Consultation as a model for providing speech and language therapy in schools: a panacea or one step too far?

Transcription

1 Consultation as a model for providing speech and language therapy in schools: a panacea or one step too far? James Law 1, Geoff Lindsay 2, Nick Peacey 3, Marie Gascoigne 1, Nina Soloff 1, Julie Radford 3 and Sue Band 2 1 Department of Language and Communication Science, City University, London 2 CEDAR, University of Warwick, Coventry 3 Institute of Education, London Abstract In recent years there has been a pressure to introduce an indirect consultative model to working with children with speech and language needs. It is favoured by educationists because it avoids the need to take children out of class and embeds any support children received in the curriculum. This paper reports the results of a recent study which indicates that Speech and Language Therapists are concerned about the universal application of this model of service delivery. It introduces and discusses a number of interrelated factors which need to be in place before the consultative model can be successfully introduced. Background While educational provision for children with speech and language needs is provided, in the UK, within educational settings, the speci c input from speech and language therapists is provided through health services. This inevitably creates tensions as to where responsibility lies for service provision. To a certain extent this has been clari ed by the ruling that the prime responsibility for children with speech and language needs lies with the health services while the ultimate responsibility lies with the education Address for correspondence: James Law, Department of Language and Communication Science, City University, London EC1V 0HB, UK. J.C.Law@city.ac.uk # Arnold = ct232oa

2 146 Child Language Teaching and Therapy authority (R v London Borough of Harrow, 1996), but the interpretation of what constitutes prime or ultimate has inevitably led to further disputes. In the autumn of 1998 the British government set up, under the auspices of the Department for Education and Employment (DfEE), the Department of Health (DH) and the Welsh Assembly, a Speech and Language Therapy Working Group, in order to address a series of issues related to the provision of speech and language therapy in schools. As one of its tasks, in 1999 the working group commissioned the present study to report on existing provision across England and Wales and to help facilitate the process of collaboration at both strategic and practitioner levels (Law et al., 2000). The study was charged with promoting effective provision of services to children with speech and language needs and go some way to resolving the border dispute that has arisen between health and education services in the provision of speech and language therapy (Dessent, 1996; Jowett and Evans, 1996). The trend in education legislation over the past 20 years has been away from segregated provision for children with special educational needs and towards inclusive education (DfEE, 1994, 1997, 1998; DfES, 2001). The philosophy underpinning the concept of inclusive education is broader than education itself. Educational contexts offer a logical starting point by ensuring that those with disabilities access the educational curriculum alongside their peers. This shift from integration to inclusion has increasingly been mirrored in thinking about different ways of delivering services. The traditional model of service provision provided by speech and language therapists (SLTs) is clinic based and provided by a single speech and language therapist to a single child. In this approach the speech and language therapist commonly focused on ameliorating or removing the impairment experienced by the child. In recent years this has largely given way to a more holistic or ecological model of intervention with an emphasis placed on working within the classroom and working via others who have regular direct contact with the child. This mirrors the development of practice of educational psychologists, who have moved from working in child guidance clinics to schools and the community (e.g. Gillham, 1978; Lindsay and Miller, 1991; Wolfendale et al., 1992). The interest in consultation rather than direct intervention, for example, has been a popular development within educational psychology (Dickinson, 2000; Wagner, 2000) and has been supported by the recent report from the Department for Education working group (DfEE, 2000) on educational psychology services in England (Kelly and Gray, 2000). This shift to consultation in speech and language therapy has been dictated by the research literature and practical experience, which suggests that the context

