increasingly in competition with universities and colleges of education. For those who persist in their application, however, speech therapy is by no means "second best": it is a chosen career to which they are prepared to make an early vocational commitment.

5.03 The length of training is the same as that for a first degree or teacher's certificate, but the qualified speech therapist has a more limited range of opportunities. The qualified teacher can in due course take advantage of well-established secondment arrangements to a variety of supplementary courses of training, but such opportunities are rarely available to speech therapists. Since the L.C.S.T. is not of itself generally recognised by universities as a qualification for post-graduate work and as financial support for advanced work is very difficult to get (10.22-28) the speech therapist's opportunities for pursuing an

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academic interest in her subject after initial training are very limited (unless she is a graduate of the Newcastle course). By contrast, selected students in all colleges of education have the opportunity of proceeding immediately from their initial training to a B.Ed. degree, and a graduate has open to him additional possibilities for employment or further training.

5.04 As is shown in Chapter 2, candidates for speech therapy training must demonstrate qualities of character which would be in demand in many other professions (2.41) and must meet the demands of an exacting training (2.42). Clearly speech therapists bring to their profession qualities of mind and personality which could readily lead them into other fields where the material rewards, and the scope for personal fulfilment and development, are greater. In the course of this chapter we shall be referring to evidence of widespread dissatisfaction and frustration in the profession. In spite of this, a remarkably high level of morale has in our view been maintained, and most speech therapists approach their work with a keen sense of vocation and are able to derive from it real satisfaction and interest, in whatever setting it is undertaken and whatever the attendant problems. Indeed, while there is some justified resentment, on the part of individuals, at lack of status and opportunity in the profession, we believe that it is the quality of speech therapists' concern for their patients which gives rise to the greater part of their frustrations. At present circumstances are such that speech therapists cannot give a service of the quality that they feel to be needed, or of which they feel themselves to be capable. We describe some of the reasons for this in the course of this chapter.

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NUMBERS AND DISTRIBUTION

5.05 Figures provided by the College of Speech Therapists showed a total of 1,283 individuals in practice in Great Britain in May 1971. A few working speech therapists are not members of the College and membership returns may not be quite complete, but this figure must represent virtually all the speech therapists working in Great Britain. Their distribution among the employing services is shown in the following table -

*Department of Education and Science Inspectorate Regions in England.
**Including speech therapy training schools.

It is worth noting how working hours are divided between the different types of employment. Figures from Department of Education returns show that at the end of 1970 the L.E.A.'s in England and Wales employed the equivalent of 509 full-time speech therapists, treating children of pre-school and school age. We estimate that a further 104 (full-time equivalent) were employed in Scotland (see Table II). The N.H.S., in September 1970, employed the equivalent of 209 full-time speech therapists, and data from a survey carried out by D.H.S.S. indicates that approximately 70 per cent of their time was spent in treating those over 16. The vast majority of the 292 speech therapists willing only to undertake private practice are married women working in what time they can spare from their domestic duties. A very limited amount of work is done in this way.

5.06 More than 99 per cent of practising speech therapists are women. At present there are only 9 male speech therapists in practice, a further 26 men who have qualified as speech therapists since 1944 having now taken up other professions or the practice of speech therapy abroad. This is in noteworthy contrast to the position in a number of other countries, for example the United States, where the sexes are more evenly represented in the profession, though with women predominating.

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5.07 Employers of speech therapists gave us abundant evidence of unsatisfied demand. A survey of English and Welsh local education authorities carried out in 1969 showed that out of 140 respondents, only 42 had managed to recruit their fully approved establishment of speech therapists, while 28 had no full-time speech therapists at all. Several authorities reported dismal histories of inability to recruit persisting over periods of years - "impossible to attract full-time speech therapist", "repeated advertising has not secured a qualified speech therapist", were typical comments. Indeed, the Bulletin of the College of Speech Therapists for February 1972 carried advertisements for over 100 vacancies in the United Kingdom alone. It is not surprising that authorities sometimes offer rates of pay above the Whitley Council scales in an attempt to attract and retain staff, though their difficulties are greatly aggravated by counter-attractions elsewhere. For example, the same issue of the Bulletin advertised a post in Canada with a commencing salary of £3,000, where even this pay scale was in process of being raised.

5.08 It was pointed out to us that official establishment figures are based less on need than on a realistic assessment of likely recruitment. As one director of education told us, increasing the establishment of speech therapists is "hardly worthwhile if a sufficient supply of speech therapists is not available". The fact that employers are unable to fill vacancies even where establishments have been based on fairly pessimistic assumptions indicates that the shortage of speech therapists is acute.

5.09 As a result of a survey of the prevalence of speech defects in school-children carried out in 1945 by the Senior Medical Officer of the Ministry of Education (as it then was), a ratio of 1 speech therapist to 10,000 school population was suggested to L.E.A.s as a reasonable basis for establishments. This ratio is still used by many local education authorities, though not by all. Table II

*As Scottish statistics are collated in July rather than December, the figures given are an average of those for July 1970 and July 1971. Full-time equivalent figures for speech therapists employed by education authorities in Scotland are not collected: the figure in column 5 was arrived at by counting each part-time therapist as 0.5 full-time equivalent. This means that there may be rather fewer speech therapists in post in Scotland than stated above.

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6.01 Our terms of reference require us to "consider the role of speech therapy in the field of education and of medicine". In Chapter 3, we describe the range of the disorders of communication and give a brief indication of the various ways in which speech therapists are involved in their management. We now consider in more detail the nature and extent of the speech therapist's work at present, and where appropriate suggest changes that we would wish to see in future. In doing this we do not wish to be considered as having defined once and for all the kind and extent of the speech therapist's concern, or as having provided a complete or still less an immutable blueprint for future development. In its brief lifetime the speech therapy profession has convincingly demonstrated its vigour and ability to assimilate ideas and respond to the rapidly growing body of relevant knowledge. Our hope and confidence is that this vigorous growth will be sustained, and in the process a number of the views which we now put forward will inevitably be overtaken or modified.

6.02 The evidence put to us nevertheless showed that there is, at present, considerable uncertainty among speech therapists themselves, and among members of other professions with whom they work, about the functions and responsibilities which it is proper for them to assume. Interpretations of the speech therapist's role vary not only from one profession to another, but also among individual members of the same profession. The majority of our medical witnesses, for instance, clearly saw speech therapists as medical auxiliaries responsible to hospital consultant or school medical officer, but a minority saw them as an autonomous profession to be consulted on a basis of professional equality. This distinction was reflected in the various patterns of organisation described in Chapter 4. Speech therapists themselves differed in their views of their functions, the amount of responsibility they should carry, and the degree of affinity of their work to medicine on the one hand and to education on the other. We offer our views on some of these problems in the hope that they will be of some help in clearing the ground and establishing a firm basis from which other questions, such as the appropriate training for the profession and its proper status, can be realistically evaluated.

THE NATURE OF THE PROBLEMS

6.03 We realised early in our work that there were very few statements we might make about the role of the speech therapist which would not be challenged by one or other of our witnesses. The scope of speech therapy as a branch of knowledge, the extent of the speech therapist's responsibility, and the kinds of patients and disorders which could benefit from speech therapy - all were subject to differing interpretations.

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6.04 The majority of our witnesses concurred in distinguishing, in the service offered by speech therapists, four elements: assessment, treatment, advice to patients and their families and an additional role, combining advice, teaching and the provision of information, in relation to teachers and members of other professions concerned with communication disorders. However, the interpretations of these functions and the emphasis placed upon them varied from witness to witness to an extent which went beyond the blurring and merging of functions that might have been expected. There was controversy about the extent to which the speech therapist's function could truly be said to be a diagnostic one. There was disagreement about the degree of the speech therapist's responsibility for treatment, and about the extent to which treatment is central to her work. Her advisory functions appeared to be less controversial, but raised questions of the degree of involvement desirable and the establishment of priorities.

6.05 There are some categories of patients whose ability to profit from speech therapy is open to dispute, and some for whom the possible usefulness of a speech therapist's involvement has to be set against the greater relevance of other professions to their particular problems. These groups include the deaf and partially hearing (6.31-38), those with delayed language development due to environmental or cultural factors (6.40-43), learning problems (6.44-46), autistic children (6.47), and those who need to be taught alternatives to verbal communication (6.48). The degree to which speech therapists would be involved with some other groups of patients, such as young children and the mentally handicapped (6.51-54), was considered likely to increase in the coming years.

6.06 Lastly, but perhaps most important for the future, there is the question of the potential for development of the profession as a whole. The College of Speech Therapists, probably wisely, avoided being sharply definitive about the nature of speech therapy: the nearest they came to such a statement was to say that 'the speech therapist's role is to assess and devise means of ameliorating disorders affecting speech which may also include disturbance in the use of written language'. Their supplementary evidence made it clear that they considered delayed or impaired language ability to fall within this definition. Nevertheless their approach was markedly more conservative than that of one speech therapist, who stated that "the speech therapist is concerned with all conditions which impair human communication". Several other witnesses also foresaw for speech therapy a wider involvement with all aspects of the communication process, based upon a more profound understanding of linguistics, psychology, neurology and communication theory.

REFERRALS

6.07 In the account of the work of the speech therapist given in Chapter 3 it is made clear that the usual procedure is for referral to a speech therapist to be made by a doctor, though references from non-medical sources might also be accepted. Various procedures for referral were reported to us, and are described in Chapter 4. Basically, however, these divided into systems whereby patients could be referred for speech therapy only by a doctor, and those where referral could come from a parent, teacher or the patient himself without medical

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intervention. Each system had its advocates, and we considered very carefully what recommendation we should make in this field.

6.08 While the analysis of disorders of language ability is the province of the speech therapist, the diagnosis of the underlying causes of disorders (as well, of course, as the frequent concomitant disorders) must be the responsibility of a doctor. Naturally there will be cases where a careful analysis of a patient's speech will tell the experienced therapist a good deal about the nature of the underlying abnormality, and enable her to make a provisional diagnosis. Nevertheless, she is entitled to expect a precise diagnosis and full medical description of the patient's condition before she plans treatment. To take a simple example, it may be easy enough for the speech therapist to recognise the presence of a cleft palate, but it is the doctor's responsibility to see whether there are other associated congenital abnormalities: these occur in perhaps a third of cleft palate patients and may include mental defect, mild cerebral palsy, hearing impairment, congenital defects of the heart and abnormalities of the eyes. It should also be the doctor's responsibility to arrange whatever further specialised investigations may be needed.

6.09 It would appear on the face of it that referral through a doctor would offer the best means of ensuring that a full and properly ordered diagnosis is made and that the medical, psychological, and social factors influencing the disorder of speech or language are identified. We cannot, however, ignore the considerable evidence that referrals from doctors are at present by no means adequate. This is touched on in 4.13 and 21. At present, many doctors (even some neurologists) lack the necessary interest in and knowledge of linguistic disorders, of the part which the speech therapist is equipped to play, and of the background information that she needs. Some general practitioners, for instance, are inclined to underestimate the significance of delayed or abnormal speech development and to give unwarranted assurance to worried parents that a child will outgrow his difficulties: in such cases there may well be a place for direct referral to the speech therapist by parents, teachers, or others.

6.10 Even when the present level of understanding of communication disorders in the medical profession has improved, as we hope it will (6.29), we consider that there will continue to be a place for direct self-referral of adult patients. Many young people, particularly stammerers, refer themselves for speech therapy when they reach an age at which they are conscious of the disadvantage caused them by their speech problem. A rigid insistence on referral through a doctor might deter such patients from seeking treatment. Our conclusion was, therefore, that while the majority of referrals should come from a medical source, there must be room for the individual speech therapist to use her discretion in accepting referrals from non-medical sources, though she must recognise that in every such case she assumes a responsibility for ensuring that her treatment is based on adequate medical examination and advice.

6.11 We therefore recommend that initial referrals for speech therapy should in normal circumstances be made by a doctor, with further specialist examination where necessary. Where, for whatever reason, a referral from a non-medical source is accepted, a relevant medical opinion must be available at as early a stage as is practicable.

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ASSESSMENT

6.12 We state above that the speech therapist should not be expected to be responsible for identifying the medical, psychological and social factors which may be involved in communication disorder. These must remain the responsibility of medical specialists, psychologists and, where appropriate, social workers or health visitors. However, we do not consider that the speech therapist's contribution to the diagnostic process is limited to the identification, for her own purposes, of the nature and severity of the particular communication disorder.

6.13 Delayed or impaired language ability may, as we have shown in Chapter 3, occur as a sign or consequence of numerous conditions, many of them exceedingly complex. Assessment, particularly in children, may be a difficult and lengthy process. In some cases several handicaps may be involved and assessment of the child's capacity for treatment or education may involve the skills of a variety of professions, according to the nature of the disability and the patient's age. The doctor and psychologist, for example, might be responsible for the diagnosis of mental retardation in a child; the speech therapist would be responsible for assessing the degree of retardation of the development of language ability. In an adult who had suffered from a cerebro-vascular accident the doctor's role would be to diagnose the nature and extent of the brain injury; the speech therapist would assess the nature and severity of the disorder of language ability which resulted and the degree to which the patient's comprehension of language (written and spoken) was impaired. In ideal conditions doctors, psychologists, social workers, teachers and nursing staff should work in close co-operation with the speech therapist in the diagnosis and assessment of the patient's speech disorder. When co-operation is close and there is mutual understanding between these experts the lines of demarcation between their different roles tend to become blurred so that speech therapists often contribute to the medical and psychological diagnosis and the doctors, psychologists, nurses and teachers assist in the recognition and assessment of the patient's speech disorder.

6.14 Where assessment is a team undertaking, the various insights of different professions, pooled and discussed, can help to produce not only a diagnosis of the basic disability but also a complete picture of the patient's problems and potential, together with a co-ordinated plan for treatment. In a number of cases such co-operation is essential to success. For instance, in the case of a spastic or multiply-handicapped child, the neurologist and the paediatrician may both be involved and responsible for part of the treatment, as well as the physiotherapist and those responsible for assessing educational potential and planning education. In cases of injury or structural abnormality, particularly damage to the lips, tongue and palate resulting from accidents, the accident surgeon, the rehabilitation physician, the orthodontist, the faciomaxillary surgeon, and the plastic surgeon may all be involved. The initiation of speech therapy, if it is indicated, will often have to depend upon the timing of the treatment given by these specialists. Outside the hospital setting, the speech therapist will need to be aware of the involvement of the general practitioner and of the assessments of social workers, educational psychologists, child guidance staff, and teachers. Whether in the hospital or in the community setting, the speech therapist

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should clearly be a member of the assessment team and she is entitled to expect clear indications of, for instance, the nature and extent of any damage to articulatory organs or related structures, or of any underlying social or emotional problem. She should also be informed of what action is being taken by her specialist colleagues in various fields and the expected results of treatment. In turn the speech therapist has a great deal to offer the other specialists from her assessment of the nature and severity of the disorder of language ability and her suggestions as to how her treatment may help.

6.15 Not every case referred for speech therapy will require consideration by an assessment team at the level we have been envisaging, and not every therapist will have an opportunity to spend part of her time as a member of such a team: some will inevitably have to work in isolated conditions. We consider nevertheless that an extension of involvement of speech therapists in assessment teams would have its effect also upon those not directly concerned. A habit of consultation would be established which should give the opinion of the individual therapist more weight and make it easier for her to elicit the advice and cooperation of colleagues in other professions.

6.16 We therefore recommend that the speech therapist should be regarded as an integral member of the assessment team for any patient with disordered speech or language and that the practice of team assessment should be vigorously extended.

6.17 Even with a growth in facilities for team assessment, most speech therapists will for a long time to come have to carry out the majority of their assessments on their own. In our view "assessment" is an integral part of the speech therapist's work and a significant amount of her time will have to be devoted to it, in whatever context it is undertaken. Evidence from a survey carried out by the College showed that therapists were spending an increasing proportion of their time on assessment. We welcome this tendency as an indication of a broadening of the speech therapist's outlook, an increase of her interest in the root causes of the disorders she treats, and an attempt to provide a firm basis upon which to plan treatment.

TREATMENT

6.18 We are fully aware of the central importance to the speech therapy profession of its therapeutic skills. Though speech therapy draws on many disciplines for its background knowledge, its therapeutic techniques are its own, evolved by a continuing process of development, absorption from other disciplines, and experimentation, since the beginning of the profession. Some of these skills are sketched in Chapter 3: at present, the speech therapist alone can supply them and she is without the opportunity of delegation. In view of the shift of emphasis within the profession toward assessment and guidance, and the demand for the involvement of speech therapists over a wider spectrum of communication disorders, we do not think that this situation can continue. While we are convinced that the care of the patient should continue to be the heart of the speech therapist's practice and training, and while we would very much regret any diminution in her mastery of clinical skills, we consider that in future, if the best use is to be made of her knowledge and training, there

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must be some formalised arrangement for the delegation of certain routine aspects of her work. In some cases, once an assessment has been made and treatment planned, treatment itself contains an element of stimulation and practice. We consider that there are aspects of the present work of speech therapists which could be carried out by personnel with a minimum of expertise, provided that they are working under the supervision and control of a therapist. We explain the development we have in mind more fully in 7.39-44. It would enable the speech therapists to make the contribution to assessment (and also to research and development in the profession, cf Chapter 10) which they are fitted by their training to make and towards which their interests are already leading them. The ultimate responsibility for devising, supervising and carrying through treatment must, however, remain the therapist's, and should be regarded as her basic role.

6.19 We therefore recommend that while the scope of the speech therapist's knowledge and competence will change, her responsibility for devising therapy (and, where appropriate, for carrying it out) should remain fundamental.

6.20 Just as treatment is the central core of the profession, so it is in this area that the therapist should enjoy the maximum professional independence. The College of Speech Therapists told us that

Acceptance, treatment and termination of clinic attendance, is rightly in the hands of speech therapists in the majority of cases. In a number of places, and too frequently, such responsibility appears to lie elsewhere: doctors, head teachers, teachers of the deaf, psychologists and clerical staff carrying out those functions which are fundamental to the speech therapist's case management.

Difficulties of this kind are in our view among those which will disappear as knowledge and understanding of the profession increases, and particularly as joint assessment and treatment become more usual. But we do not consider that other specialists should arrogate to themselves the responsibility for deciding which patients are to be accepted for speech treatment, what methods of treatment are to be used, and the point at which treatment is to be discontinued. These matters are solely within the professional competence of the speech therapist.

6.21 The speech therapist working as a member of a team, or in circumstances where relationships are good and access to other specialists easy, will often wish to plan treatment in conjunction with the otolaryngologist, psychiatrist, or general physician who has been responsible for the diagnosis, so that therapy may be co-ordinated with other medical, surgical or psychiatric treatment. A co-operative approach will provide the best guarantee against ineffective or harmful speech therapy.

6.22 We therefore recommend that the acceptance of cases, and planning and termination of treatment, should be recognised as the speech therapist's prerogative, but that in carrying out these functions she should have regard to the value of interdisciplinary consultation and co-operation.

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6.23 Treatment can have two possible aims: the establishment or restoration of language ability in those who have developed it imperfectly or in whom it has been lost or impaired; and support for those in whom no eventual improvement can be expected. While resources remain scarce, choices will have to be made.

In any overall planning of services or resources, priority would clearly have to be given to patients in whom language ability could be established or restored. Speech therapists will wish to continue to decide, on an individual basis, how much time they can afford to devote to therapy which is entirely supportive in its aim, just as they decide other difficult problems of priorities between patients. We do not consider that this is an area in which a recommendation would be appropriate.

