Therapy

Making impact in speech and language therapy 

After a career spanning 40 years and over two decades as chief executive of the Royal College of Speech and Language Therapists, Kamini Gadhok MBE  is retiring. 

Here, NR Times speaks to her about work she has done to help inspire and lead change over the past four decades.

Kamini Gadhok’s reason for going into speech and language therapy was simple, and remains the motivation even today - “I wanted to help people who are vulnerable and do what I could to improve their lives”. 
And the career choice she made aged 16 has seen Kamini pursue a stellar career in speech and language therapy, a field which has changed so much in the 40 years since she qualified in 1983 and which she has done so much to improve, for professionals and patients alike. 
Graduating from Manchester University, Kamini found herself rising to prominence through her work with Nottingham Community Health NHS Trust, particularly in terms of her commitment to bilingualism through establishing the Asian bilingual co-worker service, the first of its kind in the country. 
Her commitment to equality also saw her become ethnic health projects coordinator for the NHS and appointed by the Department of Health to set up its Race Equality Unit. 
She has also become known as an advocate for the prioritisation of children’s speech and language therapy services by the Government, having been part of the advisory group for the ten-year impact assessment of the Bercow Report. 
Having become chief executive of the Royal College of Speech and Language Therapy (RCSLT) in 2000, Kamini has become known
for her commitment to reducing health inequalities, widening provision and also for her leadership during the COVID-19 pandemic, where she played a leading role in a coalition of 18 professional bodies to help ensure members and their patients were supported during the unprecedented time. 
Here, Kamini addresses some of the major challenges for the profession going forward, and reflects on 40 years of great achievement in her profession, which also saw her awarded an MBE  in 2009. 

Challenges in provision and urgent need for change
When Kamini qualified in 1983, speech and language therapy was a growing phenomenon, a developing service which was being adopted in increasing numbers of specialist fields.
While she recalls the scope of the work was narrower in the 1980s, that has developed over time as the prominence of the profession has developed. 
But while it has developed in profile and reputation, sadly that has not been reflected in access. 
Even in the early days of Kamini’s career, she saw the vast variation there could be in regional and local provision. 
“In my first job, if you had a stroke, there was just no service. I remember feeling quite shocked at that, because I'd qualified at Manchester University, and Manchester has some some of the bigger hospitals where a lot of these services had been developed,” she recalls.
“I’d gone to a much smaller place where I think I was the second full-time speech and language therapist - and it was a shock. 
“Even at that time, I felt that some of the ways of working were out of date from what I been trained to do . That was when I saw, even as a newly-qualified therapist, how different provision could be.”
But shockingly, 40 years on from that initial experience, the local disparity - or ‘postcode lottery’ as it is often referred to - remains
a massive challenge for speech and language therapy. 
“I guess back then was a bit like what's happening now, access to provision in some areas  seems to have got worse. That is dreadful to say,” she says. 
“We very much need to reduce this variation, particularly in the community. There is plenty of focus on acute care, which is not wrong. Prevention and early intervention are so important, but how are we supporting good community care for adults and linking that with social care? And similarly for children?
“We know this is so critical but these are all big policy discussions and debates the Government has to take really seriously and actually do something about - we need to be empowering and enabling regional and local decision makers to think about the populations they are serving and the best way of meeting the needs with the resources they have. 
“There are opportunities here. We’ve had many meetings with regional leaders about how they can work more strategically with their partners and get the right people around the table. 
“With adults, which will see the workforce cut across health and social care, with children it will cut across health and education. We know resource differs and there is a lot of pressure, but we need to maximise what each area can do with the workforce they have available.”
The well-documented pressure on NHS resources is often cited as a reason for the lack of provision - which statistics have shown has been amplified massively by the pandemic - but Kamini points to reduction in provision being a much more longstanding issue. 
“The impact of austerity has been very significant. I know it has been said that the NHS wasn’t touched in 2010 (with the beginning of austerity measures) but that’s not the case, we lost a lot of leadership at that time. I think we’re still seeing the impact
of that loss of leaders,” says Kamini. 
“While it’s one thing getting rid of expensive people, that does not take account of the fact that  these are practitioners  at the top of their game helping to support the next generation. They’re a key part of the system that develops the next generation of experts. We continue to feel the impact of that. 