3 Consultation: a model for speech and language therapy 147 in which the child learns is critical. But it has also developed in response to the changes in special educational provision outlined above. A number of speech and language therapy services have reorganized to meet the needs of educational services with varying policies and procedures (Hoddell, 1995; Luscombe and Shaw, 1996; Lennox and Watkins, 1998; New, 1998; Topping et al., 1998). A variety of different methods of service delivery have been identi ed and it is now possible to look at service delivery as being de ned along a number of different parameters. For example, intervention is provided: directly by the speech and language therapists (SLTs) or indirectly by the teacher or learning assistant; within or outside the classroom; in groups or individually; intensively or at regular intervals; for a limited or extended duration. This range of options for the provision of speech and language therapy for these children is recognized in the revised Special Educational Needs Code of Practice: 8:52 It is important that the nature and extent of provision (of speech and language therapy) required for individual children should be examined very carefully and that full consideration is given as to how such provision can best be delivered. In some cases, for example, children may need regular and continuing help from a speech therapist, either individually or in a group. In other cases, it may be appropriate for staff at the child s school to deliver a regular and discrete programme of intervention under the guidance and supervision of a speech and language therapist. (DfES, 2001) Alongside the speci c interventions there is a recognition of the contribution to Individual Education Plans (IEPs). In a service offering primarily indirect intervention, a contribution of targets to the IEP may be the only tangible evidence of SLT support for the child in mainstream school. However, in a unit attached to a mainstream school where the SLT is more likely to be involved in some direct intervention, the SLT s aims are surely still best placed as targets within the IEP. If a well written language target is included in the IEP, the strategies for achieving the target might include a range of interventions some delivered by the SLT, some by other staff. The joint ownership of the educational target, albeit with a language development focus, can provide a vehicle for effective collaborative service provision. While it is possible to identify what is common practice, it is important that a model of service delivery should be developed on the basis of what is known

4 148 Child Language Teaching and Therapy to work. What then of the evidence for the impact of speech and language therapy? A recent systematic review of intervention for children with primary language dif culties demonstrated signi cant gains relative to control group children who had received no intervention (Law et al., 1998). However, it is important to note that these gains were achieved in what might be termed a clinical model, that is within a clinical setting and restricting the effects of the intervention to measurable language outcomes. They are not set within a mainstream nursery or school. Very little attention has, to date, been paid to the impact on the child s ability to cope in a classroom. Interestingly, for all but speech dif culties, the results were as good if the intervention was carried out indirectly by the child s parent under the guidance of a speech and language therapist. There is no comparable evidence for other types of indirect intervention using teachers, learning support assistants (LSAs) etc. There remain many gaps in this literature and unsurprisingly teachers and SLTs develop models of best practice based on their own experience. The focus of this paper is the exploration of consultation as a method of service delivery by SLTs. This approach is characterized by an emphasis shift from direct work with children to consultation between the SLT and other key front-line professionals, particularly teachers, assistants (whether teaching or speech and language therapy assistants), and also parents. However, this simple description does not do justice to the range of options available within this generic model. For example, consultation may replace direct work with children or may represent an overall strategy that subsumes a number of options for action, including direct work. Consultation is also a contested concept on other grounds. In particular, the notion of the consultant has, for many educational psychologists and speech and language therapists, the trappings of concerns about power relationships between professionals, medical as opposed to educational or developmental models and the question of expert practitioners. Consultation is, therefore, a potentially complex concept, whose implementation may be driven by a number of different forces, and be characterized by a number of different manifestations. Aims The speci c aims of this paper are: to explore the meaning of consultation from the perspective of the practitioners concerned and

5 Consultation: a model for speech and language therapy 149 to examine consultation within the context of other issues related to the context of speech and language therapy in schools. Procedure The project was designed in three interlocking phases. Phase 1: The horizontal phase This phase involved the development of a questionnaire aimed at ascertaining current provision. This was circulated to all speech and language therapy managers in health trusts 1 with a community children s service and 50% of all Local Education Authority (LEA) managers in England and Wales. Phase 2: The vertical phase Fifteen LEA=health trust collaborative pairs 2 were targeted for a more detailed qualitative analysis of the factors determining the process of collaboration between health and education services. In each site interviews were carried out and then analysed at managerial (including health commissioner), practitioner and parental levels. As a validation of this process, ve of the 15 phase 2 sites were then analysed separately with each of these three levels integrated. Phase 3: The research into practice phase The third phase comprised a series of ve meetings made up of managers, practitioners and parents from across England and Wales. The results of the rst two phases were summarized and participants were asked to comment on the validity of the ndings to ensure that no major themes had been ignored and to contribute to the discussion of the way forward. For the purposes of the discussion about the consultative model the principal sources of information were the second and third phases of the project, although reference is made to some of the data collected in phase 1. Participants In phase 2 both teachers and speech and language therapists were interviewed. Speech and language therapy practitioners were interviewed in small groups of 1 Health trusts provide health care for a given geographical location. At the time of the study they were the primary unit providing speech and language therapy services. 2 These pairs represented LEAs and trusts that covered the same geographical area and had both responded to the phase 1 questionnaire. Purposive sampling was employed to identify authorities with different levels of perceived collaboration.