ADVICE, TEACHING AND INFORMATION

6.24 In addition to direct treatment, speech therapists advise patients and their immediate families. The aim may be to prevent the development of an incipient disorder in a very young child by early assessment and timely advice, or to enable the family to reinforce the therapist's treatment, or to assist both patient and family to come to terms with an irremediable impairment of language ability, for instance in some post-stroke patients. A good illustration of the way in which the therapist may become involved not only with the patient himself, but also with his family and people in his social environment, is the treatment of stammerers. Once a child with a stammer has been examined to exclude the possibility of neurological damage or emotional stress, it is for the speech therapist to organise appropriate treatment. It is essential therefore that the speech therapist should not only treat the child, but also keep in close contact with his parents, family, teachers and others who see him frequently. With adult stammerers, the speech therapist's task is frequently a very difficult one and involves a consideration of the patient's personality, his environmental circumstances, the situations in which he is particularly liable to stammer and his attitude to previous (usually numerous) attempts to help him. The therapist's main aims are firstly to diminish the severity of the stammer and secondly to improve the patient's adjustment to his speech disability and thus to his environment, particularly if he has reached the stage of avoiding talking. Adult aphasics provide another example; as well as preparing the family for changes in the patient and advising them on how to help, the speech therapist may also accompany her patients, for instance on public transport or on shopping expeditions, to give them confidence in their ability to speak in a public situation. Insofar as it contains an element of "manipulating the environment" in the patient's favour, this aspect of the therapist's work is akin to that of the social worker. Its borders with social work ought, however, to be readily definable in terms of the type of problem involved. It is an important skill in itself and its exercise makes very considerable demands upon the therapist's tact, maturity and imagination.

6.25 Speech therapists are often called upon to advise other professions on the management of those with speech or language disorders or to participate in solving other problems which may bear some relation to language ability. The obvious example is advice to teachers to enable them to reinforce the therapist's work with children with defects of speech and language. There are, however,

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other more controversial areas in which the speech therapist's advice is solicited, often without her being expected to involve herself directly with the patients concerned. We examine some of these later in this chapter. Here we would say only that, in considering how much help of this purely advisory kind speech therapists should give, it is not enough to take account only of the speech therapist's relevant knowledge and expertise. It is also necessary to consider whether there are other professions, more closely concerned, which have relevant knowledge to offer. Otherwise the speech therapy profession could be impeded in carrying out its own proper functions, by the task of offering advice in areas not its main concern.

6.26 At present speech therapy is too little known and understood by other professions and by the public at large. There is an important teaching and information function to be fulfilled; this work is already being undertaken by a number of speech therapists, but its development is hampered by the current shortage of staff and pressure of other demands. We consider that there is scope particularly for more information and publicity to doctors and teachers, and to school leavers who might be attracted to the profession.

RELATIONSHIP WITH OTHER PROFESSIONS

6.27 It is evident that in order to fulfil the role we have described, speech therapists depend very greatly upon the informed co-operation of other professions. We have already mentioned the importance we attach to a team approach to assessment and treatment, and to the ready availability of advice from teachers, nurses, psychologists and social workers as well as medical specialists.

6.28 Unfortunately there is evidence that inter-professional co-operation at present is often impeded by lack of understanding and appreciation of the speech therapist's work, and by want of interest in the disorders of communication. As we have said in 6.26, speech therapists can do something to help themselves in this area. There is, however, little that an individual speech therapist can do if, for instance, the paediatrician in her area is not interested in language disorders. One of our witnesses went so far as to say that "few consultants make any pretence to know anything about disorders of speech", and a doctor working in the field of hearing and speech impairment told us that

Medicine, with certain notable exceptions, has neglected disorders of speech and language during the last half century. No medical student is taught the elements of language development (or) linguistic theory. Yet disorders of spoken language are common to neurology, accident surgery, paediatrics, psychiatry and otolaryngology (including audiology).

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Todd Report, 276, 397). We consider that this will be facilitated by the development of joint courses of study leading to a career either in speech therapy or in other professions (9.20). In some countries the speech therapy profession is headed by medical specialists in speech disorders. We considered that such a development would cut across too many existing specialisms to be universally valuable here. We hope nevertheless to see the emergence in future of a greater number of, for instance, paediatricians and neurologists with a special interest in disorders of speech and language. There is no reason why courses of advanced and specialist work should not be devised at post-graduate level to provide for speech therapists, psychologists, teachers, paediatricians, neurologist and others, who would as a result become eligible to be consultants in speech pathology. (9.29.)

INVOLVEMENT OF SPEECH THERAPISTS WITH SOME PARTICULAR GROUPS OF PATIENTS

6.30 The extent to which speech therapists should be involved in the management of some groups of patients remains open to question, either because the particular disability is not yet fully understood, and it is hence difficult to assess the contribution that a speech therapist might make, or because other professions have a more direct interest.

The Deaf and Partially Hearing

6.31 It was generally agreed that speech therapists could play a valuable part in maintaining speech in those who became deaf in adult life. Patients who suffer from acquired hearing loss tend to become extremely depressed by their inability to comprehend what is said to them and by the fact that they cannot correctly monitor their own spoken language. They have the advantage over the child who suffers from congenital deafness, however, in that they have had the opportunity to acquire full and secure patterns of spoken language which can be preserved with minimal impairment provided communication with other people can be continued. This entails teaching the irremediably deaf adult to lip read and indicating his errors of articulation to him, since he cannot hear them himself. Speech therapists can treat the articulatory disorders in such patients more or less directly, while at the same time, alone or with specialists in teaching deaf adults, they may be able to help them to learn to lip read. In acquired partial hearing loss speech therapists may play a most useful part in showing the patient how to get the most advantage from his hearing aid.

6.32 The role of the speech therapist with deaf or hearing-impaired children appeared to be much more debatable. We had evidence that speech therapists were working successfully in audiology units and in assessment teams dealing with all aspects of linguistic disorders. Several witnesses, as we mentioned in paragraph 6, took a view of the function of speech therapy which implied the underlying unity of the communication process, and hence the potential relevance of speech therapy to all aspects of communication disorder. By contrast the profession mainly responsible for the care of the deaf and partially hearing - the teachers of the deaf - took a much more restrictive view. The National College of Teachers of the Deaf, representing mainly teachers in schools for the deaf,

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suggested that speech therapists might need additional help to appreciate fully the cognitive aspects of speech development as opposed to articulation, yet conceded (apparently unaware of the contradiction) that they are already helpful in the treatment of children with handicaps additional to deafness, including cerebral palsy, aphasia and language disorders. The Society of Teachers of the Deaf, representing mainly the peripatetic service for partially-hearing children in ordinary schools, took the view that the speech therapists' primary function is the establishment or restoration of articulation, and that their proper sphere of work appeared to be the treatment of functional speech disorders.

6.33 In our opinion this view of the function of the speech therapist is unjustifiably and unrealistically narrow, ignoring as it does her training in language development and the experience acquired by many of them in the management of the full range of language disorders. Nor do we believe that hearing disorders and speech and language disorders can readily be separated or treated in isolation from one another (cf. 3.05f). Rather we take the view that there is always interaction between the various aspects of language processes - visual, auditory and executive - and communicative ability should be treated as a whole rather than by attention to its component parts - ear, brain, speech organs, etc. We accept the point made to us by the Society, in oral evidence, that the concern of the teacher of the deaf for the hearing-impaired child involves the whole field of his education and in this respect is necessarily wider than that of the speech therapist. It would be absurd to suggest that speech therapists could replace teachers of the deaf. We accept also that there are unfortunate cases where inappropriate speech therapy is given, because a hearing loss has not been detected. To help meet this situation we recommend that no child should be given speech therapy until proper assessment of hearing has taken place.

6.34 On the other hand, we are convinced that a proportion of children in schools for the deaf fail to make the progress of which they are capable because their disability includes an element which has not been understood. Children suffering from a very severe developmental speech disorder are easily taken to be deaf, and often it is only by repeated observation in a speech clinic or prolonged observation in an inpatient unit that the actual nature of the underlying disorder becomes apparent, even with the help of modern techniques of hearing assessment and the detailed studies made by clinicians. Patients in this category have been said to suffer from "severe auditory imperception" or to manifest the condition of "central deafness" - diagnoses which imply that though the hearing mechanism is intact there is some failure of the perception and realisation of the significance of sounds in the brain. Children with this type of relatively isolated language disability require detailed study by a paediatrician or neurologist (or preferably a paediatric neurologist interested in speech disorders) so that any evidence of past brain damage or current disease which may be shown by detailed history taking and examination can be diagnosed, and any necessary additional investigations made. On the other hand the analysis of the language disorder itself is the province of the speech therapist who should be able to determine the extent to which the child's difficulties of spoken language are due to inability to recognise what is said to him, and the extent to which they are due to his inability to express his thoughts in meaningful spoken language.

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6.35 In addition to these special cases, we believe that speech therapists may also have something of value to contribute in schools for the deaf. There was some evidence that the stimulation of language and training of speech in some of these schools was not as thorough and systematic as it should be.

6.36 We were pleased to find that, whatever the reservations expressed by the spokesmen of these specialist teachers, individual teachers of the deaf were co-operating fruitfully with individual speech therapists in a number of settings. We received a most interesting account of joint management by a speech therapist and a teacher of the deaf of a class of young children who showed signs both of language disorder and of hearing loss. Something of what each profession can learn from the other can be indicated by quotation. The teacher of the deaf told us

If we are honest, I think we can both admit now that in the early weeks the professional defences were a barrier at times ... my association with (the speech therapist) has taught me to look at my language teaching far more analytically - WHAT I teach, HOW I teach it and HOW the child learns. A speech therapist also has diagnostic skills which help her to pinpoint problems and disorders of speech and language of which I may be only dimly aware ...

(We) have found it necessary to spend at least one afternoon a week (at a minimum) discussing the progress of each child and planning the next steps ... this means the listing exactly of vocabulary to be taught, the syntactic concepts, the pitch pattern, the stress patterns, the actual speech sounds. ... As an offshoot of these planning sessions (we) have a wonderful chance of painlessly and almost unknowingly learning from each other's comments and insights. For instance, I have learnt a great deal about the techniques of motivating children in a group situation to communicate with the language they have. I have seen ways of encouraging creativity in children who usually have such an impoverished imagination ... I think we still retain separate identities and most people would know that we come from two different professions. ...

6.38 We therefore recommend that as speech therapists have a contribution to make to the management of the deaf and partially-hearing, they should continue to seek opportunities to work with teachers of the deaf and others concerned on a co-operative basis and not merely as auxiliaries.

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Stammerers

6.39 Though stammering is the defect of speech best known to the man in the street, and the one with which speech therapists are most obviously associated in the public mind, its complexity makes some speech therapists doubt whether they should undertake to treat it in the present state of knowledge. On the other hand, evidence and the experience of our speech therapist members indicate that successful results are currently being obtained in intensive group treatment, where interaction between stammerers can be facilitated. We believe that resources would be best used in concentrating treatment for stammerers in regional centres, where therapy of this kind could be given in close collaboration with other professions concerned.

Language Deprived and Immigrant Children

6.40 A child brought up in an unstimulating environment, where he is not talked to or played with sufficiently and has restricted scope for his curiosity, will probably be slow in developing language ability. Provided that there is no underlying pathological language disorder, and no mental or hearing impairment, such children are best helped by being placed in a more stimulating environment, such as a nursery class or a play group. There can be no doubt that the training of speech therapists equips them very well for the task of stimulating language in these children. We do not consider, however, that speech therapists ought to extend their work to include this task. It is clear that the culturally deprived are potentially normal linguistically and that their disabilities, not being of pathological origin, do not in general require the attention of a clinical specialist. In our view the role of speech therapy in this context should be limited to assessment of the stage of language development of pre-school age children, so as to identify those in need of special help.

6.41 A similar problem occurs in an acute form among immigrants, where "first language interference" can cause failure to develop normal English speech. This is nothing more than the ordinary problem of anyone learning a foreign language, made more serious in this instance by social or educational problems. We consulted a wide range of people professionally concerned with the teaching of English to immigrants and found that the consensus of opinion was that, while the therapist possessed phonetic and linguistic knowledge that well might throw light on the children's difficulties, these did not justify deploying so rare a resource where there were no pathological complications. The speech therapist's role should not in normal circumstances go beyond assisting with the assessment of language development. The problems involved are distinctly educational ones and both theoretical and practical solutions should come from the teaching profession. A number of studies are already in hand.

6.42 But a further difficulty among the immigrant child population is that the difficulty in mastering English may in a small minority of cases mask a disability of pathological origin. These cases are, of course, precisely the concern of the speech therapist. There is a need for test material to help both teachers and therapists to identify such cases and this might well be developed jointly. Treatment may have to be given in a language still unfamiliar to the child and perhaps unknown to the parents, who cannot therefore be relied upon to

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support the therapist's work. We consider that there is a case, particularly in areas with a large immigrant population, for the provision of a few therapists capable at least of communicating with parents in their native language.

6.43 We therefore recommend that the speech therapist's role with language deprived or immigrant children should be limited to assessment of language development, except where a pathological defect is observed or suspected.

Problems of Learning

6.44 It was suggested to us in evidence that speech therapy could assist with a variety of learning problems, particularly difficulty in learning to read, even when no overt speech or language disorder was present. In particular, it was suggested that children suffering from specific reading difficulty (sometimes called "dyslexia") had often shown an earlier history of delayed or disordered language development.

6.45 We have no wish to enter the present controversy about the nature, and indeed the existence, of "dyslexia", nor into the question of the relevance of speech therapy to learning problems of this kind, though we expect the profession as a whole to maintain an interest in this field, and individuals perhaps to participate in research in it. There is little doubt, however, that the learning problem of a child suffering from word-sound difficulties associated with retarded development of language ability will be lessened by any treatment designed to accelerate the development of language. When a child who has been seen because of abnormal language development attends school for the first time, the speech therapist should, as a matter of routine, ensure that the teachers concerned are aware of the history of language difficulty.

6.46 We therefore recommend that speech therapists should ensure that teachers are informed of a history of late or impaired language development, to alert them to the possibility of future learning problems, but should not at present attempt to give further professional help unless an overt disorder of spoken language is present.

Autism

6.47 The condition now generally known as infantile autism is still imperfectly understood and it is not therefore possible to assess the value of speech therapy in the management of these children. There is some experience to suggest that some of them can benefit from the speech therapist's skill in developing a one-to-one therapeutic relationship, and also from her knowledge of language development which may enable her to break down the language learning process into sufficiently small and methodical steps to overcome the child's communication difficulty. A therapist working with autistic children needs the help of a psychiatrist and, often, of a social worker. She must also obviously work in the closest possible co-operation with the child's teacher.

Non-Verbal Communication

6.48 There are certain patients in whom spoken language cannot be established or restored. Some children with receptive aphasia or cerebral palsy never develop useful speech and there are also those children who are both deaf and

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blind. In such circumstances it is highly desirable to establish some means of non-verbal communication. Speech therapists who work with these groups (who will normally be found in special schools) are usually aware of and interested in the possibility of developing systems of communication for these children, and it is in our view reasonable that they should undertake this work in co-operation with the children's teachers. This is not a skill that will be needed by the majority of speech therapists. It appeared to us that a number of projects in the field of non-verbal communication were going forward in isolation, and that if the sphere of communication open to these children were to be as wide as possible some co-ordination of effort would be needed.

Subsidiary Tasks

6.49 No consideration of what a therapist should and should not do would be complete without mention of the considerable proportion of her time that has at present to be spent on work which is only marginally relevant to her central task of caring for patients. We think it deplorable that scarce and highly-trained personnel should, as we show in 5.26, be expected to spend time in tasks such as arranging, confirming and cancelling appointments, typing routine correspondence, filing, preparation and maintenance of materials for use in treatment, and so on. We consider too that as we have said in 6.18 there are aspects of the treatment of some disorders which, once an assessment has been made and treatment planned, are largely a matter of routine supervised practice. We consider that speech therapists, while retaining a close responsibility for such subsidiary aspects of their work, ought to be able to delegate its performance and we propose a means of achieving this (7.39-44). Lastly, we consider that priorities within the service may not in all cases be the best that are possible and that resources are sometimes applied to desirable, but less essential, work at the expense of the greatest needs. This is a matter for professional examination, especially where the new organisation that we recommend enables an experienced speech therapist to look at and influence services in a whole area or even throughout the country (8.35).

AREAS OF GROWTH AND FUTURE DEVELOPMENT

6.50 Any attempt to predict areas of future growth and the direction of developments must of necessity be speculative, since much will depend on the results of research in other fields. Many suggestions for increased use of speech therapy services were made by our witnesses, usually - as is natural enough - in their own individual fields of interest. It is, however, possible to discern some areas where an expansion of services will be essential. Numbers in some categories of patients are likely to increase because of, for example, the increased rate of survival of handicapped children, increased danger of road accidents, and the growing proportion of elderly people in the community: cf. 7.16. There are, however, other areas where the demand for speech therapy is likely to grow because the need for it is increasingly being recognised. Two clear examples are pre-school age children and the mentally handicapped.

Pre-School Age Children

6.51 We have already commented at a number of points on the value of early detection of language delays or impairment. Direct treatment of very young

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children will not necessarily be appropriate, but early detection will enable parents to be counselled and supported (so as often to prevent an incipient disorder from developing) well before the child himself becomes conscious of any disability. Speech and language difficulties can also be useful indicators of the presence of various disorders and can provide an early warning, for teachers and others, of problems that may occur later. The importance of early detection of all kinds of handicap is increasingly being recognised and most of our witnesses insisted upon the importance of an extension of screening and assessment facilities for young children. Growing understanding of language development is now making it possible to detect abnormalities very early, sometimes before the age of two: the progress of such children can then be kept under review until the problem resolves itself or until direct treatment becomes appropriate.

Mental Handicap

6.52 Speech therapy now has an established place in the treatment and education of the mentally handicapped, though shortage of resources and pressure of other demands have restricted its development. With the assumption by the Department of Education and Science of responsibility for the education of severely mentally handicapped children there is a new interest in their educational potential and the paramount importance of the establishment of communication and the development of language is increasingly being recognised. A great deal can be done for mentally handicapped children from "non-talking" homes by a speech therapist who recognises the nature and complexity of the child's problems, by encouraging the family to approach the child in a more helpful manner and by providing, directly or indirectly, stimulus to language development.

6.53 In institutions for mentally handicapped adults it has been found repeatedly in recent years that the speech therapist working with mental nurses can encourage communication using spoken language to a marked degree. Group therapy is particularly valuable ill helping previously bored, silent patients to communicate with each other and with the nursing staff. Many mentally handicapped patients have a very restricted social environment if they live at home, especially if they have associated physical defects such as spina bifida, cerebral palsy, or are suffering from paralysis or incoordination of voluntary movement as a result of traumatic brain injury or other damage to the brain. If these patients can be brought together regularly, for instance at a day-centre, the speech therapist may perform a most useful service by acting as a group leader for discussion of news offered by individual patients; she can comment on their achievements and opinions and relate them to a wide environment. The speech therapist may also contribute greatly to the welfare of such patients by advising physiotherapists, occupational therapists and others about her methods of treatment.

6.54 We therefore recommend that in the future development of the speech therapy services the first priorities should be

(a) The provision of facilities for the early detection and assessment of delayed or abnormal speech and language.

(b) The provision of services for the mentally handicapped.