Kamini and the RCSLT have been vocal in the need to better support therapists, both within speech and language therapy as well as the wider transdisciplinary team. 
“We want to look at how allied health professionals can work together and with others to reduce pressure on the system. There is a huge shortage in the workforce, but we are working together where  we can,” says Kamini. 
“I am really concerned at the current situation. We know, for example, speech and language therapists are already working in A&E to assess adults who have swallowing problems. This is still considered as  innovative practice, and there are certainly pockets of innovation happening, but how do we help this to spread? How can we work differently?
“This is a huge challenge, and something we (RCSLT) have been meeting with NHS England to discuss. 
“Towards the end of 2020, I met with policy leads in NHS England to look at how we were going to support the workforce, they were  depleted, they were  demoralised, they were  exhausted. I don’t know whether they assumed the pandemic would disappear, but there wasn’t any planning in the system to think this through. 
“As a priority, we need more appropriate workforce planning and to make sure services are funded for the workforce to be able to deliver them. If a service  isn’t funded, it won’t be delivered, even if we do have the workforce.”

Provision for children 
The 2008 Bercow Report helped to lay bare the problems faced by children and families who are affected by speech, language and communication needs, looking at how such issues at an early age could lead to often profound later life consequences. As well as limited education opportunities, speech and language issues were found to be at the root of anti-social behaviour, criminality and disengagement with society. 
A great area of interest for Kamini, she was involved in the ten-year review of this milestone report and has advocated that greater emphasis be put on such vital early-life interventions. 
Since that review, the impact of the COVID-19 pandemic has significantly amplified the scale of the situation.
Yet while the need has been articulated in both 2008 and 2018 - and on an ongoing basis by RCSLT and others - the ongoing debate over funding continues. 
“The challenge that has always faced children’s speech and language therapy services and access to them are  arguments over who should fund it. Is it a health need? Is it an educational need? It is very distressing to see children’s needs being almost boxed into different containers like this, particularly when they are denied access because of it,” says Kamini. 
“This is a person, a human being. Communication is a basic human right. It is a door to our culture, our communities, our friends and family, it enables us to access the education that is fundamental to our future.
If you can’t communicate, your ability to  learn is affected.
“But the fact that health and education have these arguments is not acceptable. Does it matter who funds it? Isn’t it more important that, as health practitioners, we support and enable children’s communication so they can access all of these things?
“With the impact of the pandemic - we would never normally see the numbers of pre-schoolers being referred that we are currently - we have to make change and we can’t just see the same themes continuing.

Making a difference
During her 23 years with RCSLT, much has changed in the profession of speech and language therapy, much of which has been due to the work of Kamini and the organisation. 
Early into her time with RCSLT, she was able to address the disparity in support for children and young people in Northern Ireland through inspiring the creation of a strategy, and also played a key role in the review of the Bercow Report in 2018 - at the heart of both were Kamini’s commitment to seeing the situation on the ground, travelling extensively around the UK to find what mattered most to members and patients alike. 
“We have to be mindful of the populations we serve and how we can really make a difference,” says Kamini. 
“We work in prisons, in the justice sector, with people with mental capacity issues, with children on the edge of care, with people from all cultures, we have provided a lot of evidence around the impact of domestic abuse on children - the areas in which we touch people’s lives are very significant and varied.”
It is for this reason that Kamini is committed to promoting the importance of protecting the workforce, with their role in society more generally now more widely recognised than ever before. 
“We have had significant growth in the number of universities providing courses for speech and language therapy training, and while like with every profession in the NHS at the moment, the big concern is around morale and retention, that has to be a priority going forward,” she says. 
“This is a key thing for NHS leaders to address - how do they create a positive environment to empower their teams, like my managers empowered me when I first started in Nottingham?  
“Leadership that exists in all of us. I will say to our members that everybody's a leader, you don't have to have the title of manager, I was just an ordinary speech and language therapist but wanted to make change. We're all leaders, we all can speak up and do something positive.”
The focus on data and evidence is something RCSLT is also leading on, becoming the first membership body to create a tool, which is free to members, to collect real-world data. 
“We are collecting information for our members to record about the population they service. We want people who fund the services to ask for outcomes data, because that’s the hook here,” says Kamini. 
If we're saying there is a poor service, or what's making that service poor, we need to know why. Where is the evidence to support that?
By measuring the outcomes of care, people will hopefully start asking the right questions, looking at why things aren’t working and what needs to change. At the moment, the system places too much focus on waiting lists, waiting times and inputs. 
“We need to reduce the variation across the country and create better services  we need to influence the decision makers and can only do that effectively with proper evidence.” 
In addition to widening access of speech and language therapy through addressing language and culture barriers, RCSLT has also been instrumental in the creation of other means, including the award-winning Communication Access UK initiative, which supports
businesses to deliver inclusive communication. The steering group is chaired by Kamini and includes other partners including the Stroke Association and MNDA.  