6 150 Child Language Teaching and Therapy between two and six people in each of the 15 sites. The therapists worked with a wide range of client groups (autistic spectrum, cerebral palsy=physical disability, cleft lip=palate, hearing impairment, learning disability, speci c language impairment) and in a variety of settings (e.g. child development centres, community clinics, pre-school facilities, and both mainstream and special schools). All of the therapists had worked with class teachers and educational psychologists, with varying levels of intensity (through phone= letter contact, meetings and=or in ongoing teamwork). Where LEAs employed language teachers, the therapists had also had liaison with these professionals. The education practitioners included mainstream class teachers, language unit=resource base teachers, language teachers based centrally (usually in an SEN support team), school teachers with a special interest in language impairments and educational psychologists. The third research into practice phase took place at ve sites: Manchester, Leicester, Newcastle, Bristol and London. These locations were chosen to provide maximum accessibility to those who would be attending from the 15 sites where interviews during phase 2 had been conducted. For practical reasons, attendees were limited to 40 at each of the rst four venues, and to 80 in London, with balanced representation of professional and user groups. Results It is important to establish rst what is meant by the consultative model. Technically a consultant is one who consults (an oracle) (Oxford English Dictionary, 1979) and the model upon which the term is based is one of the consulting physician. Clearly this has contained within it the concept of consulting the expertise of the individual concerned just as he or she consults the source of his or her expertise (or oracle). The important point is that this model does not presuppose any particular way of working on the part of the individual but the title is prefaced on practical expertise. This role is enshrined within the National Health Service in the UK. It is much less clear how it translates into education where no such culture of expertise exists and where there are many other priorities beyond the individual relationship between a patient and a doctor. From the interviews reported here the terminology associated with different models needs clari cation and a mutual understanding by both parties. For example, it was apparent that some LEA contributors were con ating the concepts school-based and consultative. Similarly it was often assumed by those in education that consultative necessarily meant indirect work through

7 Consultation: a model for speech and language therapy 151 some other party, (for example, learning support assistant), as opposed to direct involvement with the individual concerned. Figure 1 represents the range of different factors that impact on the process of consultation as they do other features of the provision of services to children with speech and language dif culties. Resources The allocation of resources affects the model of service provision adopted in so far as it affects the level of staf ng and the skill mix of those in the service. If the level of funding is too low it is unlikely that it will be possible to offer any real coverage across the school-aged population. In some cases, services have dealt with this issue by simply withdrawing provision from school-aged children who do not have a statement of special educational need. In other cases, speech and language therapy services resort to a reactive model where they see individual children in clinics because they simply are not able to cover the population as a whole. It is also apparent that the level of resourcing for children on stages 1 4 of the Code of Practice is far lower than for those at stage 5 (Lindsay et al., in press). This means that the opportunities for effective application of the consultancy model may be severely limited for children whose needs have not been formally identi ed. Management of services The service managers clearly play a critical role in determining whether the process of consultation is going to work. In our discussion the issue tended to polarize along the lines of clinic=school rather than more precisely how individuals would collaborate in school. Overall, the clinic=school debate involves balancing the interests of individual children with those of the cohort of children needing therapy, and an issue here is the perception of con ict between effectiveness and resource allocation. The clinic=school-based dichotomy was characterized by one participant as a tension of ef ciency vs. community and school-based model. We identi ed considerable differences in opinion in how best to address this issue. Delegates in one group in the research into practice phase saw schoolbased therapy as more effective for a child s overall development, but pointed out that this is heavily resourced, allowing perhaps four children to receive therapy in a day, as compared with around ten in a clinic setting. The same