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SPECIALISMS WITHIN THE PROFESSION AND ALTERNATIVE PATTERNS OF TREATMENT

6.55 At present the training for speech therapy is a general one and there is little opportunity for pursuing special interests through post-Diploma study. Nevertheless, it is notable that a number of speech therapists, particularly those employed in special schools, in fact develop specialised expertise. We consider that in future this specialisation is likely to become more systematised and should be linked to specialised courses of training: we return to this in Chapters 9 and 10. In our view the particular problems posed by cerebral palsy, congenital and acquired aphasia, and mental handicap are fields in which specialisation might with advantage develop further.

6.56 There is already some pressure for new patterns of speech therapy treatment, other than short periodic treatment sessions, usually at weekly intervals. We have already mentioned (6.39) the development of intensive courses of therapy for stammerers: these usually last a fortnight in a group setting. We hope to see expansion of this provision and further experimentation with group and intensive therapy. Special units attached to primary schools, where severely speech handicapped children can receive intensive therapy, are increasingly being provided, and there is some demand for domiciliary speech therapy in the patient's home, in particular for elderly patients, where such an approach would fit in with the trend towards community care rather than institutionalised care for the old. So far, as we said in 5.21, pressure on individual speech therapists has meant that few such experiments have been possible and those that have been made have not been properly evaluated. In future, however, particularly if the therapist can as we have suggested be relieved of subsidiary and extraneous tasks, we would expect to see a new flexibility of approach to patterns of treatment.

New Techniques of Treatment and Diagnosis

6.57 As we stated at the beginning of this chapter, it is not possible for us to predict with accuracy the ways in which the understanding and treatment of speech disorders will develop in future. Work in related disciplines has, however, already indicated some areas in which advance is likely. We expect that the use of speech processing equipment and machine based tuition will become much more widespread. The production of physical correlates of intonation, rhythm, stress and sound quality may become feasible and it may be possible to match these to the user's disability, so as to enable him to employ them in practising and self-teaching situations. It may become possible to detect the more simple speech errors automatically and to prepare remedial programmes. Such developments will enable the therapist to become more productive, but they will not replace her or make a smaller call on her skill: the machine, in fact, may in future take over some of the functions which we propose in Chapter 7 to delegate to therapists' aides.

6.58 Improved techniques of speech prosthesis, with more reliable equipment and the possibility of providing fluent synthetic speech, perhaps even moderately well-matched to the user's original voice, may well reduce the necessity for oesophageal speech. The speech therapist will need to understand the working of the equipment, since success will depend on her teaching its use and control to

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her patients. Again, she may come to be involved in the development and application of devices for communication developed from the patient-operated mechanisms at present used in some non-linguistic disabilities. These and other developments may mean that the speech therapist of the future will need more understanding of the operation of mechanical and technical aids, and of their place in treatment, than is necessary at present.

6.59 Advances in the psychophysical study of speech perception, and consequent advances in linguistic theory, will probably provide part of the basis for improved diagnosis of speech disabilities. Current research seems likely to result in new diagnostic procedures for the clinical examination and definition of perceptual layers of speech processing. Speech therapists will probably be required to administer the routine tests which will be involved, and will thus require a broader understanding of the theory on which they are based.

HUMAN COMMUNICATION: AN INTEGRAL STUDY AND PROFESSION

6.60 We have already indicated our view that the process of human communication cannot be satisfactorily divided into its components and that its disorders will come to be seen as a single field of study embracing many specialisms. This view was shared by some of our witnesses, one of whom said

Recent research both in the laboratory study of normal language and the clinical study of language disorders has tended to stress the interactions between the visual and the auditory aspects of language. These points ... go to suggest that the would-be practitioner of therapy, whether of speech of hearing, of reading or of writing must in future regard LANGUAGE as the central core of his basic discipline. This does not, of course, imply that he may not opt for one rather than another speciality of interest among the various kinds of pathological manifestation. But the development of his particular skills ought to be along the lines of movement outward from the central core rather than occasional ad hoc excursions inward when problems of more than peripheral import occur.

7.01 It is evident that speech therapy services at present are insufficiently staffed for the need they have to meet. What is the real extent of this need and how many speech therapists are required to meet it? What numbers are necessary to provide an adequate service over the next few years and how can they be provided? We attempt in this chapter to answer these questions, drawing upon such evidence of the prevalence of speech and language disorders as is available to us. Because, as we show below, this evidence is in many respects inadequate, the conclusions we reach are necessarily tentative.

THE PROBLEM OF MEASURING NEED

7.02 We considered various methods of arriving at an estimate of need. One thing became rapidly clear; in present circumstances, the numbers of patients now being treated by speech therapists could give no indication of the real present need or the likely need in future. There is a natural tendency for demand to adapt itself to supply and while this is well known for its inflationary effect on demand, we may sometimes forget that its effect may equally well be deflationary. At present both L.E.A. and hospital services are so badly understaffed, particularly in certain parts of the country, that available services do not meet even the obvious needs. We have no doubt that many patients who could benefit from speech therapy at present go not only unhelped, but also unassessed and even unidentified, because it is known that resources are not available to deal with them. These patients comprise the "hidden need" for speech therapy which we refer to in 5.29.

7.03 A certain amount of information is available from surveys of the prevalence of speech defects which have been carried out from time to time. None of these was on a national scale and it is difficult to find two which are comparable in scope or design. Nearly all of them surveyed school populations only, but within this range the age-groups covered were sometimes infant or reception classes, sometimes primary school children, sometimes secondary, sometimes all ages. Few surveys assessed all children in the age-group under consideration. It was more usual for parents, doctors or health visitors to indicate which children had some speech difficulty, and for these only to be seen by an assessor who might be a speech therapist, paediatrician, or general practitioner. The criteria of defect used were vague or subjective ones such as "noticeable mispronunciation of a single syllable", or "handicapping disorder" and a secure basis for comparison was thus sadly absent.

7.04 We considered carefully whether it would be possible for us to carry out or to commission a study which would at least have the merit of employing criteria agreed by and intelligible to us and which might make a worthwhile contribution to knowledge on the subject. Our first choice among the various possibilities which suggested themselves was for a survey of a random sample of the whole

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population. We were advised, however, that because of the very low incidence of some disorders the statistical error in such a survey was likely to be so great that the results would not be worth the money and manpower needed. It could not in any case have been completed within the lifespan of the Committee. Moreover, we are rather dubious of the effectiveness of a large-scale survey of this kind, at least until there has been further investigation of the categories of disorder and the terminology used by speech therapists and others. We then looked at the possibility of a survey within a limited area of population, perhaps a particular town. Once again, however, there was a problem in establishing agreed criteria of defect and finding personnel to apply them consistently. There was also the very considerable difficulty of tracing and testing adults with speech disorders. Furthermore, we were given statistical advice that the results of such a survey might not be applicable to the national situation. Lastly, we considered using the research network of the Royal College of General Practitioners to conduct a retrospective survey using doctors' records. There were obvious drawbacks involved in scanning records for disorders which are from a GP's point of view secondary to other conditions, and so might not have been specifically recorded. We concluded that no satisfactory study was possible without indefinitely delaying the completion of this report and thus neglecting to attend to the profession's needs in a reasonable time.

7.05 We did however ask the Department of Health and Social Security to undertake for us the survey of the work of speech therapists in hospitals from which the information given in 5.11 is derived. We realised that this survey could not be expected to give us any indication of the prevalence of speech and language disorder but we considered that objective evidence on the way in which the time of hospital therapists is at present divided would be useful in filling gaps in our knowledge. For the rest, and despite their limitations, we had to fall back on the local surveys.

7.06 We were thus faced with the problem of deducing from the available, and inadequate evidence firstly how many people suffer from speech and language disorders, secondly what proportion of them might benefit from the services of a speech therapist, and thirdly how many speech therapists are needed to provide an adequate service for these people.

THE AVAILABLE EVIDENCE

Children

7.07 Surveys of speech disorder among children have been conducted on a variety of bases and covering differing populations, The result is a series of estimates of the incidence of disorders ranging from 1.7 per cent to 37.4 per cent. Even skilled and experienced assessors varied in the criteria of disorder they used and in their prognostications, some arguing that the majority of childhood speech disorders are outgrown, with the aid of teachers, before the age of 7, while others considered early speech therapy essential. Clearly, more refined methods of assessment and prognosis are needed and research will be necessary to this end (10.14). Many more children, particularly those of pre-school age, will have to be assessed and kept under observation than will eventually prove to require treatment. As we say in 6.51, we are convinced of the need for assessment services for very young children and we believe that this will necessitate a

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growth in speech therapy services: this has implications for the number of speech therapists needed which must not be overlooked. At the same time, an improved speech therapy service for pre-school children should eventually reduce the numbers of school children coming forward for treatment: it will, however, be some time before this effect is felt.

7.08 The only guidance offered to local education authorities in setting their establishment for speech therapists derived from a survey carried out by a medical officer of the then Ministry of Education in 1946 among school children in East Ham. The finding was that just under 2 per cent of children had speech defects, though many of those in infant schools acquired normal speech by the age of 7, and the conclusion was that "a school population of 10,000 children fully justifies the employment of a whole-time speech therapist". These findings were supported by those of a survey undertaken by Parken in Poole in 1956. With similar scope and methods (i.e. a survey of the entire age-range, head teachers providing lists of "suspects" for assessment by a single worker), Parken found 3.9 per cent with speech defects and 2.1 per cent requiring therapy. A repeat in 1960 gave figures of 3.1 per cent and 2 per cent, demonstrating at least some considerable internal consistency.

7.09 Both the Ministry of Education and Parken found a higher prevalence of disorders among infants and juniors. This may help to account for the fact that several other surveys, which concentrated on the younger age-groups, produced appreciably higher prevalence figures, even the most apparently reliable varying from 2.5 per cent to 5 per cent. Dr. Muriel Morley, in her study of The Development and Disorders of Speech in Childhood, gave a figure of 19 per cent at age 3½, declining to 5 per cent at 4 years 9 months. Dr. Mary Sheridan, analysing the results of the National Child Development Survey's study of 11,000 seven-year olds, found that teachers indicated a 2.4 per cent prevalence of speech disorders at that age, while doctors using a series of test sentences - not in our view a reliable means of assessment - found about half that percentage to have disorders. The recent study of 9-11 year-old children in the Isle of Wight, carried out by Rutter, Tizard and Whitmore and published as Education, Health and Behaviour (1971), analysed parents' and teachers' replies to a questionnaire on speech disorder (other than stammering) and found 5 per cent of children with defects and 3 per cent in need of therapy.

7.10 So far as children in ordinary schools are concerned we consider that a reasonable estimate, and probably the best which can be made from the available evidence, is that at least 2 per cent will require speech therapy. Bearing in mind that prevalence tends to be higher among the younger age-groups, we feel that this is probably a very conservative estimate, and that the traditional ratio of one speech therapist to 10,000 school population has been a grave underestimate: the ratio should be something nearer 1 : 5,000.

7.11 There have been no valid surveys of pre-school children, but even on the assumption that only 3 per cent of the 2,000,000 children between the ages of 2½ and 5 may need the services of a speech therapist, provision will be needed for 60,000. A high proportion of all pre-school age children show disordered or delayed language: this is not, of course, reflected by surveys, most of which have been conducted on school populations. If speech therapy services develop in the way we envisage the effect will be to increase the need for early assessment but not

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overall to reduce the amount of speech therapy given: our hope is that it would be given earlier, say between age 3 and 6 rather than between 6 and 9.

7.12 There are children for whom disordered language ability is such a serious problem that they need to attend one of the three special schools, or one of the special units, that exist for these children at present. A fourth school is at the planning stage and will open in the next few years. These schools also cater for the very small minority of children with gross articulatory disorders in whom no language disorder can be discerned. Because severe language disorder can be difficult to distinguish from deafness or mental handicap, it is likely that some children who should be in special schools for speech defects are in other special schools. There is a need for more educational provision for children with severe disorders of speech and language. Speech therapists are required for these children in very high ratio; for example, at Moor House School even at present five speech therapists are employed for 61 children.

7.13 In 6.48 we mentioned the autistic children, and the possibility that speech therapists may in future be called upon to play a greater part in dealing with their disabilities: again, this is a numerically small problem which may require a high ratio of specialised speech therapists.

7.14 Apart from these comparatively small groups, there are the larger numbers of mentally and physically handicapped children who require speech therapy. Hitherto we have used the term "mentally handicapped" to cover all children with a significant degree of retardation, and now that the Department of Education and Science has assumed responsibility for the education of severely subnormal children these are no longer officially distinguished from the educationally subnormal (E.S.N). However, for our present purpose it is convenient to use such a distinction, and we shall refer to E.S.N (severe) and E.S.N (less severe). Few figures are available, but the consensus of opinion from witnesses in the field of special education was that about a quarter of the physically handicapped, one-fifth of the E.S.N (less severe), and possibly as many as half of the cerebral palsied and E.S.N (severe) would benefit from therapy. We have already noted (6.52-54) that speech therapy for the mentally handicapped will be an area of growth in future, and this may increase these figures even more.

7.15 We know of no survey of speech disorder in the adult population in Great Britain. We are forced to arrive at an estimate of the number of adults in need of speech therapy by considering in turn the conditions which most usually give rise to speech disorders and making a series of assumptions about the numbers in each category who could benefit from speech therapy.

7.16 Among the groups at risk of developing speech or language disorders are the elderly, and patients who have had strokes or head injuries. Our task is made no easier by the fact that the first two categories overlap, and an increase can be expected in the numbers in all three. A greater proportion of people are living into old age, so that the numbers of older patients can be expected to increase. Medical advances have meant that stroke patients now survive who some years ago might have died, and changes in social life may be having a tendency to increase the numbers of younger patients. Lastly, we can unfortunately see little prospect of a decline in the numbers of head injuries resulting from road accidents, and there appears to be an increase in the numbers of

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those sustaining brain damage after surviving drowning accidents or other mishaps involving subsequent resuscitation.

7.17 About 15 per cent of head injury cases have detectable disorders of speech or language, and many more complain of some difficulty in speaking. A Danish survey of patients surviving strokes showed that about a third suffered from dysphasia immediately afterwards. There are also comparatively small groups of patients who have had the larynx surgically removed, and of patients who have progressive neurological disorders. In the case of, for example, laryngectomies, speech therapy is usually readily available in the specialist centres where surgery is done, but it may be difficult to organise continued therapy after the patient returns home. The problem where rare disorders of this kind are concerned is less one of numbers than one of deployment of a scarce skill.

7.18 Evidence on the need for speech therapy among the elderly varied. A survey carried out in one geriatric hospital indicated that about 12 per cent of patients had a handicapping speech or language disorder requiring therapy, but the Royal College of Physicians reported that in a similar hospital less than 6 per cent were considered to need therapy. No estimates were available of the extent to which old people outside hospital could benefit. Language stimulation might be valuable in helping the elderly to maintain speech and so avoid social isolation: this field of work, which might well be a large one, would not always require a speech therapist, since less skilled help might often be beneficial.

THE NUMBERS NEEDING TREATMENT

7.19 Having assembled the available evidence on the prevalence of disordered language ability, we had next to try to form an estimate of the actual numbers currently needing speech therapy. Since reliable figures for populations, as well as for the prevalence of disorders, are often lacking, our figures at some points are merely the best informed guess we were able to make, taking into account the experience of our speech therapist and doctor members.

7.20 We were on somewhat firmer ground with school children, since school population figures and a very rough indication of the prevalence of disorders are available. Assuming the proportions in need of speech therapy to be as stated in 10 and 14, we arrive at the following figures

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Allowing for other categories, such as children with impaired hearing or severe communication disorders and perhaps "autistic" children, we think it reasonable to assume that there are well over 200,000 children of school age in need of speech therapy. To these must be added the pre-school children noted in 11, giving an overall total of at least 275,000.

7.21 There are at present 40,000 geriatric patients in hospitals, of whom, averaging the two estimates available to us, 9 per cent or 3,600 need speech therapy. Over 16,000 hospital beds are taken by stroke patients: assuming that about a third of these require speech therapy, they yield at least a further 5,000 patients. Even allowing for some overlap between these two categories, we consider that they provide about 10,000 patients. We could find no figures for the numbers of patients requiring speech therapy for voice disorders, head injuries, or neurological disorders, nor for the large number of adult stammerers. We do not think it unreasonable to assume, however, that these disorders might produce a further 30,000 patients. This suggests that in all about 40,000 adults in Great Britain are now in need of speech therapy.

7.22 This gives a total of well over 300,000 children and adults in need of treatment for speech and language disorders. We reiterate that such a figure is and in the present circumstances can only be the product of a careful scrutiny of fragmented data and an informed guess at its implications. However, we are satisfied that our estimate is the best approximation that can be offered at present, and we are convinced that it can err only in being too low.

7.23 We envisage that if, as we have recommended (6.54), services for the very young are developed as a priority, the numbers of schoolchildren seeking therapy will decline and speech therapists will be able increasingly to divert their attention to other groups, a numerical increase in which we find difficulty in predicting. We must also point out that our total, large as it is, makes no allowance whatsoever for some of the developments in speech therapy services which we have noted in Chapter 6 and elsewhere as desirable or in some cases, indeed, as urgently necessary. It does not, for example, make any allowance for more extensive work with the mentally handicapped, for greater involvement with deaf children and adults, or for the establishment of services for the growing number of old people in the community, as distinct from those in the geriatric wards of hospitals.

NUMBERS OF SPEECH THERAPISTS NEEDED

7.24 Careful discussion with speech therapist members led us to assume that each speech therapist might on average carry a case-load of about 100 patients, meaning by "case-load" the number of patients on the therapist's treatment and observation register at any one time. This figure would include at the one extreme those patients undergoing regular weekly or more frequent treatment, and at the other those seen perhaps once in three months for review: it would therefore, of course, be perfectly possible for a speech therapist carrying far fewer than 100 patients to be overworked.

7.25 The concept of case-load is needless to say a matter of averaging, and actual case-loads must vary considerably from month to month in a speech therapist's practice, and from speech therapist to speech therapist according to the nature of the work undertaken. Any concept of the "typical speech therapist" and her

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work is therefore unreal, but the following two examples will illustrate some of the common variables encountered in practice: both assume that the speech therapist is working full-time in one centre.

Examples of Present Case-loads

Both examples assume that the necessary paper work, discussions, administrative duties and so on are fitted in as opportunity arises, often during lunch breaks or in the therapist's leisure time.

7.26 We next attempted, again drawing upon the experience of our speech therapist members, to establish a case-load figure in respect of each category of patient, assuming that the therapist was treating only patients within a single category. They found it difficult to assess on this hypothetical basis possible case-loads which would clearly vary within fairly wide limits, according to the experience of the individual speech therapist, the degree of difficulty of the cases, and the conditions in which she was working. They suggested, for example, that the case-load of a speech therapist working entirely with pre-school children might vary from about 80 to about 100; with children in ordinary schools,from 100-120; with the less severely E.S.N. children, from 50-60; with the severely E.S.N. or with mentally handicapped adults, from 30-40; and with the physically handicapped, from 40-60. They agreed that a speech therapist working only with severely speech disordered or "autistic" children could handle no more than about 10. A therapist working only with stroke patients could deal with perhaps 20 and with geriatrics, about 60. With other adult patients up to 100 would be a reasonable figure.

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7.27 Using these tentative figures, and taking a rough average where range figures were suggested, we are able to estimate the requirement for speech therapists as follows:

*The help needed may vary from assessment only to regular treatment.
†Improved services for pre-school age children should in the course of time reduce this requirement.

7.28 An estimate on this basis of course contains an element of unreality, since if it were possible to import tomorrow a force of 4,000 speech therapists to work on the basis we have postulated, one might reasonably hope that patients would be discharged as cured faster than they were replaced by new ones. However, we considered the important factor to estimate was CURRENT NEED, and considering the time needed to build up a force of speech therapists of anything approaching this magnitude, we do not think there need be any fears of overproducing speech therapists for the tasks the profession faces.