Championing equality
In the early stages of her career in Nottingham, Kamini realised the need for greater emphasis on non-English speech and language interventions. 
Having established the first-of-its-kind bilingual co-worker service, having secured the funding to do so, Kamini won an award from Nottingham City Council for her commitment to race and community relations - something she still regards as “quite a thing” three decades later. 
And it was through working in multicultural areas, with clients who did not speak English as a first language, which made her realise the need for change. 
“When I moved to working in an inner city clinic, I thought it was a bit strange that the majority of the population were from a particular region of Pakistan - but if you looked at the caseload we had, there were hardly any children from that community,” Kamini recalls.
“It made me realise that if people didn’t refer, there was a problem in picking those children up if they had a need, and making them aware that a service was available to them. I didn’t speak the dialect, so became very aware I needed do something to address this issue.”
But while Kamini implemented that service over 30 years ago, for some areas, this remains something that is only being looked at now. 
“At the moment, I think some some areas are trialling this as a model, where there is a majority community where you can make a business case to say rather than working with interpreters, and training interpreters, we need somebody who's more highly trained and skilled that's from the community and can speak the language,” says Kamini. “We know we have a long way to go. We’re still quite shocked that a lot of schools and NHS services do not employ interpreters as part of the system. I have raised this with
NHS England because it doesn’t align with what our expectations should be, particularly in this day and age.”
For Kamini, the need to ensure this equality has been prevalent throughout her career. In 1997, Kamini became ethnic health projects coordinator for the NHS and was seconded to the Department of Health to set up the Race Equality Unit, continuing her commitment after joining the RCSLT by establishing a bilingual e-learning platform. 
“As a society, we need to be looking at the needs of the population and making sure resourcing is appropriate and meeting needs,” says Kamini. 
“It’s not just about language, it’s also about culture and religion. How can we make sure we are supporting personalised care? For speech and language therapy it’s an absolute must, because how can you make a diagnosis of communication difficulties if you can’t assess them in their home language? 
“Being able to communicate in their language of choice is critical, because language is a door to your culture. We need to think about this, and we need to do better.” 