8 152 Child Language Teaching and Therapy Figure 1 The interdependence of factors in the provision of services to children with speech and language needs

9 Consultation: a model for speech and language therapy 153 group felt that clinic-based therapy, while isolating the child in the clinic, tends to perpetuate isolation of the child in society. Other delegates too, expressed the view that children with developmental S&L dif culties should have S&L provision in school. By contrast, however, in other discussion groups, SLTs felt that work in clinic is preferable, in spite of LEAs attempts to push [us] towards doing therapy in schools. The comment of an EP, taking the viewpoint of the head teacher, and the rejoinder of an SLT manager illustrate the tension surrounding this issue: How can I deliver a National Curriculum when children are going off to clinic? and How can I justify sending one member of staff to one school, for one child?. The manager is held to account for the deployment of staff. This means that they are responsible for the time allocation for individual children. One aspect of the consultation=collaboration process is that it is less likely to be effective if there is not enough time allocated for the process. The time allocation for liaison is an important management consideration. This can be considerable and needs to be written into IEPs=statements, if it is not to become marginalized as the pressures of this type of work increase. SLT services are also extensively involved in training LEA staff. Some 94% of trusts are involved in this activity, representing a signi cant input that is not directly client related. Liaison, training, continuing professional development and assessment are all key features of the service provided by speech and language therapists irrespective of the speci c approach to intervention adopted. They all take time and need to be part of the package of care on offer. Likewise, these features need to be written into the work of the LSA. Thus it may be appropriate to indicate that while the greater part of the LSA s work may be in the classroom, there may be situations where it is more appropriate for the LSA to work outside the classroom alongside the SLT. It is important that the standard data collection method used in the NHS relates to face to face contact and would not, as it stands, re ect accurately the process of consultation as it is envisaged here. Level of caseload The data from phase 1 of the study indicated that the average primary school caseload for children with speech and language needs was 123. However, it only follows, of course, that this applies to the children that are known to the service. On average 14.3 speech and language therapists work with children in any given health trust and the average ratio of SLT to child population was 1:4257. If we take an estimated prevalence of 7.4% corresponding to the

10 154 Child Language Teaching and Therapy most recent prevalence data quoted for school-aged children (Tomblin et al., 1997) the typical caseload would be 315 children. The report recommended that it would be helpful to see 40 children as the most appropriate level for a notional caseload (Law et al., 2000). There is obviously a considerable discrepancy here. It may be argued that we need more economical means of covering these numbers and the most obvious way of doing this is to develop a consultancy model with speech and language therapists passing on their expertise to others who are attached to the child s school and who are able to work in the classroom on a regular basis. There is, of course, the alternative explanation that the number of speech and language therapists could be increased considerably, but there are counter arguments here as far as service providers are concerned. The result is that from the caseload perspective an indirect model of working appears to be a pragmatic solution to the problem of coverage. Conditions, training and contracts There was considerable concern about the differences between the conditions of employment for teachers, therapists and assistants. This is not the concern of the present paper, but clearly it does have the potential to have a bearing on effective collaboration. At the very least those concerned with a given model of service delivery need to be able to meet at regular intervals. The alternative is that collaboration becomes impractical simply because those concerned are not able to meet. Beyond this all those interviewed in the study identi ed different types of knowledge gaps, whether about speech and language dif culties or about the application of the National Curriculum. In one case a health trust was offering training for speech and language therapists in how best to negotiate with parents to reach attainable goals. To a certain extent the need to provide good quality training for teachers and therapists was pre-empted by the time the reports recommendations were known by the DfEE s funding of I-CAN 3 to prepare the Joint Professional Development Framework Training. This became available in late There remains an issue of how to improve the SEN input and the information about speech and language development in particular in the curriculum of the initial teaching training. From the point of view of the consultative model one of the key identi ed training needs was for teaching learning support or speech and language therapy assistants. Currently the provision for such training is ad hoc and there is no guarantee that assistants will have a good knowledge in this area. This, of