7.29 This view is to some extent supported by an alternative basis of estimation. Some evidence put to us, and the experience of some medical and speech therapist members, suggested that an establishment of six full-time speech therapists to a population of 100,000 could maintain a reasonably adequate standard of service. Applying this ratio to the total population of England, Wales and Scotland (54,186,700), we arrived at a total requirement of 3,252 speech therapists. As

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the ratio was based on experience in fairly compact urban areas where distances were not large, however, we considered that it would probably need to be increased to provide an adequate service to all areas of Great Britain.

7.30 Taking into consideration the uncertainty of some of the figures with which we were working, and the highly speculative nature of many of our assumptions, we were somewhat reassured to find that estimates on several different bases should all point to a need for between 3,250 and 4,000 therapists. We concluded that a force of about 3,500 would be reasonably adequate for current needs.

7.31 As we have seen, the existing speech therapy force numbers about 822 in terms of full-time equivalents. With a service organised on present lines, this figure would have to be at least QUADRUPLED to have a significant effect on the "hidden need" demonstrated in this chapter. Even an expansion on this scale would allow no margin for expected growth and development, and would permit very little flexibility in the organisation of treatment.

7.32 Our terms of reference do not include salaries or career structure. Nevertheless we feel bound to draw attention to the formidable amount of evidence we received, from within the profession and from those outside, indicating that pay and career structure were glaringly out of proportion to the responsibilities carried by a speech therapist and were a disincentive to recruitment, particularly the recruitment of men. Wastage among speech therapists also appears to be more severe than in some other professions, partly perhaps because of poor inducements to remain in service, but mainly because of the predominance of women. We are convinced that a better balance between men and women is essential for the stability of the profession, and while our recommendations will go some way towards redressing this balance, we think that further thought must be given to the problem.

MARRIED WOMEN

7.33 We discuss the problem of wastage in speech therapy in 5.13-14. It is clear that there exists a pool of married women therapists who might be induced to return to the profession: the fact that nearly 300 therapists are prepared to undertake private work testifies that many women would welcome work which could be combined with domestic duties. All predominantly female professions suffer from wastage on marriage or motherhood and any general solution to this problem will depend upon wider social changes and the extent to which combining a career with domestic duties becomes acceptable and is made easy. A general increase in the provision of nursery schools and play-groups would, for instance, make it easier for the mothers of young children to return to work, but the extent to which such facilities are made available will depend upon questions which go beyond our concern with speech therapy.

7.34 There are certain particular problems for married women wishing to return to speech therapy which employing authorities might consider. There appears to be reluctance on the part of some employers to make full use of part-time staff, and we received some evidence of unwillingness to arrange services in a way that would allow a married woman to combine the work with caring for her children. In this connection we were impressed by the example of Hertfordshire, one of

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the few local education authorities to maintain a fairly adequate establishment of speech therapists: twelve of Hertfordshire's twenty therapists have school-age children and have returned to work part-time. Buckinghamshire too has been particularly successful in attracting married women back into its service. We do not underestimate the problems involved for employers in accommodating part-time workers, but we consider these preferable to establishments three-quarters empty. In particularly, there was evidence from a survey conducted by the College of Speech Therapists that to allow school holidays would be perhaps the biggest single inducement to return that married women could be offered. Authorities might consider the conditions necessary for offering married women the option of school holidays. The problem of interruption to treatment could often be overcome by concentrating periods of intensive therapy into school terms. Other possibilities which employers might explore are the provision of crèches, as is now being done by some authorities and hospitals, and arrangements to enable a married woman to work in her own home or in association with a general practitioner in a practice near her home.

7.35 Not all the problems faced by the returning speech therapist, however, are external to the profession. After some years away from work skills are partially lost and, because of the rapid advances being made in speech pathology and related disciplines, knowledge becomes out of date. Colleagues can do much to help in these respects by keeping in touch with those who have left the profession, including them on mailing lists, inviting them to professional meetings, and so on. However, many of those replying to the College's survey said that they would lack the confidence to return to work without some form of retraining. "Refresher courses" would be difficult to organise centrally because candidates for them would be scattered and unable to travel far to train: however, it might be feasible to organise courses in London and other urban centres. Otherwise, we suggest that employers should make arrangements for those returning to the profession to retrain locally, either by means of short in-service courses such as are organised in Buckinghamshire, or by means of attachment to an experienced serving therapist for the first few months of employment.

7.36 We therefore recommend that employing authorities should endeavour, by means of improved working conditions and a greater readiness to make special arrangements, to encourage married women therapists to return to the profession, and should make suitable arrangements for such therapists to have retraining.

MEETING THE NEED: A NEW DEPLOYMENT OF SKILLS

7.37 Even if training facilities can be expanded, and a determined and successful effort is made to reduce wastage, we see little prospect of meeting the need by these means alone, and certainly no prospect of meeting it quickly. A report of a Conference of the American Speech and Hearing Association held in February 1969 contained the following:

A disparity has always existed between the supply of and the need for clinically competent speech pathologists and audiologists. This disparity continues, and in the future it is almost sure to increase. It is in no sense an abandonment of established concepts of minimal clinical competence to recognise that if there is ever to be an adequate supply of services in speech and hearing, we cannot get there from here.

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7.38 We find ourselves in precisely this position, and equally unable to envisage the scale and standards of service we see are needed, from the standpoint of the present deployment of speech therapists' time and skills. The A.S.H.A. report went on to say:

We are compelled, then, to recognise an element of impracticality in insisting that every function presently performed by a speech pathologist or audiologist must, for all future time, be performed by personnel as elaborately trained as those who, by definition, are competent to do every task that a speech pathologist or audiologist ever performs.

THE ROLE OF AIDES

7.39 We have already indicated in Chapter 6 our conviction that there is in the work of the speech therapist an element, partly consisting of ancillary work but including some aspects of treatment, which is routine and repetitive and does not call for the skill and knowledge of a speech therapist. At present delegation of such work is achieved by seeking help of parents or other relatives, teachers, nurses or voluntary workers, not all of whom are able to find time from their other concerns, though we have been interested to hear of an experiment in County Down, involving teachers in generously devoting some leisure to undertaking work delegated by speech therapists. Our proposal is that routine work should in future be delegated to aides working under the supervision of a speech therapist. This should represent a fundamental improvement, since instead of being an extra task undertaken by very busy people, the help given would be the aide's primary responsibility: it could also be applied to aspects of the speech therapist's work, such as the maintenance of equipment and the making of materials, for which she cannot at present enlist any help at all.

7.40 We will give an example of the pattern of work we have in mind. A speech therapist visiting a special school or a long-term hospital once a week would, as now, plan the treatment of her patients and would demonstrate to the aide, where she saw that work could be delegated, the practice she was to carry out with each. She might if she wished also have the aide with her whenever she saw any of her patients. In between visits the aide would see the therapist's patients, either singly or in small groups, two or three times a week for routine practice or language stimulation as prescribed by the speech therapist. The aide might also look after equipment and where clerical support was lacking, file case records, but liaison with school or hospital staff would continue to be the province of the therapist. In some instances the use of aides would enable existing patients to be given more intensive treatment: in others, it would enable a therapist to treat more patients.

7.41 Aides could be of either sex and part-time or full-time. They might be recruited from older women or from young people, including some who were contemplating training as a speech therapist or as a teacher. They would need to have a pleasant personality, the ability to get on well with patients and staff, a good speaking voice, skill in observation - and the capacity to follow their brief meticulously without exceeding it. They would also have to be prepared to treat information about patients as confidential, in the same way that speech therapists do. Careful guidance and induction on this and other aspects of their

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duties would obviously be necessary: this would be given on an in-service basis (9.35).

7.42 We are aware that this great opportunity to release the speech therapist's time for the more exacting of her tasks will need to be accompanied by careful definition of the aide's role. First and foremost, in no sense could an aide ever be regarded as a speech therapist. There are features of her work which a speech therapist must not delegate, for example assessment, interviewing parents and attending case conferences, though she might if she wished take her aide with her to the latter. Secondly, if a therapist who resigned her appointment could not be replaced immediately, any aide she had should only continue working with the same patients if another therapist could assume full responsibility for them; otherwise she would have to cease work with them and transfer to work under another therapist. This would be easier to arrange with the bigger pool of therapists that there would be with the proposed unification of speech therapy services in an area (8.050-09). Thirdly, there will be a limit to the amount of time that a therapist can devote to supervising aides, in relation to her other commitments and the circumstances of the area, and the precise ratio of speech therapists and aides will have to be evolved through experience. Lastly, speech therapists in their first year of practice should not have any aides working under them.

7.43 The use of aides is not an entirely untried proposal. Some of our members had had experience of the successful use of voluntary workers in a similar capacity, under the supervision of a speech therapist, and a recent pilot study in Colorado, U.S.A., showed that aides could be successfully used provided that speech therapists had a part in their selection and were given a free hand in deciding what aspects of their work to delegate.

7.44 Experiments will need to be made before the profession can be sure of the best ways to use aides; but we are in no doubt that it is only by this means that the highly trained skills and knowledge of the speech therapist can be made available over a wider field. Such a development would also carry the advantages of making the therapist's work more intellectually satisfying, and hence more attractive, and in appropriate cases setting her free for the research and development work so essential to the profession's growth. The proposal is a recognition that the profession of speech therapy has developed the self-confidence that is essential for important expansion coupled with a significant increase in its responsibilities and a rise in status.

EFFECT OF THE USE OF AIDES ON THE REQUIREMENT FOR SPEECH THERAPISTS

7.45 It is extremely difficult to quantify the effect which the widespread use of aides might have on the total requirement for speech therapists. Even those of us who had had some experience of the use of voluntary aides found it difficult to estimate the effect of a full-time one. The amount of work which, can be delegated will vary considerably with the types of patients being treated. We considered, for example, that with the E.S.N. in both categories, with the adult mentally handicapped, with children in ordinary schools with defects of articulation, and with elderly patients the work might lend itself particularly to delegation. Depending upon the nature of her case-load, her particular circum-

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stances, and also her personal temperament, a speech therapist might well be able to make good use of more than one aide (e.g. if she was dividing her working time between two major clinics), whereas another might not have suitable work to offer even to one.

7.46 Taking these variables into account as much as possible, we thought it reasonable to assume that overall perhaps three-quarters of all speech therapists might be prepared and able to employ an aide, and that the use of an aide might save perhaps a third of a speech therapist's time. This would reduce the number of speech therapists required by about 1,000, i.e. from about 3,500 to something over 2,500.

EXPANSION OF TRAINING FACILITIES NEEDED

7.47 The maximum intake figures given us by the schools of speech therapy (2.22) give a total training capacity of 248 a year. The total intake for 1971 also amounts to 248, since although two schools reported a small number of vacancies these were counterbalanced by overcrowding elsewhere. Total capacity will increase to 254 in October 1972, when one school raises its present intake by six to thirty.

7.48 Output figures for the three years 1969, 1970 and 1971 were 138, 163 and 152 respectively, compared with intakes of 166, 180 and 189 in the corresponding years 1966, 1967 and 1968. This gives wastage rates of 16 per cent, 19½ per cent and 19 per cent respectively. There are many reasons for wastage from training, but the tendency to such high figures may reflect a difficulty in obtaining good recruits.

7.49 Assuming that the schools of speech therapy can continue to fill all available places, and that wastage in training will not rise above about 15 per cent, 210 speech therapists a year will be entering the profession from 1974 onwards. At present rates of wastage perhaps 700 of these can be expected to be in post 10 years later.

7.50 The improvement in staffing in both services since 1959 (see 5.10) is perhaps greater than could be expected from the increasing output of trained speech therapists and may indicate that there is already some tendency for those who have left service to return to it. Implementation of the suggestions in 7.33-36 will we hope increase this tendency. There are no complete records of the numbers of speech therapists who have been trained since 1930, but there can hardly have been more than about 3,500; allowing for death, emigration, and miscellaneous reasons that would rule out a return to work, there are probably no more than about 2,000 speech therapists (including about 1,200 already in post) to be drawn upon. How many of these will be prepared to return to service will depend upon the inducements offered and on the ingenuity and flexibility with which employers can make use of the services of women who are, for example, unable to travel far to find posts. A sophisticated calculation is impossible but we would estimate that the maximum increase from this source over a ten-year period would be no more than another 500 individuals, with a full-time equivalence of perhaps 350. An increase on this scale would require a very determined and continuing campaign to find married speech therapists and attract them back into the service.

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7.51 To sum up, our very rough estimate for the situation in 10 years' time would be:

This is very seriously short of the 2,500 full-time speech therapists we estimate in 7.46 to be needed even with the use of speech therapists' aides. The position in 10 years' time may be rather better than the one we have painted, since over that period the various factors will begin to interact: for example, the increase in the numbers trained will if maintained enlarge the pool of possible married returners to a significant extent. Nevertheless, it is evident that the present training capacity of the profession will not succeed in providing, even in 10 years' time, the numbers of speech therapists that we estimate are needed now.

7.52 We propose in Chapter 9 a new pattern of training, which will inevitably take some years to introduce and develop. Even if, as we shall suggest, the existing Diploma courses are not merely continued alongside the new types of course for a lengthy transitional period, but are also expanded, it will still be difficult to bridge the gap of 850 in the full-time equivalent figures in 7.51. We believe, however, that, if the problem of the shortfall is attacked with vigour on all sides, including the publicising of speech therapy in schools as a possible career and making conditions in the service more attractive to men, it should be possible to reach our target within 20 years at most.

7.53 We therefore recommend that:

(i) 2,500 should be accepted as the target for the force of full-time speech therapists and that this target, and progress in achieving it, should be kept under regular review.

(ii) A cadre of speech therapists' aides could be established.

(iii) Energetic publicity campaigns should be undertaken:

(a) To persuade married women who have left the profession to return to it.
(b) To increase the recruitment of school leavers to speech therapy training.

(iv) Additional courses relevant to speech therapy training should be established as soon as is compatible with the changes in level of training recommended in this report.

AIMS AND CONTEXT OF REORGANISATION

8.01 In considering how speech therapy services should be organised in future the aim we have kept in view has been that of making a good speech therapy service available as conveniently as possible to those needing it, with ready access to more expert advice in the most difficult cases. Internally, the profession should be organised in such a way as to assist this aim and also to offer the speech therapist support at the outset of her career and a satisfying prospect of advancement within it.

8.02 We were aware that whatever changes we might propose in the organisation of speech therapy services must be looked at in the light of the much more far-reaching changes in the organisation of the National Health Service. Briefly, the Consultative Documents on National Health Service Reorganisation in England and Wales, and the National Health Service (Scotland) Bill now before Parliament, all propose a new structure - outside local government - bringing together general practitioner, local health authority and hospital services under Area Health Authorities. (In Scotland the term "Health Boards" is to be used.) The Welsh Area Health Authorities and the Scottish Health Boards will be responsible direct to the respective Secretaries of State for Wales and Scotland. In England, where the number of area health authorities will be much larger, it is proposed to create Regional Health Authorities as an intermediate tier. These will deal with very broad policy and resource allocation. It is the area health authorities which in England also will be 'the operational National Health Service authorities, with responsibility for planning, organising and administering comprehensive health services to meet the needs of their areas'.

8.03 In general, boundaries of area health authorities are intended to follow those of reorganised local authorities. In England (outside London) they will be coterminous with the new counties, or in metropolitan areas the new metropolitan districts. The Government's intentions for London have not been announced but it is expected that one area health authority might cover two or more existing London Boroughs. In Wales too the area health authorities will have boundaries matching those of the new counties. In Scotland the health boards will correspond to new local government regions, except that in one Region there will be two health boards and in another, four. The populations will vary from under 100,000 to over 1,300,000.

8.04 The Consultative Documents contained no proposals about the future of the School Health Service in England and Wales. We were advised, however, that a possible outcome would be that the School Health Service - based upon Section 48 of the Education Act, 1944 - might be transferred to the new area health authorities, whilst the ascertainment and provision of education for handicapped children (under Section 34) would remain with local education authorities. The Scottish White Paper stated that the School Health Service in that country would become the responsibility of the health boards. However,

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we understand that it is now envisaged that speech therapists should be employed by health boards and seconded as necessary to education authorities.

THE CASE FOR A UNIFIED STRUCTURE

8.05 As we have shown in the preceding chapters, speech therapy, by its origins and history as well as by present organisation, stands between medicine and education and both draws upon and serves each. It is likely that individual practitioners will continue to be attracted towards work with either children or adults, according to their own interests and preferences. There are some important differences in the techniques of assessment and management used, and the speech therapist who is expert with children is not necessarily so with adults. We do not, however, see this as a valid reason for perpetuating the present artificial division into two separate services, since we are convinced that there is a fundamental unity in the work undertaken by speech therapists in the education service and those working in hospitals.

8.06 We were given convincing evidence that the present divided structure of speech therapy services is wasteful of resources and has hindered the development of the profession. Speech therapists in general felt the need for unification of the services: one of them, for example, said

... I would like to plead strongly for the integration of hospital and schools services. The present system has many disadvantages in terms of communication with regard to referrals, reports, overlap of work, etc. Having had experience of work in both areas, I am convinced that ... a central organisation would remove many of these difficulties.

has resulted in wide differences in attitude amongst speech therapists themselves whether they see themselves as paramedical therapists or as special teachers of handicapped children ... the division ... has retarded ... total development. It would seem more sensible to develop a single speech therapy service for a defined geographical area, which would offer facilities both in schools, in special units and elsewhere.

8.07 Several witnesses considered that a unified structure would offer the best career conditions for speech therapists. As one of them put it

The opportunity would arise to develop a better career structure and more specialisation within the profession, and better arrangements for the supervision of newly appointed speech therapists, with less isolation than is commonly the case at present. In this way both the professional independence and inter-dependence of speech therapy would be secured.

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attractive as a career. As the study and treatment of communication disorders come increasingly to be seen as a single integrated subject, the present division into hospital and L.E.A. services, if continued, might create an unnecessary administrative barrier in a service which should be whole and comprehensive. Meanwhile unification is essential to provide means for liaison and mutual help (especially important for such a small profession) between therapists working only with children and those working also with adults. The establishment of such a service would not preclude the development of specialisations by individuals within it, or indeed of regional services which, while providing comprehensive treatment for the commoner disorders, were themselves biased towards the treatment of certain rare conditions.

8.09 Our recommendation therefore is that the organisation of speech therapy services should be unified.

RESPONSIBILITY FOR A UNIFIED SERVICE

8.10 The evidence presented to us showed much less agreement on the way in which a unified service could best be achieved. As in the case of training, on which we comment in Chapter 9, witnesses on the whole argued the case for unification according to their own interests and experience. The Association of Education Committees, for instance, told us that 'It is important that the integration of speech therapists into the education service be increased and facilitated'. A majority within the Association for Special Education saw speech therapy as primarily an educational profession and suggested that speech therapists should be employed by L.E.A.s to work as members of the school staff under the headteacher's administrative control. Evidence from two areas where joint services covering hospitals as well as education already exist under L.E.A. administration - Leicester and Aberdeen - recommended wider application of this pattern, and several other witnesses suggested joint services. The reasons given for regarding speech therapy as a part of the education system were that speech therapy has much in common with teaching, and the distinction between them is thus artificial; that the role of speech therapy in education is increasing and that co-operation with teachers can be most readily obtained when the therapist is a member of the staff.

