Introduction: Acquired swallowing impairment is a major public health issue that often leads to increased morbidity and slower recovery. Speech and language therapists (SLTs) have taken the lead in the assessment and treatment of dysphagia, which is reflected in guidelines where early intervention is recommended. This is in addition to the central role that SLTs play in the management of acquired communication impairments since research indicates that patients with communication difficulties benefit from early and intensive therapy by SLTs. This increasing demand for SLTs is expected to cause conflicting pressures in their workload and, therefore, beneficial to consider workforce planning. The aim of this study was to examine real-world data in the UK to investigate this issue regarding changes in referral patterns of patients with dysphagia and/or communication disorders to SLTs over time, to assist with workforce planning. Methods: We interrogated the Royal College of Speech and Language Therapists Online Outcome Tool, a national database, in this retrospective cohort study. We included patients evaluated between 2018 and 2022. We performed a subgroup analysis of patients aged ≥40 years who had a primary medical diagnosis of stroke. Data on age, primary diagnosis, time on caseload, primary Therapeutic Outcome Measure (TOM) scale and initial TOM score on impairment were examined. Results: From the database of 44,444 referrals to speech and language therapy, 5,254 referrals were included in the stroke and overall subgroup analyses. Referrals were 55.1% male, with a median age of 71 years. More than half (56.1%) of these referrals were for dysphagia. Referrals decreased during the COVID-19 pandemic but began to recover from 2021 onwards. The time on the SLT caseload has increased over the years from a median of 14 days (interquartile range [IQR] 0–56) in 2018 to 20 days (IQR: 3–81) in 2022. While there were more referrals to SLT services for assessment and management of dysphagia than for communication in the overall population, in the stroke subgroup, referrals for communication disorders outnumbered referrals for dysphagia from 2020 onwards. Additionally, the severity of impairment on referral increased over the years. Conclusion: Real-world data indicates that referrals to SLT services are changing over time to include more complex and severely impaired patients, with a demand for both swallowing and communication disorders. These findings should inform staff allocation and remodelling of education/training for SLTs to better meet clinical and public health needs. The retrospective nature of this study limits the strength and generalisability of these data, and this topic warrants further investigation.

The Increasing Prevalence of Dysphagia

Swallowing impairment, otherwise known as dysphagia, is becoming increasingly prevalent. One reason for this is the ageing population. The number of adults >65 years of age living in England and Wales is 11 million [1]. Studies report the prevalence of dysphagia to be 30–40% in independently living older people, 44% in those admitted to acute geriatric care, and up to 60% in those who are institutionalised [2, 3]. Therefore, dysphagia has become recognised as a “geriatric giant” [2, 3]. Dysphagia is also a common symptom of many neurological diseases, though often under-recognised [4]. Many adults admitted to the hospital will have pre-existing swallowing impairments associated with a chronic neurological disease or deconditioning as a result of an acute illness e.g., stroke, post-operatively or following admission to critical care [4‒7]. Dysphagia is associated with complications such as choking, malnutrition, pneumonia, dehydration and difficulties with the route of medication administration which affect patients in both the short and longer term [2].

The Extended Role of Speech and Language Therapy

Assessing and managing oropharyngeal dysphagia in many countries including the UK, USA, and Australia, now falls to Speech and Language Therapists (SLTs), in collaboration with the wider multidisciplinary team [8]. SLTs have, in the past 2 decades, become the profession that takes the lead on assessment and treatment of dysphagia, and this is reflected in professional and National Health Service (NHS) guidelines which urge early intervention. Dysphagia, however, is not the sole focus of the SLT work; traditionally, their role centred on assessment and treatment of acquired communication impairments such as aphasia and dysarthria. Research indicates that patients with these communication difficulties benefit from early and intensive therapy by SLTs [9]. Professionals are concerned that referrals for the assessment and management of dysphagia have “swallowed up” the time required for the management of communication impairments [10]. Enderby et al. [10] have commented that “Whilst there were 12 times as many dysphasic patients as dysphagic patients referred to speech and language therapy in 1987, the position was reversed by 1995 with twice as many dysphagic as dysphasic patients being referred to these services. Dysphagia in 1987 accounted for less than 1% of the referrals to speech and language therapy. This percentage increased, until in 1995 20% of referrals were for dysphagia” (page 604). To optimise service provision and education to meet the current needs, it is important to investigate the most recent referral patterns by interrogating real-world data to examine the balance between referrals to SLT for swallowing and communication disorder and whether this has changed over time. The COVID-19 pandemic is also expected to have affected referral patterns and staff allocation [11] which warrants an investigation to include those time frames. To our knowledge, no other study has investigated the change in referral pattern to SLTs other than studies focussing on COVID-related changes [12‒14].

The Therapy Outcome Measure

The Royal College of Speech and Language Therapists (RCSLT) developed and made available to members a national database called the Royal College of Speech and Language Therapists Online Outcome Tool (ROOT) [15]. The ROOT facilitates the collection of demographic diagnostic data (ICD-10 codes) [16] and Therapy Outcome Measure (TOM) scores [15, 17‒19] as core data fields.