11 Consultation: a model for speech and language therapy 155 course, has implications for the introduction of an indirect service because an untrained assistant is not in a position to take on the responsibility for implementing intervention programmes and may require a considerable amount of hands-on training. Of course, there are many such assistants who are well able to meet this need, but this remains an issue every time a child s needs and the intervention to be provided are discussed. There also remains the concern that assistants are being asked to take on roles where they do not have the necessary competence, do not receive any realistic training and where learning on the job is questionable. Equity of provision The discussion with practitioners and managers was permeated by an assumption that the service should be striving towards inclusion of all children and an equitable access for all children to the services that best met their individual needs. At the same time it was mediated by a recognition that services were not equitable and that some children got a better deal than others. In many ways these two objectives are antithetical to one another and the dif culties that services experience with coverage within a given population arise out of them. Thus if we want to include all children in their local mainstream school and not concentrate resources in a specialist unit, this has implications for the specialists concerned. This can be problematic where schools are widely spread geographically. By the same token this process becomes attenuated still further if there is an active process of identifying children with individual needs. Those children who come through with statements of special educational need only represent a proportion of those who actually have needs. Although 38% of all children with statements had language needs, a substantial number of children who were clearly prioritized, by speech and language therapy services because of the severity of their dif culties, did not have a statement and were therefore only eligible for limited support services. We re nding increasingly that the children that we prioritise who ve got speci c speech and language impairment aren t getting statemented and therefore haven t got an LSA. The statemented ones jog along quite nicely because 3 I-CAN is one of the major voluntary sector providers of services to children with speech and language needs in the UK.

12 156 Child Language Teaching and Therapy they have the LSA, particularly if it s more of a global dif culty. It s just the more speci c (language impaired) ones that are the issue. (Head of Children s SLT services, shire trust) Again a consultation model can only work if there is someone with whom to consult. If there is no LSA support it is unlikely that a consultative model will prove feasible. Staff wellbeing Although it is rarely considered as a part of the equation it was clear that, from the practitioner s perspective, job satisfaction was a critical element of whether effective collaboration could take place. Probably inevitably, practitioners feel happiest if they are doing what they were trained to do and in an environment with which they are familiar. This poses an interesting problem for the speech and language therapist adopting a consultancy model of service delivery. It is likely that they will be de ning a role with which historically they may be unfamiliar. Some respondents spoke of a comfort zone beyond which they were having to go in rede ning their role. They were not necessarily averse to this, simply noting that they were entering new territory with which they were unfamiliar and for which they would probably require support. There s a danger... if we go down the consultative model (route) too much that we actually become teachers... that we ve left the therapy bit behind. (Paediatric therapies manager, London) Of course, some services have speci cally set up networks to deal with just these issues and in some cases there was already developed a culture for how to work in schools. These are important issues because if speech and language therapy services in schools are to be developed they must attract staff who actively want to work in them. Similarly, staff must be opting to come back into school services once they have taken career breaks. Unfortunately the uncertainty and the unfamiliar and unsupported experience of many staff suggested that there was a long way to go in many areas. Recruitment and, in this context in particular, retention, are critical issues. For if professional establishments fail to recruit, the responsibility for the service delivery is likely to be spread across a smaller number of staff with the resultant strains on the possibility of effective collaboration.

13 Consultation: a model for speech and language therapy 157 Opportunities to collaborate The discussions with almost all those interviewed suggested that both therapists and teachers were anxious to collaborate with one another but all too often there were obstacles to that process of collaboration. The obstacles were often practical: timetables, common work space, etc. [There are] constraints of resources, time and staf ng. You can t always follow the ideal pathway of care for each child, we do have waiting times, and children do have breaks from therapy, just so as we can get other children in. (SLT in urban=shire trust) Unless these obstacles were overcome there would be very little chance of good collaboration taking place, with a corresponding dif culty in developing the network of connections upon which the consultative model depends. Indeed it is probably true to say that only in those authorities where these problems had been overcome could good consultative practice thrive. Parental satisfaction Parental satisfaction is clearly related to the level of support that their child receives and on how well they feel that the service providers communicate with them. This issue of parental involvement is covered in greater detail elsewhere (Band et al., in press). From the parent s perspective the real concern was that the indirect=consultative model was simply a cheap way of providing services. This was particularly the case if it was clear that the LSA had no experience in the eld, or if the school made no attempt to draw the parent into their discussions about the child s needs, in which case they felt they were simply getting a worse deal than they would be if their child was receiving one to one therapy, a view reported by one learning support teacher as you don t want to be fobbed off with the registrar when you need the consultant. Although there was much talk about managing parents expectations, there is no available evidence to date that LSA focused intervention provides as good a result as speech and language therapy services. Consequently, practitioners often feel that they are trying to persuade parents to accept one sort of service when they do not necessarily believe it is most effective. In other cases there was clearly a belief that parents needed to listen more carefully to the practitioners. The issue is how to persuade the parents that they don t actually have to have hands-on therapy by a quali ed, trained expensive therapist, and that the