8.11 Most medical witnesses, on the other hand, took the view that speech therapy should be organised as part of the health service. Many pointed out that the forthcoming reorganisation of the National Health Service would provide a good opportunity to organise a unified service under area health authorities. One witness suggested a future pattern of 'community medicine practised at field level by integrated teams' and suggested attachments of speech therapists to general practice. Another, from the Royal College of Physicians (London), suggested a joint service run by a 'Department of Rehabilitation and Community Medicine' in hospital and by the Medical Officer of Health in the community. The reasons given for these various recommendations were that, as speech therapy involves diagnosis, it is a paramedical function; that some of the research needed in the field of speech pathology is carried out by or in co-operation with doctors; that the medical setting offers more variety of work and more scope for investigation and research; and that those who need speech therapy have problems which are more often medical than educational. The speech therapy service in Oxford, which is based on the United Oxford

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Hospitals, is an example of a joint service under NHS auspices. Some of our members visited Oxford and were impressed by the excellence of the service being offered to children and their teachers and to adults alike.

8.12 Speech therapists were themselves divided on the issue. One told us that 'The essential link between speech and other aspects of language, and therefore between speech therapy and education generally, must be recognised' and went on to suggest that 'therapists of the future should work full-time in schools, with some of their work overlapping with that of teachers'. The schools of speech therapy established in Colleges of Education on the whole considered that the profession's links with education were stronger than those with medicine. Speech therapists working in hospitals, on the other hand, more often saw a case for integrated services under the health authority; again, many looked to the reorganisation of the NHS to provide the opportunity for this. The Sub-Department of Speech in the University of Newcastle upon Tyne told us that

We see in this reorganisation of the health services in larger areas the opportunity to create a unified speech therapy service working in hospitals, schools and in the community, with a more efficient organisation and with larger groups of staff in each administrative area.

8.14 While wanting to see a unified speech therapy service, we would not wish it to be administered independently of other health or local authority services. For administrative purposes it would obviously be advantageous to organise so small a profession through a larger unit. We would, however, emphasise that, whether the speech therapy service is organised under NHS or local authority auspices, the closest liaison and co-operation with the other authority is essential, both for overall planning and in day-to-day activities.

8.15 We looked carefully at the various solutions put to us in evidence. The suggestion that speech therapy services should be organised under local authority Social Service departments impressed us only as a means of evading the central issue of the orientation of speech therapy. There is admittedly an element in speech therapy which bears an affinity to social work, but it is a peripheral element. The dominant concerns of speech therapy do not touch upon those of the social service departments and there is little in the theory and work of those departments which could nourish or support speech therapy services. We consider that to reorganise speech therapy services in this way might needlessly jeopardise the relationships which have been established with both education and medicine, and which must be preserved.

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8.16 There was, we considered, a prima facie case for organising the services under local education authorities, since these are at the moment by far the major employers of speech therapists. If, as some of our witnesses suggested, speech therapy should be regarded as a branch of remedial teaching and speech therapists should receive a teacher's basic training followed by training in speech therapy (cf 9.09), then it would be logical for them to be employed by L.E.A.s and seconded as necessary to hospitals, in the same way as the L.E.A. provides teachers for hospital schools. In our view, however, L.E.A.s are not appropriate bodies to organise services for adults, despite the existence of a number of services organised on these lines. L.E.A.s have no experience of the needs of adults for speech therapy and adult services would almost inevitably assume a secondary importance in their minds, which would be very damaging to patients and to the profession alike.

8.17 We were in any case unable to accept that speech therapy is a branch of remedial teaching. We do not think that, because the speech therapist needs considerable understanding of learning processes in children, and employs in treatment techniques akin to those of teaching, she is either an educationalist or a teacher of handicapped children. Except in a few cases where she is employed full-time in a special school, the speech therapist does not have the teacher's comprehensive and continuous concern with all aspects of the child's development. Typically, her role is to assess the nature and extent of the child's speech disability, to give treatment or arrange for it to be given, and to discharge the child when the disability has been overcome or improved as much as is possible. In many respects, her nearest counterpart in the educational world would be the peripatetic remedial teacher. While we emphasise that the speech therapist cannot work successfully in schools without the closest co-operation and mutual understanding, both at individual and managerial level, we think that the arguments for organising speech therapy services as part of the education system lean too much on the comparatively unusual situation of the speech therapist working full-time in a special school.

8.18 We were impressed by evidence that the speech therapist's basic function is a therapeutic one, involving a large and increasing element of assessment and continuing observation with guidance to parents and families. That research and advances in the field of speech pathology must proceed hand-in-hand with advances in related medical and other disciplines seems to us equally self-evident. We had also to bear in mind that the proposed reorganisation of the National and School Health Services may remove local education authorities' responsibility for the school health service. Most of those who are now the speech therapist's colleagues in the school health service would then come under the area health authorities.

8.19 Some of our witnesses seemed to fear that if speech therapy services were to be organised under health authorities, treatment would no longer be given to children in school or school clinics. This does not and should not follow. As we say in 8.01, the aim of any reorganisation should be to make speech therapy available as conveniently as possible to those in need of it. Some of these may temporarily be hospital in-patients, others will be in residential special schools and other establishments, but the majority will be living in their own homes. It follows that treatment must be made available as locally as possible at health

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centres, clinics or out-patient departments. In the case of school children, treatment could also appropriately be given at school as at present; it follows that suitable accommodation must be made available to the therapist (5.23).

8.20 Before reaching a decision that services should uniformly come under the area health authority or, alternatively, under the local education authority, we considered one further possible pattern based on local option. It would be possible to allow each area to decide for itself, in the light of local experience and circumstances, whether the area health authority or the local education authority should be responsible for the speech therapy service. We have already drawn attention to the existence of successful examples of both types of organisation. But such an arrangement would pose a number of practical problems in places where area health authorities and the new local authorities were not coterminous. Furthermore, local authorities tend in providing facilities to keep more closely to their own catchment areas than would health authorities. More fundamentally, it is in our view essential that the responsibility for the provision of an adequate speech therapy service should be clearly laid on one authority or the other, and the appropriate resources allocated to that authority. With powers divided between the new area health authorities and the new local authorities, and neither having the primary duty, both might fail to give sufficient importance to the substantial development which is urgently needed.

8.21 The College of Speech Therapists made yet a further proposal, suggesting that both area health and local education authorities might employ therapists and arrange for mutual exchange of staff - L.E.A. therapists being seconded to work in hospitals, and hospital therapists working in specialised fields being used by the L.E.A. We rejected this idea as being incompatible with the aim of achieving a unified service.

8.22 In all the circumstances it appeared to us that the most appropriate and logical course might be for the new area health authorities to assume responsibility for a unified speech therapy service, particularly if they took up responsibility for other functions which at present come under the L.E.A.s as part of the School Health Service. The necessary arrangements for close co-ordination with the L.E.A.s could be discussed along with the organisation of other health services for children. Special arrangements might perhaps be necessary to enable L.E.A.s to employ speech therapists, for example to form part of the full-time staff of some special schools, though we would hope that this need might be met by long-term secondment from the unified area service.

8.23 We therefore recommend that speech therapy services should in future be organised under area health authorities in England and Wales and under health boards in Scotland.

A POSSIBLE STRUCTURE

8.24 The numbers and composition of the corps of speech therapists will obviously vary considerably from one area to another. Nevertheless, we see a pattern common to all, which in each area will provide a much-needed career structure.

8.25 Each area will employ a number of qualified speech therapists (including newly qualified therapists working under supervision) (cf 9: 26-27). They would

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treat the majority of children and adults requiring help, apart from those in special schools or otherwise receiving treatment in special centres. With the prevailing shortage of speech therapists, which is likely to continue for some years, the aim must be to conserve the time of highly-trained personnel as much as possible. The speech therapist should not, therefore, usually be expected to spend a large proportion of her time in travelling between centres, though in rural areas, distances and poor public transport services may make travelling to isolated schools and centres inevitable.

8.26 In all except the smallest area health authorities, there will be experienced speech therapists (who would usually be Senior Speech Therapists) responsible for groups of staff either working in a geographical district or in a large hospital department or special unit. Experienced therapists would co-ordinate the work of the therapists and auxiliary staff in their group, supervise newly-qualified speech therapists and those returning to the profession, and assist in the clinical training of students: they should also spend a defined proportion of their time in clinical work.

8.27 There should also be provision for others with a highly specialised clinical role to become senior speech therapists. Some of these might for example be seconded to residential schools such as those for severe language disorders, or to specialised hospital units or assessment units. In these contexts the speech therapist would be working as a member of a multi-disciplinary team. At present there is no opportunity for a speech therapist to attain senior status on the grounds of special experience and clinical responsibility. We feel it important to reward clinical as well as administrative skills.

8.28 In each Area there should be a speech therapist responsible for the direction of the service and for overall planning. She should have access to the area health authority and should act as the voice of the service, putting its needs to management, helping to formulate policy and taking responsibility for its implementation. She would play a major part in the appointment of other therapists. Where possible, she also should be able to spend part of her time on clinical work.

8.29 Areas will differ considerably in population and geography. Some will be split into districts for day-to-day management; others will not. Some will provide more specialised facilities - perhaps for a region - or may have greater commitments in teaching or research. It is thus impossible for us to make precise recommendations on the structure of area services. However, we thought it useful to select from amongst the large number of possible variations, three examples of differing fictitious authorities, and to suggest how their speech therapy services might be organised. These structure charts are attached as an Annexe to this chapter: the numbers of staff deployed in them are intended to approximate to the numbers which area health authorities might take over in 1974. We stress that these numbers will, as the preceding chapter has shown, be quite inadequate to provide the service we consider necessary. Moreover, adequate secretarial and clerical support must be provided if speech therapy resources are to be fully and properly used (see 5.25; 6.49).

8.30 We therefore recommend that

(i) Within each area health authority there should be an establishment of speech therapists organised in a career structure reflecting levels of re-

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sponsibility (clinical as well as administrative), experience and academic distinction.

(ii) The establishment of speech therapists should be provided with an adequate supporting staff of clerical and secretarial workers.

8.32 We therefore recommend that special attention should be given to the accommodation provided for speech therapy, and guidelines should be produced at national level.

LEADERSHIP OF THE PROFESSION

8.33 We hope that the measures we propose in Chapters 9 and 10 for raising the standard of training and increasing the scope of research will mean that in time the profession will increasingly provide leaders of high academic and clinical standing. If speech pathology, or human communication, becomes established as a clinical entity and as a subject of study in universities we would expect to see the foundation of one or more Chairs of Speech Pathology and the appointment of clinicians of consultant status in this field. We think it likely that these would in the first instance be practitioners of other disciplines, such as neurology, paediatrics, psychology and linguistics, who have developed a particular interest in and knowledge of speech and language, but we look forward to the time when a number of these posts will be filled by those who have practised speech therapy.

8.34 Similarly, the speech therapy profession stands in need of senior administrative leaders. We commented in Chapter 5 on the lack of representation of the profession at the highest management level. We foresee that this problem might be perpetuated under the new arrangements we propose, and that the speech therapy services might therefore fail to secure a proper share of available resources. We regard it as important that provision be made at area health authority level for the speech therapist in charge to speak for the service directly at meetings of the authority and its committees. The needs of the service will also have to be made known at Regional level if they are not to be overlooked in planning. We consider that there should be an advisory committee representing speech therapists working in the Region, and that where necessary its chairman or elected representative should have access to the Regional Health Authority.

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Without further clarification of the role of the regional authorities in England, it is not possible for us to decide whether in addition a post of Regional Speech Therapy Adviser would be desirable.

8.35 It was suggested by several witnesses that the situation would be improved by the appointment of an adviser in speech therapy to either the Department of Education and Science or the Department of Health and Social Security, or both. We consider that there is a strong case for such an appointment, particularly over the next few years which will, we hope, be a period of rapid change for speech therapy. The appointment or appointments should be in the central government departments responsible for health, and among the matters to which early attention might be given are firstly the design of speech therapy premises (8.31) and secondly, the establishment of priorities in speech therapy to ensure that scarce resources are not deployed on inessential work (6.49).

8.36 We therefore recommend that

(i) In the structure of the new health service in England and Wales and in Scotland provision should be made for advisory committees representing speech therapists which would have access to the committees of the health authorities responsible for the planning of services.

(ii) A national adviser should be appointed to the Department of Health and Social Security to assist the development of speech therapy services and training. The Scottish Home and Health Department and the Welsh Office may wish to appoint their own advisers.

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A ASHBRIDGE AREA HEALTH AUTHORITY

Ashbridge is envisaged as one of the smaller authorities with a population of under 200,000, serving a compact urban community which is part of a large conurbation. Its boundaries are coterminous with those of the Ashbridge Metropolitan District Council, which as L.E.A. maintains one special school for E.S.N. pupils. Children with other handicaps are sent to special schools in adjoining areas. The area has a district general hospital and long-stay annexe but looks to a teaching hospital in an adjoining area for more specialised services.

Of the (inadequate) number of speech therapists taken over by this Area Health Authority in 1974, Therapist (1) is newly qualified. Having worked under guidance from Therapist (4) in a hospital setting, she is, in addition to retaining two hospital sessions, now gaining further experience in schools and clinics with help from Therapist (3).

Therapist (2) also works with patients of all ages and visits schools and clinics as well as treating in-patients.

Therapist (3) works entirely in schools and clinics and devotes two sessions per week to the special school.

Therapist (4) has senior status by virtue of her experience, a higher qualification and the fact that she helps with the clinical teaching of students from the speech pathology department of the university in an adjacent area. She concentrates her work on hospital patients, including the long-stay annexe.

Therapist (5) has overall responsibility for the service in the area. She is making long-term plans, discussing needs with colleagues in various other disciplines, and is preparing a report for the A.H.A., stressing the need for a considerable development over the next few years. In the meantime she has the difficult task of using limited resources to the maximum benefit and ensuring that the service is well coordinated with both the schools and the various hospital departments.

In addition she normally undertakes five sessions clinical work per week.

B BIRCHESTER AREA HEALTH AUTHORITY

This is seen as a medium-sized authority with a population of approximately 500,000, coterminous with the new county of Birchester. There is a medium-sized county town, Bramley, with a population of 100,000, together with a number of smaller towns and a fairly scattered rural area. There is a natural geographical division of the area into two. Of the two district general hospitals one, situated in the county town and serving a population of some 300,000, has a specialised paediatric assessment unit: research activities are undertaken in collaboration with the local University Department of Linguistics. The second

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district general hospital at Beechwood looks to other centres for its more specialised facilities. The L.E.A. runs five special schools for E.S.N. pupils as well as one for the physically handicapped. There are four units, attached to ordinary schools, for partially hearing and speech defective children.

Even with the inadequate staff of 13 taken over in 1974 geography and specialised work call for some administrative division. The therapist in charge of the area spends two or three sessions per week in clinic duties and initially coordinates the work of her colleagues in the Bramley district, but a colleague in the Beechwood district is responsible to her for the services there. In the district based on the county town of Bramley, circumstances have led to the need for two groups of therapists, one undertaking work in schools, health centres and out-patient clinics at peripheral hospitals, the second working exclusively in the district general hospital and in the assessment unit, and participating in research activities. In the Beechwood district all the therapists work in schools, health centres and in the hospital.

C CHILTONSHIRE AREA HEALTH AUTHORITY

This would be an example of the larger authorities, with a population of well over 1,000,000, containing the major cities of Coxtown and Clarebury as well as the county town of Chilton and a developing new town, Camford. There are four district general hospitals of which the one in Clarebury is the university teaching hospital. The Clarebury hospital also contains a regional assessment unit and a special rehabilitation unit. A speech therapy training school has recently been set up in association with Clarebury University.

The size of the authority and the range of services to be provided mean that the therapist in charge of the area spends virtually all her time on administrative duties. Additionally she is Chairman of the Regional Speech Therapy Com-

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mittee, is a member of the Council of the College of Speech Therapists, and has been elected by the profession as one of their nominees to the new Council for the Training and Registration of Speech Therapists (see 9.50).

The Area Therapist is personally responsible for the Chilton district but a 'district therapist' in each of the other three districts is responsible to her for the operation of the service in her district and for liaison with teaching and medical colleagues: each of these district therapists spends much of her time on clinical duties.

In the Clarebury district the needs of the service require some therapists to work exclusively in the teaching hospital and Regional Assessment Centre. In the other districts the therapists all work with both children and adults in schools, clinics and the district hospital. One from the Chilton district is seconded on a full-time basis to the L.E.A.'s small special school dealing with children with communication disabilities.

LIMITATIONS OF PRESENT TRAINING

9.01 We show in Chapter 2 how the present training for speech therapists has evolved from tentative beginnings and individual initiatives. The College of Speech Therapists has over the years since its foundation maintained a critical scrutiny of the content of courses, and the syllabus in a number of subjects has been revised. Nevertheless it is true that the curriculum has grown up sporadically and that while over the years a number of items have been added, very little has been discarded. There has been little attempt radically to revise training in the light of what is now and will in future be required of a speech therapist.

9.02 The College sets a high standard of clinical competence and we found very little evidence of dissatisfaction with the performance of speech therapists as clinicians. Such criticisms as were made related more to the effects of staff shortage - for instance lack of flexibility in treatment programme and inexperienced therapists working without proper support - than to any shortcomings in the training in the application of therapeutic techniques.

9.03 There was, however, considerable criticism of the theoretical basis of training. This was considered to impose a substantial burden on students in terms of the amount and variety of information to be mastered, without equipping them with the necessary range and depth of knowledge or making clear the relevance to speech pathology of other disciplines. The head of one speech therapy school described the present course as 'a ragbag of miscellaneous pieces of information'. This does not imply criticism of the components or of any individual component, but rather the difficulty of providing an integrated course of study on the present basis.

9.04 There is considerable variation in teaching. Some schools give too little attention to subjects such as psychology: in others anatomy and physiology, for instance, are taught in such a way that their relevance to speech pathology is not adequately demonstrated. This failing perhaps occurs because the schools are obliged to use visiting lecturers - though often university personnel - to teach these subjects. This may mean that there is little opportunity to plan a coordinated approach to teaching, and the visiting lecturers may not fully understand what aspects of their subject are relevant to the speech therapist's needs. The result is, often, a fragmented, repetitive and unsatisfactory course, sometimes further unbalanced by over-emphasis on specific technical aspects of speech pathology. The Chairman of the College's Examinations Board, speaking in his personal capacity, told us that there was some 'overloading of the syllabus with a degree of specialisation through the enthusiasm of members, out of keeping with a first qualification'.

9.05 Many of those involved in the training of speech therapists are aware of the need to absorb new knowledge and insights from other disciplines. This was pointed out several times in evidence. The Royal College of Psychiatrists

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considered that at present therapists are 'inadequately trained in psychodynamics, family dynamics and psycho-therapy', while the Royal College of Surgeons of Edinburgh took the view that 'current advances in phonetics, linguistics, audiology and neurology ... may soon require further advancement in speech therapy training'. The difficulty is that the present course is so overloaded that these new elements can be incorporated only at the price of even greater fragmentation and superficiality.

9.06 Despite the complexity of the disorders treated and the variety of background knowledge involved, the approach to the training of speech therapists is basically geared to the efficient performance of a somewhat limited range of clinical functions. Even where schools of speech therapy form part of a larger educational institution, staff and students are rarely brought into contact with fundamental issues in the related disciplines, and speech therapy tends to remain a somewhat isolated specialism. Though the qualifications for entry are high, the training arduous, and the standards for qualification rigorous, the L.C.S.T. as such is not acceptable to the universities as a qualification for postgraduate work, and at the same time the universities have not themselves developed a comparably broad-based academic approach to human communication. This has serious implications for the research on which the development of the profession and the welfare of its patients ultimately depend. It also perpetuates the isolation of speech therapy: because so few speech therapists can equip themselves to participate in or interpret relevant research, research findings tend not to be reflected in practice or in training, and there is thus a continuing tendency to narrowness.