Impact of the pandemic
Even before the COVID-19 pandemic, speech and language therapy - like most other branches of therapy - faced significant pressure on resources. But through lockdown, and access to therapy being restricted, the needs of many people have increased significantly.
Statistics have shown that over half of those living with neurological conditions who could not access speech and language therapy
during COVID-19 lockdown have seen their mental health, social and home lives worsen as a result. 
“For many people, we know it has had a significant impact,” says Kamini. 
“We know of people who have conditions they were not able to be diagnosed with during the pandemic, or were not able to access early therapy, so have now got more significant difficulties than they perhaps otherwise would have. 
“Our members are reporting their distress when they are seeing patients who are coming in with more significant needs th because their needs were not being met during the pandemic. We have  excellent members and they are deeply affected by this. 
“We are seeing how it is starting to pan out in terms of accessibility, and we have seen how big the waiting lists now are. All of our members are reporting an increase in waiting times for care. The system is so depleted and we are very aware of the issues. It’s something we are all worried about, and we’re committed
to doing what we can to bring down the challenges that exist with hospital pressure.”
As well as the concerns around provision, RCSLT had huge concerns for its membership during the pandemic and the lack of access to PPE, given the levels of interaction it has with patients. This inspired Kamini’s work within the COVID-19 coalition.
“We realised very early that there was a problem. Our members were contacting us because they were doing dysphagia assessments and when you assess someone’s swallow, you generate a cough, and they’re doing that with clients several times every day,” says Kamini. 
“At that time, nobody knew if someone was COVID positive or not, so there was great anxiety about viral load and having exposure to a virus we knew could kill you. This was literally a life and death matter for our members. 
“I wanted them to be protected from this as far as possible, so we joined forces with over 18 professional bodies and experts to work together to make our concerns heard. 
“Healthcare workers were dying, and we had to consider whether these lives could have been saved, what were we being exposed to.
That’s something that we were jointly very, very concerned about. 
“That was a very challenging time, but absolutely vital we protected our members, particularly until we had the access to PPE, which was a challenge in itself.”
While many therapists, in the absence of being able to see patients face to face, did turn to remote communication during the pandemic, while Kamini sees it does have some role, for speech and language therapy it will never be a substitute for in-person therapy, she says. 
“We did use Telehealth and push out guidance to our members on Telehealth, but we’re very aware that there are people with communication needs who just cannot access Telehealth because of their needs. For them, it is just not appropriate,” says Kamini. 
“We also have people who live in digital poverty, or may not be digitally literate. We have to think about the health inequalities that exist in society to think about how these things will work practically. 
“While yes it is an innovation, and has been used successfully in some cases, we need to think about who we are working with, what is the best approach for them. That isn’t necessarily the case for everyone.”

Meeting the need
Back in 2008, amidst a lack of provision in the North East for children with Cerebral Palsy and other disabilities - and significant waiting lists for parents to secure diagnoses and access to NHS therapy - a group of families took the initiative to do something themselves, or else face a potentially lengthy wait for the support their children badly needed. 
“My friend has a child with Cerebral Palsy, but the place they were accessing Conductive Education therapy was closed down because there was no funding. So my friend and other parents got together and decided they wanted to provide a service to do the same thing,” recalls Jane. 
“It all started in response to a service that was being pulled away, and they sought help from people from different backgrounds to help make a success of it. My background is in business development, so I came in to support with the development of Heel and Toe as a charity, and it has grown so much from there.”
And from the very earliest days, the need for this new service quickly became apparent, with huge demand from families. 
“When we started, it was really difficult for parents to get a formal diagnosis for their child, they were essentially working with their clinical teams to try and establish the milestones their children were supposed to be hitting at certain times, and realising from there that their development might be quite delayed in certain areas,” says Jane. 
“They were absolutely desperate for access to therapy that would help their child, but waiting lists were absolutely exhausted and when they did get access to therapy, the staffing situation was a massive problem as well. There just wasn’t the quality or quantity of therapy they badly needed. 
“So when we opened a centre where families could come and access a range of therapies, the demand was huge. We expanded our services based on what was needed - from Conductive Education to physiotherapy to occupational therapy and so on, we now have a whole range of support that has grown as the demand increased.”
And with NHS waiting lists continuing to grow, and the huge additional pressure put on the healthcare system during and in the aftermath of the COVID-19 pandemic, demand for Heel and Toe’s services has never been greater. 
“While access to therapies is wider than when we first started, because demand is so high, capacity is a problem for many services. We just keep growing in response to that,” says Jane. 
“Yes, the demand is absolutely massive, but we've got an incredible team of therapists and fundraisers, and we all work to maximum capacity. We just want to see children thrive and be able to develop in a way that's going to make things accessible in life that they didn't think was going to be possible.
“We always try and provide as much as we can. We have had families come to us from miles away. If we can support them, we will. And if we find any other centres or charities that have facilities and availability, we can forward on that information to our parents. We want to do the very best we can for every child.” 
Through the work of the Heel and Toe team, children are enabled to exceed expectations, having fun while taking part in life-changing therapy. 
“Many children who come to us have never taken any steps so their core stability is quite weak, the muscle tone is quite weak,”
says Jane. 
“But after three or four weeks of sessions with us, the difference is massive. They realise they really enjoy their therapy, so want to do as much as they can. 
“We’re always getting calls through to the fundraising office saying ‘You have to come and see this’. We share the joy as a whole
team in seeing children progress like there are - and that’s what it’s all about.”

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