14 158 Child Language Teaching and Therapy programmes can be provided by the therapist, there can be ongoing advice and monitoring, but the actual delivery can be done by someone else. (Assistant director, London) Parents start saying what they want rather than asking us [educational professionals] what he needs. Parents expectations are very important. (Special needs co-ordinator [SENCo], metropolitan LEA) School satisfaction Our respondents told us clearly that they were opposed to the clinical model being applied in schools and that it was essential for speech and language therapists to talk the same language as educationists. Our sense was that in many areas teachers were pushing at an open door here. The therapists were anxious to become involved in those schools. However, teachers often assumed that once the therapists were in the schools they were necessarily going to be based in the classroom, while therapists said that there were many activities including formal assessment, liaison with parents and training of LSAs that did not best t within the classroom. Schools were often apprehensive when they were not able to provide therapeutic support for children with statements of special educational needs. Often services were spread too thinly or it was simply not possible to recruit to a post. This led to considerable frustration on the part of the schools because they were often held accountable by the parent for something over which they had no control. Level of service provision Whether the consultancy model is feasible depends to a certain extent on the number of speech and language therapists able to provide that consultancy. These levels are determined by the Department of Health. Although there have been increases in therapy establishments in recent years the recommended levels differ little from those rst recommended a quarter of a century ago (Quirk, 1972). The consultancy model offers the potential to increase the coverage of SLT provision by making creative use of the range of skills that are already available in the school: SENCos, classroom teachers, peripatetic teachers with a special interest in language impairment, and teaching assistants as well as speech and language therapists. Such an approach presents the additional bene t of providing in-service training to the staff concerned. However, it relies heavily on the availability and commitment of educational staff with whom to consult. In

15 Consultation: a model for speech and language therapy 159 terms of specialist support personnel the numbers of peripatetic teachers and LSAs with specialist skills in this area are very low with 83 92% of LEAs reporting that they had no designated peripatetic teachers to work with this client group. Realistically, if there are not enough appropriately skilled LSAs in place it is unlikely that speech and language therapists will be able to function effectively in the educational context. If they are not able to rely on LSAs to implement programmes they are likely to continue to support the children themselves, working directly rather than indirectly. In the research into practice phase of the study one group made the speci c recommendation that there should be SLT assistants for all schools. There was a common perception that the presence of the SLT made a difference to the way the service was delivered. A lot of it comes down to the number of us that there are and the amount of time that you can give these schools, because you can only make them aware of what it is we re trying to do if you are there doing it, and if you re involving them... let them see what s happening and train them up to do it and then pull out. (Specialist SLT in learning disability) Recruitment and retention Of all speech and language therapy services, 55% reported that they were having dif culty recruiting speech and language therapists to work in schools. This gure rose to 80% of the LEAs questioned. There are a number of issues here that are being addressed. In the rst case there is a shortage of speech and language therapists generally in the UK because of initiatives such as Sure Start. To a certain extent this is being addressed by new initiatives of the NHS Workforce Confederations, which commission speech and language therapy places in universities. There is also an issue of the salaries of SLTs and again this is currently being addressed with an extensive regrading programme in But there are some issues that are more speci c to the educational context. LEAs make extensive use of short term contracts, which are not appealing and there is a high turnover of staff. In part this may be attributed to the very high caseloads that SLTs are required to carry in education and the lack of job satisfaction that results. There were also concerns about the level of specialization that SLTs were allowed to develop in education. Litigation Litigation represents the ultimate breakdown of communication in the system. This has posed a great many problems for LEAs, health trusts and, of course,