9.07 In Chapter 6 we look forward to developments which will have to be adequately prepared for in future training. We envisage the ultimate development of a profession which accepts 'language as the central core of a basic discipline'. To this end, we consider that the proper training for speech therapists in future should be one which, in the words of an eminent psychologist, 'will enable them (a) to grasp what is known of the language function as a whole and the relationship of particular therapeutic problems to this knowledge; (b) to follow the progress of on-going research and make such changes in their procedures as are suggested by it; (c) in certain instances, themselves to engage in research'.

ORIENTATION OF TRAINING: MEDICINE OR TEACHING?

9.08 The majority of our witnesses inevitably saw the problems and their solutions from the standpoint of their own particular interest. It would be possible, but unprofitable, to compile from the evidence an anthology of wholly incompatible suggestions for an appropriate training. To give only one example, the National Union of Teachers told us that 'the training of the speech therapist is based too much on the medical and pathological approaches rather than on child development and socio-educational considerations', while the British Medical Association considered that 'those who need therapy have problems that are more medical than educational'.

9.09 Some witnesses suggested as a solution to this problem, and to that of the overloading of courses, different courses of basic training for the 'hospital' and the 'educational' speech therapists. The Royal College of Surgeons of Edinburgh, for instance, suggested a two-year basic course with an extra year's specialised

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training for either the health or the education service, or 2 years' additional training to equip the therapist for either. Others considered that training for speech therapy with children should be more closely integrated with teacher training, as is common in Scandinavia and New Zealand, or even that speech therapy in this area should become a branch of remedial teaching, as in Austria and Japan.

9.10 We were unable to accept that there was a case for two distinct forms of basic training leading to separate qualifications. Even with the expansion of numbers that we suggest in Chapter 7, speech therapy will remain a small profession: we do not think that barriers should be raised against the fullest interaction between its members. The existence of two qualifications would hinder the operation of a unified organisational structure such as we envisage in Chapter 8. Quite apart from these considerations, however, we do not consider that the knowledge, expertise and skills required by a speech therapist working in the educational setting can be separated from those needed in the hospital setting. Both rely on a background of medical and other related knowledge, both make use of techniques comparable to those of teachers, and while adults are treated only by N.H.S. therapists, both treat children. While we certainly see similarities between some of the work of some speech therapists and that of some remedial teachers, we see no advantage to these members of the speech therapy profession in merging their identity with that of the remedial teachers, and we see very considerable disadvantage to the remaining members of the profession, whose work is not so closely equated with teaching. We consider that the way must be left open for therapists to acquire varied experience, in schools or special schools as well as in hospitals, at different stages in their careers, and to bring to work in one context the knowledge and insight gained in the other. This presupposes a single form of basic training qualification. But of course it does not, in our view, preclude the development of varying orientations within basic training, or more especially the pursuit of specialisms once a basic qualification has been gained. (9.29).

9.11 We therefore recommend that the training leading to registration as a speech therapist should qualify for practice in all fields.

9.12 A large number of our witnesses, both within the speech therapy profession and outside it, urged that the training of speech therapists should be conducted within universities at degree level. The British Medical Association took this view, while many other witnesses considered contact with related disciplines of paramount importance. We carefully noted the evidence from the U.S.A., where there is no formal qualification for speech therapy at a lower level than a bachelor's degree, and where indeed the American Speech and Hearing Association recommends that no practitioner shall have less than a master's degree and a certificate of clinical competence. We also had before us the examples of Czechoslovakia and South Africa, where speech therapists are of graduate status, and of many other countries where many of the practitioners corresponding to British speech therapists have had a university training. The College of Speech Therapists told us that it was already their policy to recognise only those new courses started in institutions offering degrees, or where degree courses will be available in the foreseeable future, in the hope that ultimately all courses would be organised at degree level. We recognised, however, that the natural aspirations of those within the profession are not enough to make a case for

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university training unless we were ourselves satisfied that solid, objective arguments existed.

RECOMMENDED PATTERN OF FUTURE TRAINING

9.13 The need as we see it is for changes in basic training which would end the present isolation of the speech therapy schools' staff and students, bring them into day-to-day contact and cooperation with those working in related disciplines, provide for recognition of the complexity of the diagnosis, assessment and treatment of communication disorders, and open the way to advanced work and specialisation. Training should also offer to recruits of good calibre rewards in terms of personal satisfaction, academic standing and opportunity, to the ultimate benefit of those in need of speech therapy. We also consider it important for training to be brought into direct relation with relevant research, so that students are taught by those in day-to-day contact with research work and so that the implications of new developments can be promptly reflected in training. Unless this is achieved, training will inevitably perpetuate out-dated concepts and methods of treatment.

9.14 We do not believe that these changes can satisfactorily be made within the existing system of training. The curricula of the training schools could not be thoroughly revised to meet the criticisms in 9.03-07, while maintaining their present isolation. There would still be no continuous contact with work in progress in other disciplines and the effect of revising the curricula would therefore be only superficial and temporary.

9.15 The experience of the existing degree course at the University of Newcastle-upon-Tyne has demonstrated the tonic effect upon staff and students of involvement with a wide range of other disciplines in a context of high academic and teaching standards. Courses shared with other departments (for instance that in psychology) have widened the horizons not only of potential speech therapists but also of students in other disciplines. Staff from other departments lecture to speech therapy students, while members of the Sub-Department of Speech teach in other departments; in the process an integrated and coherent approach to teaching in the field of speech pathology has been developed, while knowledge and understanding of the speech therapy profession by others is extended. The Board of Studies for the B.Sc. (Speech), by bringing together professors from several departments, provides a forum in which the standards and aspirations of the Sub-Department can be objectively assessed. Insight into standards of appointments in other university departments has led to a more critical approach to the selection of staff. Above all there is a constant daily process of exchange and sharing of information among staff in different departments.

9.16 The Committee of Vice-Chancellors and Principals have recently stated that 'the special character of university courses lies in the fact that they reflect the direct link between teaching, and research and scholarship up to the boundaries of existing knowledge' (University Development in the 1970s, April 1970). It is this link, extended in their case over the many branches of learning which are relevant to speech pathology, that we regard as indispensable for the speech therapist of the future. The Royal Commission on Medical Education, 1965-68, saw a similar need to ensure that the undergraduate education of doctors is not conducted in isolation from other relevant disciplines and from research. In

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paragraph 386 of the Todd Report it is stated that 'the modern medical school must be an integral part of a university which can be expected to provide in due course a full range of opportunities for instruction and research in those biological, physical and behavioural sciences which are relevant to medicine'. The involvement of more speech therapists in relevant research investigations would likewise be facilitated by training at degree level. This would help achieve a link between theoretical research and clinical experience which is essential for advance in the treatment of numerous groups of patients. To sum up, we believe that the necessary enrichment of education, broadening of outlook and extension of opportunities can be achieved only through degree courses.

9.17 We therefore recommend that

(i) The future training of speech therapists should be at degree level.

(ii) A number of universities should develop the necessary departmental structures for the training of speech therapists as such, or should create degrees which, with appropriate supplementary courses, would provide students with a sound academic and clinical basis for careers in speech therapy. We would hope that the UGC would respond favourably to approaches on these lines.

9.19 We therefore recommend that training should be conducted in universities which have medical schools or in institutions which have very strong links with medical schools and hospitals having a special interest in speech disorders, and which are adequately staffed and equipped to teach the relevant subjects.

Possible Developments in Courses of Training

9.20 As we have indicated, courses within universities might take a variety of forms. Some might develop on similar lines to Newcastle where, initially, the course was modelled fairly closely on the LCST course, a pattern which has since been modified in a number of important ways. There is a strong case also for the development of degree courses in, for instance, linguistics and psychology which would provide a basis for a career in speech therapy. We have read of proposals for degree courses in the field of speech pathology at Birmingham, Glasgow, London and Manchester. At Reading a 4-year joint degree course in Linguistics and Language Pathology is proposed. This would be in two main parts: a two-year introductory course in which a 'core' range of subjects is studied, and a 'specialist' two years in which students would choose, if they had not already done so, to follow speech therapy, remedial education, audiology or deaf education as a vocational specialism. We hope that proposals such as these will find increasing interest and acceptance in universities, and indeed we

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consider that there are good grounds for hoping that universities will become increasingly receptive to the claims of new courses of training and of research in new fields. The Committee of Vice-Chancellors and Principals, in the 1970 report to which we have already referred, noted that 'a number of entirely new professions calling for university education have appeared'. We regard speech pathology and therapy as unquestionably one of these.

9.21 Training based on a university (or analogous institution), with the connections we recommend above, and perhaps additionally associated with assessment centres for handicapped children, would provide much needed stimulus for advance and investigation in speech therapy and allied disciplines. The potential would be very great not only for the treatment of intractable cases, but also for investigation, research, teaching and the dissemination of knowledge. Individual centres might develop their own specialities, depending on the interest of those working in them and in the associated training schools and hospitals. For speech therapists this arrangement would not only provide opportunities for a more varied and satisfying career, with the possibility of specialised work, but would also, given that a satisfactory interchange of staff could be arranged, ensure a more even distribution of rare skills throughout the country.

9.22 We are aware, however, that to a university considering the establishment of a degree course relevant to speech therapy the high vocational content of the existing Diploma courses, and the large proportion of time spent in clinical training, may represent a possible obstacle. We understand that the clinical standards at Newcastle are maintained though fewer hours are devoted to this part of the curriculum, and it is likely that universities may decide to introduce courses in which the clinical content is quite small. We consider that more could be done to increase the effectiveness of clinical training and reduce the time spent by students in travelling and observation by the use of audio-visual aids - film, film loop, video tape and closed circuit television - to demonstrate examples of the best clinical work. Such techniques could not entirely replace the experience of working in a clinical setting on a one-to-one basis with an experienced clinician and with real patients, but greater use of them would help to ease the shortage of clinical placements, which is at present a major obstacle to the increase of numbers in training. Alternative methods of organisation of clinical practice - for instance the use of fewer, but longer, 'block practices' - might also be helpful.

9.23 The main reason for the shortage of clinical placements is the generally poor staffing situation, and in particular the lack of senior appointments (see 5.16-17). Some therapists find it impossible to supervise a student in the inadequate accommodation at their disposal. At present, moreover, no salary allowance is made to speech therapists for undertaking the supervision of students. The work is time-consuming and its great importance should in our view be properly rewarded. If no arrangements can be made for national salary scales to take account of responsibility for the clinical supervision of students, universities themselves might well consider some form of remuneration for clinical supervisors in future.

9.24 We therefore recommend that

(i) Those involved in planning courses of training for speech therapy should

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consider the increasing contribution that audio-visual techniques and alternative methods of organisation could make to clinical training.

(ii) Speech therapists with responsibility for supervising students should be appointed in a supervisory capacity and remunerated accordingly.

9.25 The development of a range of degree courses, varying in emphasis and in the amount of vocational content, will create the need for a body charged with the responsibility of assessing courses from the point of view of the practice of speech therapy and of licensing graduates to practice. Such a body would be able to decide, for instance, that graduates of course 'A' could be licensed to practise immediately after graduation, whereas graduates of course 'B' must first complete an additional approved course of clinically orientated training designed to make up any gaps in their knowledge or experience. An arrangement of this kind is in our view essential if (a) a variety of courses is to be stimulated which will lead to fresh thinking and advance, while (b) graduates from such varied courses are to be fully equipped for the practice of speech therapy and adequate and uniform standards of clinical competence are to be maintained. We discuss the establishment and possible composition of the licensing body in 9.50ff.

9.26 In addition to these supplementary vocational courses, we consider that the first year in paid employment after licensing should be spent under the supervision of an experienced speech therapist. If practicable, it would be an advantage if the year could be divided between experience of work with children and with adults. This supervised year would enable speech therapists to develop skills and techniques that might have been insufficiently practised during training, such as, for example, audiometry or the use of the many different tests of comprehension, spoken language and articulation which are now available. It would also end the situation noted in 5.17, whereby newly-qualified speech therapists are appointed to single-handed positions, and would put the speech therapist, with her improved skills and confidence, in a better position to decide to which aspects of speech therapy she was particularly suited.

9.27 We therefore recommend that training should be followed by a year of paid supervised practice.

Advanced and Specialist Training

9.28 As we have noted before, the LCST is not of itself recognised as a qualification for higher degree work at universities, although individual students may, very infrequently, be admitted to some courses on their merits. There are certain specific post-graduate courses, such as those leading to the Diploma in Audiology at the University of Manchester, the Diploma in the Teaching of Speech Therapy at Reading, and the newly-established MSc in Human Communication at Guy's Hospital, London, which are open to speech therapists.

9.29 We hope to see the development of a range of post-graduate courses in particular aspects of human communication; for instance linguistics, psychology or physiology in relation to speech pathology. Some of these would constitute the essential supplementary courses for particular degrees, and would have to

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be taken before a licence to practise speech therapy would be granted. Others would provide training in research methods: others again would give an opportunity for advanced study of a particular aspect of the subject. They should be open not only to speech therapists, but also, like the Guy's Hospital course, to paediatricians, neurologists, psychologists, linguists and others, and would thus assist the development of mutual understanding and co-operation amongst the professions concerned with communication disorders. There is also a need for short courses of specialised in-service training for serving speech therapists. These should be open both to graduate speech therapists and to LCST's. Among the subjects they might cover are the particular demands of speech therapy with the mentally handicapped, cerebral palsied, aphasics, and those who have undergone laryngectomies.

9.30 We therefore recommend that

(i) A range of post-graduate courses should be developed in aspects of human communication and its disorders, open to speech therapists and to members of other professions.

(ii) Increased opportunities should be provided for serving speech therapists to obtain specialised training on an in-service basis.

FIGURE 2

DISTRIBUTION OF CENTRES OF TRAINING

9.32 We are not in a position to particularise the places and institutions where centres of training might develop. Some parts of the country which apparently have particularly severe difficulty in recruiting speech therapists are Wales, SW and NE England, and Northern Scotland. We understand that a proposal for a course of training in Wales is now under discussion and we recognise that there is a need to train some therapists to give treatment in Welsh. While there is no conclusive evidence that the establishment of a course of training in

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an area will necessarily improve recruitment to its services, a number of our witnesses and members considered that some relationship did exist.

9.33 We therefore recommend that in the establishment of new training facilities attention should be paid to areas with severe problems in filling speech therapist posts.

SPEECH THERAPISTS' AIDES

9.34 In Chapter 7.39ff we argued the need for a cadre of speech therapists' aides who, by undertaking under supervision some of the more routine aspects of treatment, day-to-day maintenance of equipment, and so on, would relieve the speech therapist of some work and enable her to make fuller use of her skills and training. We consider that as speech therapy becomes increasingly a graduate profession the difference between the high level of training which is unquestionably necessary, and the fact that at present speech therapists are called upon to spend too high a proportion of their time on work of a routine nature, will become more and more apparent and the need to employ a number of less skilled workers with less specialised skills will become more pressing. Other professions are being led to similar conclusions. We examined various proposals for introducing these less skilled workers by means of differing levels of training, producing a horizontal division in the profession between fully-trained graduate speech therapists and the less highly qualified. We concluded, however, that such a division would be a potential source of weakness and tension in a small profession, and that the best means of avoiding it was the use of aides, under the conditions and with the safeguards set out in 7.39-44.

9.35 Aides could probably best be introduced to their work through guidance on an in-service basis from the therapists responsible for their supervision. A probationary period to establish suitability might be advisable. Speech therapists will themselves need guidance on how to delegate work and manage staff effectively, tasks which in our view constitute an essential part of the growth of an established and self-confident profession. Speech therapists should in the course of their professional training be taught how to undertake these responsibilities.

9.36 We therefore recommend that the professional training of speech therapists should include guidance on delegation to aides.

FUTURE OF EXISTING SCHOOLS OF SPEECH THERAPY

9.37 Our ultimate aim is for a fully graduate profession and we hope that rapid progress will be made towards this. We accept, however, that the establishment of degree courses for speech therapists will take time and that the transition period may well be a lengthy one. In the meantime there is, as we made clear in 7.24ff, an immediate need for an increase of numbers in the profession. To some extent this can, as we say in 7.33f, be met by a campaign to bring married women back into the profession, and early implementation of the system of using aides will also make an appreciable contribution. But there remains a need which can be met only by training more speech therapists.

9.38 There is thus a conflict of interest between the development in training which we wish to see and the immediate need for recruits to the profession. In

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this situation we might have been tempted to recommend an interim increase in the number of courses at the existing Diploma level, with the hope that these may in due course be upgraded to degree status. We do not believe that such a solution would be in the best interests of the profession. There is already some evidence of a shortage of good candidates for training and while better public understanding of speech therapy and more publicity in schools may lead to an improvement in recruitment, this will be marginal until the academic basis, opportunities and prospects of the profession have been improved. At the risk of a continuing shortage of members in the profession, therefore, we recommend that no further Diploma courses in speech therapy should be established.

9.39 The same considerations do not in our view apply to an increase in numbers on existing courses of training. Diploma and degree-trained therapists will continue to co-exist in the profession for some time to come. The single measure most likely to ease the transition to an all-graduate profession would be recognition by universities of the L.C.S.T. as the equivalent of a first degree. This would open the way to advanced courses and to postgraduate research for all speech therapists, not only graduates, and would thus reduce the disparity of opportunities. We hope that with the increase of interest in speech pathology which we look for in the universities, they will be prepared to reconsider their attitude to this qualification. Schools of speech therapy should in their turn be prepared to modify their courses to meet university requirements. Where schools wish to continue to take the College's examination during the transition period, we hope that the College will find it possible to continue their examining functions in coexistence with the licensing body we suggest in 9.25, to which changes in L.C.S.T. courses will have to be referred.

9.40 We therefore recommend that the schools of speech therapy should discuss with the universities the conditions under which L.C.S.T. would be acceptable as a qualification for post-graduate work.

9.41 Where, in contradistinction to the situation we envisage in 9.39, a school has become a large centre of academic and clinical initiative in the field of speech pathology, and where such a school desires autonomy in the assessment of students and the conduct of examinations, there is a good case for encouraging such a development, again subject to the constraints on the maintenance of standards to be provided by the licensing body. Developments towards autonomy might well also play a part in assisting schools in coming closer to neighbouring universities, and so would aid the transition to an eventual all-graduate profession.

9.42 A very great contribution to the development of the profession has been made by the early-established schools of speech therapy - the West End Hospital School, run under National Health Service auspices, the three independent London schools and the independent school in Edinburgh. In terms of numbers alone, these five schools provide more than half the present total training capacity. Training facilities on this scale will obviously not become quickly available elsewhere, while the experience and skill in the training of speech therapists possessed by these schools are indispensable. We understand that one of them, the speech therapy school at the Central School of Speech and Drama, has an assured future existence when the Inner London Education Authority assumes responsibility for the Central School.

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9.43 Nevertheless, we strongly affirm that the future of speech therapy courses must be in units which, by affiliations with larger institutions, can command greater teaching resources and more easily make the transition to degree-level courses. The West End Hospital School and the other London schools might well profit either from greater cooperation among themselves or from developing closer links with the (many) clinical and teaching institutions around them. It occurred to us that some of the London schools might make joint arrangements for the assessment of students and the conduct of examinations, on the lines we propose in 9.41. At the same time, or as an alternative, the schools in London and Edinburgh might seek affiliation with teaching hospitals and universities. We understand that plans have already been made, in some instances, for the establishment of degree courses, as a result of which Diploma courses will be phased out. Other schools are exploring the possibility of the award of degrees through the Council for National Academic Awards. Developments of this nature will be facilitated by links with larger teaching institutions.

9.44 There is also a possibility that some of the existing schools of speech therapy may in future find a developing role in the provision of post-graduate courses of professional training such as we recommend in 9.30. Here again, very close working relations with the universities providing the initial courses would be essential to ensure adequate coverage of all necessary theoretical and clinical aspects of the work. The schools might also expand their role to cover provision of the specialised in-service courses we suggest in 9.31.

9.45 We therefore recommend that

(i) Schools of speech therapy should seek means to increase their intake as much as possible and should make a vigorous attempt to reach a target of 350 per annum by 1982 at the latest;

(ii) Existing diploma work should seek integration with larger teaching institutions.

CENTRAL COUNCIL FOR SPEECH THERAPY

9.46 If the training of speech therapists becomes the responsibility of universities, the College of Speech Therapists will lose a large part of their current role. They will no longer be responsible for controlling the age of and qualifications for entry to training, for approving new courses of training, for inspection of courses, for the content of the curricula or for the conduct of examinations and the award of a qualification (though in the interim period before degree courses become universal arrangements would naturally need to be made for them to maintain their present role where required, see 9.39). The College's evidence made it clear that they regarded the establishment of a graduate profession as so important that they were prepared to accept this diminution of their influence over the profession. We consider in any event that the College's present dual function as examining body and professional organisation is anomalous.

9.47 In 9.25 we explained the need we saw for a central body with the function of assessing courses from the point of view of professional practice, saying what additional training should be undertaken, and licensing graduates to practise. We do not think that this function could be successfully undertaken by the

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College as it is at present constituted. The College's ultimate authority is its Council, a body of elected members of the profession on which the training establishments as such are not represented. We have reason to believe that assessment of courses and licensing of graduates by such a body would be unacceptable to the universities providing courses. We considered the possibility of widening the membership of the College's Training and Registration Board to enable it to undertake these functions. According to the College's constitution, however, the Training and Registration Board is formally responsible to the College Council. For the Board to attain the independence that we would see as essential for the discharge of its new responsibilities, fundamental changes in the College's constitution would be needed: the result of these would be to change completely the College's nature as a representative professional body.

9.48 We concluded that it would be preferable to separate completely the role of professional body from the function of awarding a licence to practise. This would mean that of its present roles the College would retain only that of professional body (though the College and the Union of Speech Therapists should give early consideration to what appear to be their partially overlapping functions).

9.49 We therefore recommend that the college of speech therapists should concentrate in future on a purely professional role.

9.50 The assessment of courses and the registration of students as qualified to practise could in our view be best undertaken by a separate Council for Speech Therapy, to consist of elected representatives of the profession, delegates from institutions offering teaching and training in this field, and central government departments. We would assume that such a body would include among its numbers representatives of medicine and other related professions. Its responsibilities would extend to all courses of training and it would thus be able to maintain parity of clinical standards between university graduates, L.C.S.T.'s and the products of schools conducting their own examinations. It would be reasonable for the Council to assume also the College's present responsibility for the assessment and recognition of overseas qualifications. Registration by the Council would be a statutory requirement for employment as a speech therapist in Great Britain. The Council's expenses would be met in part by a registration fee charged to candidates and in part from central government funds.

9.51 We regard the establishment of the Council, with its power to approve courses as qualifying students to practise, as a measure which, along with the year of supervised practice (applicable to all newly-qualified speech therapists, graduate or non graduate), will give the schools of speech therapy the opportunity to reduce their emphasis on clinical work, widen their academic horizons and bring their courses closer to university requirements on the lines recommended in 9.43.

9.52 We therefore recommend that

(i) A central council for speech therapy should be established for the approval of courses of training and the registration of speech therapists as qualified to practise.

(ii) Employers be required to appoint as speech therapists only those so registered.

RESEARCH AND PROFESSIONAL GROWTH

10.01 We make no apology for including in our report a chapter on the need for research in the field of language pathology. It is unfortunately evident at several points in the preceding chapters that the information available to us about the current need for and state of the speech therapy services has been gravely inadequate. Because of the paucity of information on the prevalence of speech disorders, the relatively few evaluative studies made of the effectiveness of speech therapy, and the lack of studies which extend the understanding of the communication processes, neither the need for speech therapy nor the capacity of the profession can be accurately gauged at present.

10.02 By our emphasis on research, we want moreover to attest our sense of the profession's importance. Despite its small numbers and modest beginnings, there is no other profession so centrally devoted to remedying defects in man's most important attribute: language. We consider it essential for the profession to develop its potential, and this can be achieved only by long-term basic research in a number of academic disciplines and with continuous clinical observation and experiment. The needs of those suffering from impaired speech and language cannot be met simply by an increase of numbers in the profession. The eventual result of research of the breadth and on the level we propose will be, as we foresee in Chapter 6, a profession embodying a far wider concept of its role in the treatment of communication disorders.

10.03 We have already commented extensively on the relevance to speech pathology of such other fields of study as audiology, linguistics, neurology and psychology. It is to research in these disciplines that the speech therapy profession must look for many of the advances on which their future practice will be based. Some of this will be theoretical research entirely within the discipline concerned, and speech therapists will not themselves be involved in the investigations. There is also, however, a large role for interdisciplinary research into various problems. Much of this will have a clinical aspect, and in many cases suitably-trained speech therapists will be valuable members of the research team. Work in these two categories will almost always be university-based. In addition, we see a useful place for independent studies by speech therapists themselves, perhaps on the basis of data collected and recorded in the course of clinical practice.

SOME AREAS WHERE RESEARCH IS NEEDED

(a) In Other Disciplines

10.04 Research is the area in which it is most obvious that the problems of the speech therapy services do not lie completely within the profession itself, and

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cannot be satisfactorily met from within it. The study of speech disorders, as has been shown, cuts across many disciplines and will increasingly have to draw its substance from advanced work in those disciplines. A witness told us that "A large quantity of research into many and varied aspects of the communicational functions is at present in progress by linguists, phoneticians, physiologists and psychologists as well as that which goes on in the more traditionally involved clinical and educational institutions. Unfortunately the implications and potential usefulness of such basic work are by no means appreciated by those engaged in therapeutic practice." Several speech therapists showed, however, that they were fully aware of this deficiency at least: we were told that "speech therapists are not sufficiently aware of developments in related disciplines which affect their own practice. The last two decades have seen an enormous increase in the study of communication and in particular into all aspects of language ... The development of theories of speech perception, verbal learning, and theories of learning generally, suggest that much of the work at present carried out with children is inefficient in and based on very scanty knowledge of the problems involved. "

10.05 Although research in these fields is already under way, our impression was that insufficient was being done compared with that undertaken in other countries and reported in, for example, The Journal of Speech and Hearing Research. Moreover, the research is scattered and is not always readily accessible to speech therapists, who may not in any case be well equipped to understand and apply the results. Though we applaud the work of the College's monthly Bulletin in listing a wealth of relevant research references, these doubtless constitute an embarras de richesse for the practising speech therapist who does not have easy access to a major academic library. We considered that the British Journal of Disorders of Communication might contribute more to the dissemination of research findings by publishing abstracts of relevant research, on the lines of the American Deafness, Speech and Hearing Abstracts but preferably with an evaluative element as well. This attempt was, we understand, made by the British Journal's predecessor, Speech Pathology and Therapy, but was abandoned for want of the necessary time and funds.

10.06 We therefore recommend that

(i) More research should be undertaken by Audiologists, Linguists, Neurologists, Psychologists and others in related disciplines, into all aspects of normal and impaired human communication.

(ii) Speech therapists should be made more aware of and better equipped to understand and apply the results of such research.

10.07 Many of the problems facing the speech therapy profession can be solved only by multi-disciplinary research, and we consider that there is a good case for the involvement of speech therapists in relevant projects. To a limited extent, such opportunities arise already: we were told of a number of speech therapists who had participated in a variety of neurological and linguistic projects. The potential contribution of the speech therapist to research has not yet, however, been fully explored, partly because of the lack of opportunities for therapists to equip themselves for work at this level.

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10.08 In our view the contribution of the speech therapist, with her clinical experience of speech and language disorders, can be extremely valuable in bridging the gap between theoretical knowledge and clinical application, and in making available in an organised form the clinical data on which research in her own and other professions will depend. A linguist, for example, is unlikely to know enough about speech pathology to appreciate the full complexity of the problems with which therapists are faced, while the therapist will not in the normal course of her work have the opportunity for basic reading and practical analysis of linguistic structures. Working together on, for example, a study of infant vocalisation and its development into early speech, each can complement the expertise of the other.

10.09 One witness suggested that "the kind of individual therapeutic personal relationship properly established between therapist and patient is not always the most conducive to the dispassionate and objective habits of mind required of a research worker." We readily concede that not all speech therapists will be temperamentally suited to multidisciplinary research work or will wish to undertake it. That some do so wish was, however, made very clear in their evidence to us, and we see no reason to suppose that speech therapists in general are likely to be less objective than other workers who combine a practitioner and a research role (eg. in medicine, education, psychology). We recognise, however, that selected therapists will need some guidance in research techniques before they will be acceptable to other research workers as colleagues.

10.10 We therefore recommend that greater opportunities should be available for speech therapists to work as members of research teams engaged on relevant problems.

10.11 An example of a problem requiring an inter-disciplinary approach is the classification of the disorders of speech and language. The terminology used in the profession is itself problematic and a bar to communication with other professions. We have already commented in 7.04 on some of the difficulties involved, and the profession is well aware of them. The Union of Speech Therapists told us that "The current arbitrary system of classification of speech disorders makes it impossible to arrive at an accurate estimate of the incidence of speech disorders in terms of 'conditions' ..." We consider that the deficiencies of the present system are such as to be a real barrier to growth within the profession and to communication outside it, and that this is an outstanding example of a problem which demonstrably has not been, and cannot in the future be, resolved within the profession itself. The terminology has been under internal review for a considerable time without appreciable progress, and the extent to which it is unsatisfactory is in fact a measure of the unsatisfactory status of the theories it reflects. A new terminology and system of classification will have to be based on theoretical developments (in or involving other disciplines) which have not yet taken place. For instance, we were told that categories of speech disorders should ideally be defined in linguistic and phonetic terms rather than on the basis of clinical findings, but this would depend upon very considerable developments in the linguistic and phonetic study of abnormal speech. It seems likely that, provided they were trained to do so, speech therapists could contribute to basic research of this type.

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10.12 The establishment of a universally accepted and understood system of classification of speech disorders, and of defined criteria of defective speech, would open the way for a national study of the prevalence of speech and language disorders. As we showed in 7.03ff, several studies have been made of the prevalence of deviant speech and language in various sections of the community but, since varying criteria of defect have been used, no acceptable figures have emerged. The resolution of this problem will, as we say above, involve research work on a wider front than speech therapists can be expected to cover alone, if we are to remedy not merely the shortage of data but the grave imperfections in the criteria on which data are collected. In the meantime, however, something of value could be added to the available information if a properly planned study of language development and the incidence of disorders of language ability, in the planning of which speech therapists should have a part, were to be included in one of the existing longitudinal studies of child development such as the British Births Survey Follow-up Study.

10.13 We therefore recommend that more attention should be given to speech and language in longitudinal studies of child development.

10.14 A third area in which inter-disciplinary research is needed is in the development of standardised tests as indicators and predictors of language disorder and delay. Reliable prognostic tests would avoid the risk of overlooking a child likely to develop a serious speech or language difficulty and at the same time would reduce the expenditure of scarce resources on minor defects likely to correct themselves fairly quickly in the course of maturation. Two of our members had experience in developing and standardising tests of this nature but there is room for a good deal more work.

10.15 The last example we wish to give of a possible field for inter-disciplinary research in which speech therapists might play a part is the study of the relationship of certain kinds of learning difficulties to the the central communication disorders. We noted in 6.44-46 the difficulty we found in defining the speech therapist's role with children suffering from specific difficulties in learning to read and spell. Our conclusion was that, apart from those cases with an overt disturbance of spoken language, the speech therapist should avoid becoming involved in treatment until more evidence was available to support such involvement. There does, however, seem to be prima facie evidence of a connection between this difficulty - and other learning problems with writing and arithmetic - and disorders of language ability, and we would support the involvement of speech therapists in experimental work in this field.

(c) Research carried out by speech therapists alone

10.16 We do not subscribe to the view that every speech therapist should be trained to undertake research, nor that every practising speech therapist should be encouraged to attempt to fit some kind of "research work" into an already crowded working life. This would in our view be impracticable and could very easily lead to a proliferation of ill-planned and ill-executed projects. The advances in knowledge that will be of greatest benefit to the profession and its patients will come, we believe, from university-based studies of the kind we have outlined in 10.04-16. On the other hand, we were impressed by the almost universal willingness to undertake research expressed by the speech therapists

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who submitted evidence to us, and by their awareness of the need for research and development to improve the standard of service offered to their patients. One therapist told us that "there is a desperate need for research if we are to improve our techniques", another said that "it is only through such disciplined investigation that our knowledge of the speech and language mechanism can be increased and, subsequently, our treatments improved", and yet another elaborated on the need "to carry out research ... to examine more closely the exact nature of the work we are doing, and to plough back the findings ... to improve the standard of therapy". We think that there should be scope for putting such enthusiasm and concern to fuller use.

10.17 There is in our view a clear if limited place for studies of particular problems planned and carried through independently by speech therapists, possibly as part of their work for a higher qualification such as those at present offered by the College (2.47). Speech therapists undertaking such studies should have had some previous training in research methods, should be relieved, for the duration of the study, of all or a substantial proportion of their clinical duties, and should ideally have the support of an experienced university-based supervisor in designing and carrying out the study.

10.18 There are a number of problems which might lend themselves to this kind of study. Several witnesses, for example the British Medical Association and the Royal College of Psychiatrists, drew our attention to the need for surveys of the prevalence of disorders in particular populations such as pre-school children, children in independent schools, and children and adults in institutional care. There is ample room too for more evaluative studies of the effects of various kinds and patterns of treatment. Some work has already been done on the evaluation of intensive treatment for stammerers and aphasics, but overall there was clear evidence of a want of scientific evaluation of methods of treatment. Many speech therapists are themselves keenly aware of the profession's deficiencies in this respect. One told us that "As a result of their isolation therapists have become too accepting of their methods and also of their results". There are good grounds for hoping that recent developments in training and in methods of assessment are already changing this situation for the better, but there is still scope for valuable follow-up and evaluative studies.

10.19 We do not consider that research work can profitably be undertaken by the therapist who has at the same time to carry a full load of clinical and associated duties. The kind of work which can be combined with clinical practice, and which is sometimes loosely referred to as "research", in reality consists of record-keeping and data collection, or indeed the facility to keep up with the reading of other people's research results. These are important tasks, the latter since therapists in the field must be aware of research results if they are to apply them, and the former since data collection provides the indispensable material for research. We were attracted by a suggestion made by the British Paediatric Association that "careful records of standardised type, suitably prepared for studies of aetiology and of the success or failure of different technical methods of treatment, would shed much light - but would need time, thought and secretarial assistance". We are glad to note that there has been considerable improvement over recent years in the methodical keeping of records and we would hope for further developments.

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10.20 We therefore recommend that

(i) The profession should give consideration to methods of case-history recording and the maintenance of records with a view to their possible use as research data.

(ii) The case-load of the individual speech therapist should be such as to allow time for careful and thorough record-keeping.

PROVISION FOR RESEARCH: I: THE PRESENT

(a) In Other Disciplines

10.21 We have stated our view that insufficient research work on problems related to speech pathology is being undertaken at present. However, we consider that there are already encouraging signs of a developing interest in these problems on the part of audiologists, linguists, neurologists and psychologists. We hope that the changes proposed in the previous chapter in the training of speech therapists will, by bringing the problems of speech pathology fully within the university ambience, stimulate dialogue with other disciplines and further encourage the development of research work on normal and deviant language.

(b) Participation by Speech Therapists

10.22 A number of speech therapists, particularly those working in hospitals, are already invited to participate in research projects. In one or two instances, speech therapists are employed as research assistants on university research projects in related subjects. In most cases, however, the speech therapist wishing to undertake research at present faces three major problems: lack of training, lack of time, and lack of financial support.

10.23 The present basic training for speech therapy contains no specific training in research methods (except at Newcastle, where students have practical opportunities to study and develop elementary research methods in their psychology course). At several schools, students are expected either to undertake an individual child study or to submit a dissertation on a particular problem: these exercises provide some experience in collecting and marshalling material, but can scarcely be regarded as an adequate preparation for research. We do not think that the situation will be fundamentally altered by the progress we hope to see towards degree-level training, since it is not, in our view, realistic to expect students to emerge from basic training equipped both as clinicians and as researchers. Training for research should be a matter for advanced study by those suited to it in ability and interest. There are practically no opportunities for such advanced study available to speech therapists.

10.24 The other difficulties, lack of time and lack of financial support, are closely linked. We have already stated that it is unreasonable to expect a speech therapist to undertake research work as well as full clinical duties. It follows that the speech therapist who undertakes research must either rely upon her employer to grant secondment or release from some part of her clinical work,

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or find an alternative means of financial support. There is no state or local authority financed support for which speech therapists qualify: LCSTs are not eligible for state studentships, and the charitable scholarships and bursaries for which they are eligible are few indeed.

10.25 Although almost all the employing authorities we consulted conceded the importance of providing research facilities (either for their own sake or as a possible inducement to recruitment), few apparently were in practice prepared to grant secondment or long study leave for speech therapists to undertake advanced study or research. Staff shortages, and the consequent burden of treatment cases, many of them urgent, mean that speech therapists can very seldom be released from even a proportion of their clinical duties, to enable them to undertake part-time research.

10.26 It is impossible not to sympathise with employing authorities. In the present circumstances those fortunate enough to recruit a speech therapist must be faced with a great temptation to hang on to her at all costs and to use her time as fully as possible in treatment. Nevertheless, we cannot consider this attitude to be in the best long-term interests of the profession or of those suffering from speech or language disorders. We have already commented on the relevance of research to improved techniques of treatment: in addition, we had evidence that in some academically-minded therapists the frustration engendered by lack of opportunities for advanced work was enough to drive them out of the profession. At the risk of making an assertion inevitably unsupported by objective evidence, we would say that recruitment to the profession of entrants of good calibre would be improved by the prospect of wider horizons and the possibility of more intellectually demanding work. We would therefore hope for a more liberal attitude to the provision of research opportunities.

10.27 We therefore recommend that

(i) Employing authorities should make more generous provision of study leave, secondment, and financial support for research and advanced study, and of opportunities for therapists to combine clinical and research work.

(ii) Candidates with good results in the LCST examination should be eligible for postgraduate state studentships.

II: THE FUTURE

10.29 We set out in Chapter 9 our reasons for considering that the basic training for speech therapy should in future be at degree level. This would remove one

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practical barrier to training for advanced work and research, since the way would be open for the establishment of advanced courses in speech pathology and graduate speech therapists would be eligible to apply for other relevant postgraduate courses. We have also made it plain that in our view a university, or other multi-disciplinary institution, provides the most natural setting for the association of teaching and research to which we attach particularly high importance. We were told in evidence that

a Department of Speech has and must have two kinds of aim - the short term and the long term. The short term aim is to equip students to give immediate help to patients in the light of existing knowledge critically assimilated: but the long term aim is to relate the training process and professional practice to continuing research and enquiry in order to foster a growing understanding of the nature of speech and language and their disorders, and the kind of treatment that is appropriate to them. This involves the staff of the school in a research obligation, and in the need to consult colleagues in related disciplines in order to try and define and explore the nature of speech and language themselves and to diagnose and classify their disorders on more reliable lines ... we consider that the training of the speech therapist must be conducted in an atmosphere of research and enquiry, that the participation of experts in related disciplines is essential ...