16 160 Child Language Teaching and Therapy parents. While this does not necessarily bear directly on the model of service delivery it is clearly advantageous for the parent to be in direct contact with practitioners who understand well the needs of the individual child. Although some schools really focus on this issue, in many cases the person with the most experience in this area is the speech and language therapist. The consultancy model as indicated above presupposes that the therapist knows the individual child well. However, if indirect work simply means handing over therapy programmes with a loss of direct contact with the child and the parent, this may result in the loss of one of the parental support mechanisms. This relates to the management issue of liaison time and to professional satisfaction. Therapists commonly see themselves as well trained to work with parents but they may simply not have the time at their disposal to do so. Discussion The consultative model, as it has come to be known, is clearly widely accepted as a model for delivering speech and language therapy in schools. That said, the term consultative model often seems to mask more about speci c practice than it reveals. For some it is synonymous with exclusively providing indirect intervention through learning support staff (speech and language therapy or teaching assistants). For others it is a much more exible service, which incorporates direct and indirect work, classroom focus and withdrawal. For speech and language therapy services the term consultant is not con ned to indirect work via another party. For example, it may be very appropriate for the therapist to spend time speci cally modelling techniques to an LSA. Similarly the assessment process may, in some cases, be particularly complex and this may require the therapist to take the lead in direct assessment. Equally, it is important to emphasize that while the consultative model may predominate it is not the only element of the mainstream service. There may be a range of personnel with specialist and generalist skills available in a given speech and language therapy establishment, some of whom may function more readily as consultants. There needs to be specialist recognition for SLTs who are very experienced in working in educational settings, but it would be wrong to suggest that only experienced therapists can work in schools. In part this is a matter of de nition. Consultant may refer to a role de ned by activity or by degree of expertise, as within the medical profession. There is a case for skill mix

17 Consultation: a model for speech and language therapy 161 within teams and this requires teams of suf cient size for a range of different grades to be supported. Thus less experienced SLTs may be doing more direct work with children and as they become more experienced they may act in a more indirect fashion. Nevertheless, the question of whether the actual term consultant should be used or avoided in the educational context is one that still needs to be addressed. This pattern of moving from hands-on practitioner to consultant is a route followed some years ago by educational psychologists (Watkins, 2000) and is one that needs to be negotiated carefully. In addition to the intervention itself, it is evident that SLT services place considerable emphasis on their involvement in child development centres and assessment units. Whatever the model of intervention adopted assessment will take up a substantial part of the speech and language therapist s workload simply because, by de nition, many of these children have very complex needs and take time to assess properly. Of course there is another side to this coin and one which has the potential to bring many bene ts to all concerned. Good collaboration can aid and streamline the assessment process if, for example, the SENCo has collected IEP information and other classroom observations about the child before involving the SLT. The consultant therapist model discussed above is close to that proposed in the 2000 NHS Plan (NHS, 2000). However, the NHS plan does not consider the particular issues that will lead to this level of specialization in different areas of clinical expertise. As we have illustrated, the consultative model within education is the product of a series of interacting phenomena which goes beyond what is done with an individual child in a classroom. For it to work effectively it must be instigated across a service and in a manner that is accepted across both health and education services. Similarly there needs to be a career progression towards this consultant model giving recently quali ed therapists a chance to develop their expertise both in assessing and treating individual children but also in fully understanding the education service within which they will be working. Finally, then, the consultative model is broadly favoured by practitioners as long as a number of prerequisites are in place. Consultancy is certainly not a panacea, in part because there is no single model of consultancy that is widely applied. Rather, there are elements of practice that are common to other professionals undertaking consultation and within this general approach there is room for variety. However, the present study, together with other work including that within educational psychology, suggests that there may be positive aspects to consultancy as a model for practice. The task now is to explore the effectiveness of those elements.

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