10.31 We should, however, deplore a division of the profession into theoreticians and clinicians, such as we understand has occurred in Russia, where academic research logopedists are more highly regarded and better paid than those engaged in clinical work. Nevertheless, the profession in Great Britain suffers at present from the lack of a cadre of advanced workers with research experience from amongst whom its leaders and teachers could be drawn. A speech therapist pointed out to us that the contribution which a therapist can make as a member of a research team may decline as she becomes more remote from the therapeutic practice of her profession. We would therefore hope to see the development of opportunities for speech therapists to participate in both theoretical and clinical research, and to move between academic and therapeutic work at different stages of their careers. If centres for teaching, research and advanced treatment develop on the lines sketched in 9.21, it should readily be possible for speech therapists to spend part of their careers working in them, perhaps moving on afterwards to take up increased clinical and/or administrative responsibilities elsewhere.

FINANCIAL ARRANGEMENTS

10.32 As we have made clear, we regard the backing of a university as almost essential for most of the research, both academic and clinical, which will be required. We would expect resources for research to be found by the universities

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themselves, from whichever of the usual sources of support for university research projects - research councils, government departments, charitable trusts - may be appropriate in a particular case. Doubtless the profession's own recently-established Research Trust (supported by public subscription) would find a useful role here. As the majority of speech therapists undertaking research in future will, we hope, do so under university auspices as part of an interdisciplinary team, their participation should be financed out of the funds available for the particular project. In the case of experienced speech therapists who wish to undertake research during some part of their careers, employers may consider it to be in their own best interests to second them on full salary for the duration of the project. The recommendations already made in 10.27 are relevant.

10.33 We therefore recommend that financial resources for speech therapy research be concentrated on enabling speech therapists to participate in research under the auspices of universities or comparable academic or scientific bodies.

11.01 Our recommendations are listed below under six subheadings. Each section is prefaced by a brief introductory paragraph.

SPEECH THERAPISTS' WORK

11.02 We found that the scope of the speech therapist's responsibility and competence is not fully appreciated either by the public or, often, by the professions with which she works. We have therefore tried to give a clear account of the extent and limitations of the speech therapist's role in the present state of knowledge of human communication. In particular, we have distinguished on the one hand those conditions to the management of which she could in our view make a greater contribution than at present, from those on the other hand in which the relevance of speech therapy is not yet clear. We have aimed at establishing both the speech therapist's proper sphere of professional independence and the points at which cooperation with other professions is essential. Lastly, we have indicated some points at which growth and development are likely in the near future, while admitting in addition the possibility of more far-reaching changes as knowledge and understanding of human communication increases. Our recommendations are

(i) The therapist should be regarded as an integral member of the assessment team for any patient with disordered speech or language, and the practice of team assessment should be vigorously extended. (6.12-16)

(ii) The acceptance of cases, and planning and termination of treatment, should be recognised as the speech therapist's prerogative, though in carrying out these functions she should have regard to the value of interdisciplinary consultation and cooperation. (6.20-22)

(iii) While the scope of the speech therapist's work and competence will change, her responsibility for devising therapy (and, where appropriate, for carrying it out) should remain fundamental. (6.18-19)

(iv) Initial referrals for speech therapy should in normal circumstances be made by a doctor, with further specialist examination where necessary. Where, for whatever reason, a referral from a non-medical source is accepted, a relevant medical opinion must be available at as early a stage as is practicable. (6.07-11)

(v) In the future development of the speech therapy services the first priorities should be

(a) the provision of facilities for the early detection and assessment of delayed or abnormal speech or language.

(b) the provision of services for the mentally handicapped. (6.50-54)

(vi) As speech therapists have a contribution to make to the management of the deaf and partially hearing, they should continue to seek opportunities to work with teachers of the deaf and others concerned on a cooperative basis and not merely as auxiliaries. (6.31-38)

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(vii) No child should be given speech therapy until a proper assessment of hearing has taken place. (6.33)

(viii) The speech therapist's role with language deprived or immigrant children should be limited to assessment of language development, except where a pathological defect is observed or suspected. (6.40-43)

(ix) Speech therapists should ensure that teachers are informed of a history of late or impaired language development, to alert them to the possibility of future learning problems, but should not at present attempt to give further help unless an overt disorder of spoken language is present. (6.44-46)

ORGANISATION AND CONDITIONS

11.03 We considered the present organisation of speech therapy services divisive and wasteful of resources. Within the separate NHS and education services, inexperienced therapists receive too little support and protection, while the responsibilities and superior skills of the more experienced go virtually unrewarded. The conditions in which speech therapists are expected to work are too often deplorable. Our aim has been to provide one uniform and coherent organisational framework for the development in services which we hope to see and to allow scope within this for adequate career incentives to enable the profession to produce its own leaders and administrators. Proper working conditions and supporting services are in our view essential. We therefore recommend

(i) The organisation of speech therapy services should be unified. (8.05-09)

(ii) Speech therapy services should in future be organised under Area Health Authorities in England and Wales and under Health Boards in Scotland. (8.10-23)

(iii) Within each Area Health Authority there should be an establishment of speech therapists organised in a career structure reflecting levels of responsibility (clinical as well as administrative), experience and academic distinction. (8.14-30)

(iv) The establishment of speech therapists should be provided with an adequate supporting staff of clerical and secretarial workers. (8.24-30)

(v) Special attention should be given to the accommodation provided for speech therapy, and guidelines should be produced at national level. (8.31-32)

(vi) In the structure of the new health service in England and Wales and in Scotland provision should be made for advisory committees representing speech therapists which would have access to the committees of the health authorities responsible for planning services. (8.33-36)

(vii) A national adviser should be appointed to the Department of Health and Social Security to assist the development of speech therapy services and training. The Scottish Home and Health Department and the Welsh Office may wish to appoint their own advisers. (8.33-36)

SUPPLY

11.04 Our estimate of the current need for speech therapy shows that the expansion of services required is so great that a fundamental change in the present

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wasteful deployment of speech therapists' skills is essential. As well as a very large expansion of numbers of speech therapists, we urge the establishment of a substantial force of aides to undertake, under her supervision, the work of a routine nature which the therapist feels she can delegate, and we make suggestions about the necessary conditions and safeguards for their use. Our recommendations are

(i) 2,500 should be accepted as the target for the force of full-time speech therapists required and this target, and progress in achieving it, should be kept under regular review. (7.47-53)

(ii) A cadre of speech therapists' aides should be established. (7.39-44; 47-53) (iii) Energetic publicity campaigns should be undertaken

(a) to persuade married women who have left the profession to return to it,

(b) to increase the recruitment of school-leavers to speech therapy training. (7.47-53)

(iv) Employing authorities should endeavour, by means of improved working conditions and a greater readiness to make special arrangements, to encourage married women therapists to return to the profession, and should make suitable arrangements for such therapists to have retraining. (7.33-36)

(v) Additional courses of speech therapy training should be established as soon as is compatible with the change in level of training recommended. (7.47-53)

EDUCATION AND TRAINING

11.05 A training which will equip the speech therapist for the future role we envisage, and which will enable her to make the contribution to the understanding of communication disorders which is necessary for progress, can be provided only at degree level. We indicate a pattern of education and training, for the time being incorporating and expanding the present Diploma courses, by which universities might provide academic courses in aspects of human communication. We outline the necessary procedure for providing appropriate professional training and ensuring that depth of academic knowledge is not achieved at the expense of clinical competence. Suggestions are made for the provision of the advanced, specialised and in-service courses which we regard as essential. Our recommendations are

(a) Initial Training

(i) The training leading to registration as a speech therapist should qualify for practice in all fields. (9.08-11)

(ii) The future training of speech therapists should be at degree level. (9.13-17)

(iii) A number of universities should develop the necessary structures for the training of speech therapists as such, or should create degrees which, with appropriate supplementary courses, would provide students with a sound academic and clinical basis for careers in speech therapy.

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We would hope that the University Grants Committee would respond favourably to approaches on these lines. (9.13-17)

(iv) Training should be conducted in universities which have medical schools, or in institutions which have very strong links with medical schools and hospitals having a special interest in speech disorders and which are adequately staffed and equipped to teach the relevant subjects. (9.18-19)

(v) A Central Council for Speech Therapy should be established for the approval of courses of training and the registration of speech therapists as qualified to practise. (9.46-52)

(vi) Employers should be required to appoint as speech therapists only those so registered. (9.46-52)

(vii) Those involved in planning courses of training for speech therapy should consider the increasing contribution that audio-visual aids and alternative methods of organisation could make to clinical training. (9.22-24)

(viii) Speech therapists with responsibility for supervising students should be appointed in a supervisory capacity and remunerated accordingly. (9.22-24)

(ix) The professional training of speech therapists should include guidance on delegation to aides. (9.34-36)

(x) Training should be followed by a year of paid supervised practice. (9.25-27)

(xi) A range of post-graduate courses should be developed in aspects of human communication and its disorders, open to speech therapists and to members of other professions. (9.28-30)

(xii) Increased opportunities should be provided for serving speech therapists to obtain specialised training on an in-service basis. (9.28-30)

(xiii) In the establishment of new training facilities attention should be paid to areas with severe problems in filling speech therapist posts. (9.32-33)

11.06 The new pattern of training proposed has implications for the future of the schools of speech therapy and of the College of Speech Therapists. We discuss the developments we would wish to see, both in the period of transition to an all-graduate profession and in the long-term future. Our recommendations are

(a) Schools of Speech Therapy

(i) No further Diploma courses in speech therapy should be established. (9.37-38)

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(ii) The schools of speech therapy should discuss with the universities the conditions under which LCST would be acceptable as a qualification for post-graduate work. (9.39-40)

(iii) Schools of speech therapy should seek means to increase their intake as much as possible and should make a vigorous attempt to reach a target of 350 per annum by 1982 at the latest. (9.41-45)

(iv) Existing Diploma work should seek integration with larger teaching institutions. (9.41-45)

(v) The College of Speech Therapists should concentrate in future on a purely professional role. (9.46-49)

RESEARCH

11.07 The understanding of human communication and its disorders is still gravely limited and can only be increased by a greatly expanded programme of research in all the relevant disciplines. Speech therapists, with their clinical and practical experience, have a unique contribution to make to such research. Greater provision should be made for those willing and able to do so to obtain the necessary training and to divide their careers between clinical work and research. We accordingly recommend that

(i) More research should be undertaken by audiologists, linguists, neurologists and others in related disciplines, into all aspects of normal and impaired human communication. (10.04-06)

(ii) Speech therapists should be made more aware of and better equipped to understand and apply the results of such research. (10.04-06)

(iii) Greater opportunities should be available for speech therapists to work as members of research teams engaged on relevant problems. (10.07-10)

(iv) More attention should be given to speech and language in longitudinal studies of child development. (10.12-13)

(v) The profession should give consideration to methods of case-history recording and the maintenance of records with a view to their possible use as research data. (10.19-20)

(vi) The case-load of the individual speech therapist should be such as to allow time for thorough and careful record-keeping. (10.19-20)

(vii) Financial resources for speech therapy research should be concentrated on enabling speech therapists to participate in research under the auspices of universities or comparable academic or scientific bodies. (10.32-33)

(viii) Employing authorities should make more generous provision of study leave, secondment and financial support for research and advanced study, and of opportunities for therapists to combine clinical and research work. (10.24-27)

(ix) Candidates with good results in the LCST examination should be eligible for postgraduate state studentships. (10.24-27)

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Mrs. C. E. Delap
Department of Health and Social Security
Department of Speech Therapy, Leicester College of Education
Miss J. Derrick
Edinburgh Corporation
Edinburgh School of Speech Therapy
Educational Institute of Scotland
Ewing School, Manchester
Mrs. M. Fawcus
Mr. R. Fawcus
Mr. N. Fitchett
Professor A. C. Gimson
Mr. W. G. Good
*Miss M. Gordon
Guild of Teachers of Backward Children
Professor E. Hawkins
John Horniman School
Inner London Education Authority
Isle of Man Board of Education, Health Department
Kingdon-Ward School of Speech Therapy
Mrs. L. M. Levett
Mrs. A. Locke
Miss M. J. Marshall H.M.I.
*Dr. A. H. McAllister
Mr. P. K. Millens
Miss J. C. E. Mitchell
Dr. Peter Mittler
Moor House School
Mr. J. H. Munday H.M.I.
National Association of Head Teachers
National Association of Schoolmasters
National College of Teachers of the Deaf
National Research Trust for Speech Therapy
National Society for Mentally Handicapped Children
National Union of Teachers
Nuffield Hearing and Speech Centre
*Professor R. C. Oldfield
Oldrey-Fleming School of Speech Therapy
Patient Operated Selector Mechanisms Research Project
Mrs. M. Rogers

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Royal College of Physicians
Royal College of Physicians in Edinburgh
Royal College of Physicians and Surgeons of Glasgow
Royal College of Surgeons, Edinburgh
Royal Medico-Psychological Association (now the Royal College of Psychiatrists)
Royal National Institute for the Deaf
Miss E. Rudd
Miss Judith Rutt
Miss Y. B. Saklatrala
School of Speech Therapy, Jordanhill College of Education
School of Speech Therapy, North Birmingham Technical College
Miss G. Scott
Scottish Association for the Study of Dyslexia
Scottish Council for the Care of Spastics
Scottish Society for Mentally Handicapped Children
Dr. Mary Sheridan
Mrs. Rae Smith
Society of Medical Officers of Health
Society of Medical Officers of Health (Scottish Branch)
*Society of Teachers of the Deaf
Spastics Society
Dr. Monnica Stewart
Mrs. M. C. Stinson
Mrs. Anne M. Stoneman
Sub-Department of Speech Therapy, Leeds College of Technology
Sub-Department of Speech, University of Newcastle-upon-Tyne
Mrs. V. Tait
Training Council for Teachers of the Mentally Handicapped
Mr. J. L. M. Trim
Union of Speech Therapists
Welsh Joint Education Committee
West End Hospital Speech Therapy Training School
Miss S. M. Whitehead
Mr. James Wight
Dr. J. Wilks
Dr. J. Williamson
Mr. L. Willmore
Mrs. A. G. Wolff

[page 128]

APPENDIX B

QUESTIONNAIRE SENT TO WITNESSES

COMMITTEE OF ENQUIRY INTO THE SPEECH THERAPY SERVICES

TOPICS ON WHICH INFORMATION IS REQUESTED

INTRODUCTORY NOTES

1 This list of topics on which the Committee particularly seeks information has been prepared for the guidance of persons and organisations submitting evidence. It is not exhaustive, and evidence on any matter related to the speech therapy services, whether or not these are mentioned below would be welcomed. The Committee appreciates also that many will not have direct experience of all the topics listed, and may not wish to give evidence on all of them - for example some may have experience of hospital conditions, others of work in schools.

2 It would be helpful to the Committee if comments were to distinguish between

(a) the current situation and
(b) desirable changes, or developments.

A THE NEED FOR SPEECH THERAPY SERVICES

1 The Conditions which require the services of a speech therapist.

2 The incidence of such conditions either generally or in particular sections of the population (eg pre-school children, school children, adults, the elderly).

3 The adequacy of present provision to meet these needs. Evidence of current needs, with some indication of priorities.

B THE ROLE OF SPEECH THERAPISTS

1 The nature and range of the work of speech therapists with various conditions and disabilities with different age groups and in different environments (eg. hospitals, schools, patients at home etc.) bringing out features common to the whole range of work, and features special to particular circumstances. Current case-loads, and those considered operationally desirable.

2 Any part of this work which could appropriately be undertaken by or delegated to someone other than a speech therapist.

3 Any work not at present within the normal duties of speech therapists which might more appropriately be done by them.

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C ORGANISATION OF THE SPEECH THERAPY SERVICES

1 Administrative responsibility for the organisation and direction of the Service, distinguishing between speech therapists working in hospitals, schools, special units, or elsewhere.

2 Relationship of the Speech Therapy Service with educational or health services, as the case may be.

3 Responsibility for acceptance, treatment, and termination of treatment of the individual case. How are cases referred to the speech therapy services?

4 Co-operation, liaison and sharing of responsibility with members of other professions.

5 The nature of supervision by senior speech therapists and others.

6 Differences of responsibility of various grades of speech therapist.

7 Nature and adequacy of facilities provided, including facilities for research.

D TRAINING

1 Training as at present organised. Its relationship to the work of speech therapists in various contexts, and at various levels of responsibility, as at present organised, and in the light of possible developments. Output of training schools. Location of training schools in view of regional needs.

2 In-service training for the newly-qualified therapist. Refresher courses.

3 Training for higher qualifications. Training for research.

4 The need for specialised courses for qualified members of other professions.

5 The place of speech therapy as an element in the training of other professions.

E RECRUITMENT AND WASTAGE

1 Requirements (academic and other) for admission to training. Availability of candidates who meet these requirements. Calibre of recruits to training. Shortage of candidates with particular qualifications. Shortage of male recruits.

2 Extent of wastage during training.

3 Wastage of trained therapists from the profession.

4 Difficulties in recruitment of trained speech therapists.

5 Subsequent employment of individual trained speech therapists within the profession.

6 Career prospects in the profession.

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APPENDIX C

QUESTIONNAIRE TO OVERSEAS WITNESSES

1 How long is the training course for speech therapists in your country?

2 Are they trained in a university? If not, in what institution are they trained?

3 How much of their training is shared with students of other disciplines, eg. teachers, teachers of the deaf, audiologists, doctors, nurses?

4 Do they have a basic qualification before training as a speech therapist, or a further qualification additional to speech therapy, ego teaching, nursing?

5 Are they all given training of the same level and type or do you have

(a) an upper echelon of highly trained speech therapists and a subsidiary or auxiliary one OR
(b) a series of specialisations (eg. in developmental disorders, aphasia, stammering).

(i) Are speech therapists in your country predominantly women?

(ii) If so, is there a problem of wastage from the profession because of marriage?

(iii) Are special arrangements made to enable married women to return to the profession later in life?

8 Who refers patients to your speech therapists for treatment, eg. doctors, teachers, etc. ?

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9

(i) Are speech therapy services for children organised separately from those for adults?

(ii) If so, is it broadly the case that children's services are organised mainly through the schools, and adults through hospitals?

(iii) Is there much difference in terms of organisation and conditions of service between speech therapists working in the two settings?

11 Are there current trends in recruitments, training, organisation or research that seem firm enough to merit attempted summary?

[page 132]

APPENDIX D

Form SBH 183

QUESTIONNAIRE TO HOSPITAL SPEECH THERAPISTS

DEPARTMENT OF HEALTH AND SOCIAL SECURITY

Survey of persons receiving speech therapy during the period 6 June 1971 to 3 July 1971.

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Form SBH 184

DEPARTMENT OF HEALTH AND SOCIAL SECURITY

Survey of persons receiving speech therapy during the period 6 June 1971 to 3 July 1971.

[page 134]

Form SBH 185

DEPARTMENT OF HEALTH AND SOCIAL SECURITY

Survey of Persons who completed a course (1) of Speech Therapy during the period 6 June 1971 to 3 July 1971

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