The TOM for Rehabilitation Professionals [11, 16, 18‒23] was designed to be a simple, reliable, cross-disciplinary, and cross-client group method of gathering information on a broad spectrum of issues associated with therapy/rehabilitation. Three of the four TOM domains (impairment, activity, participation) are based on The International Classification of Functioning [24], and a further domain (well-being of the client and carer) is incorporated. The TOM is an ordinal rating scale, with “0” representing the severe end of the scale and “5” representing normal for age, sex, and culture. Half points increase the scale to 11 points.

We hypothesised that swallow-related referrals are increasing and predominating SLT referrals. To answer the question on how swallow/communication referral ratio changed over the past 5 years, we analysed data using the ROOT database to investigate the changes over time in referral patterns to SLT for these impairments. We chose to interrogate the ROOT database as it contains real-world data which reflects the current clinical situation across the UK.

Study Design

This was a retrospective cohort study using the ROOT database. Advice from the Health Research Authority NHS UK indicated that ethical approval was unnecessary due to there being no identifiable information on the database. Access to the data was granted by the RCSLT Governance Committee.

Subjects

We obtained data from ROOT on 30th June, 2023, for inpatient and outpatient records from NHS Trusts in the UK dated from 1st January, 2018, till 29th June, 2023. For the general analysis, we included patients of all ages who were evaluated for an initial TOMs score between 1st January 2018 and 31st December, 2022. This timeframe was chosen to compare before, during and after the acute effects of the COVID-19 pandemic. Patients who were referred in 2023 were excluded as many of the records had not been completed. In addition, we inspected the general database, to analyse the ratio of dysphagia and communication disorder referrals. For the subgroup analysis, we included patients who were 40 years old and above and had a primary medical diagnosis of stroke. Adult strokes are the most common neurologic condition that initiates referral to SLTs, making it suitable to compare dysphagia and communication related referrals [12]. While the majority (59%) of strokes occur in the older generation, Public Health England’s figures found that over a third (38%) of first-time strokes happen in middle-aged adults (between the ages of 40 and 69) [25].

Data Collection and Analysis

We analysed data on age, primary diagnosis, time on caseload (calculated from the initial and end rating dates), the chosen adapted TOMs scale (dysphasia, dysarthria dyspraxia or dysphagia), and initial TOMs score on impairment of either or both of these. We performed descriptive analyses and simple descriptive statistics to study the general demographics and trends over time. We performed calculations using Microsoft Excel. Variable denominators are due to missing data. We did not perform analysis where 70% or more of the data were missing.

Patient Background

Initially, 49,381 records were obtained. After excluding patients that were initially rated for TOMs before or after the study period (2018–2022) or did not have a recorded initial date, a total of 44,444 patients were included in the general analysis. We refer to this as the “general database population.” Patients 39 years old and younger and those without a recorded age were excluded. Only those whose primary medical diagnosis was stroke thus 5,254 patients were included in the subgroup analysis. The patient selection process is shown in Figure 1.

Fig. 1.

Patient selection process. From an initial record number of 49,381, patients were excluded according to study period and data availability. A total of 44,444 patients were included in the general analysis and 5,254 in the stroke subgroup analysis (TOM: Therapy Outcome Measure).

Fig. 1.

Patient selection process. From an initial record number of 49,381, patients were excluded according to study period and data availability. A total of 44,444 patients were included in the general analysis and 5,254 in the stroke subgroup analysis (TOM: Therapy Outcome Measure).

Close modal

Demographic data and general trends are shown in Table 1. It should be noted that the number of NHS services entering data increased from 26 in 2018 to 38 in 2022. However, there is surprising consistency in the information being provided.

Table 1.

Trend in demographic data for the general database population (N = 44,444)

All20182019202020212022
Number of participating Trusts, n na 26 32 27 38 38 
Number of referrals, n 44,444 10,016 7,936 6,592 9,595 10,305 
Average referrals per Trust, n na 385.2 248.0 244.1 252.5 271.2 
Age, years, median (IQR) 71 (40.83) 71 (39.83) 74 (51.85) 74 (55.85) 70 (26.83) 72 (44.84) 
Time on caseload, median (IQR) 18 (2.83) 14 (0.56) 14 (0.83) 21 (4.118) 22 (5.116) 20 (3.81) 
Male sex, %a 55.1 54.3 55.6 56.0 54.9 54.9 
Primary TOM: dysphagia, % 56.1 59.4 55.3 51.7 56.2 56.2 
All20182019202020212022
Number of participating Trusts, n na 26 32 27 38 38 
Number of referrals, n 44,444 10,016 7,936 6,592 9,595 10,305 
Average referrals per Trust, n na 385.2 248.0 244.1 252.5 271.2 
Age, years, median (IQR) 71 (40.83) 71 (39.83) 74 (51.85) 74 (55.85) 70 (26.83) 72 (44.84) 
Time on caseload, median (IQR) 18 (2.83) 14 (0.56) 14 (0.83) 21 (4.118) 22 (5.116) 20 (3.81) 
Male sex, %a 55.1 54.3 55.6 56.0 54.9 54.9 
Primary TOM: dysphagia, % 56.1 59.4 55.3 51.7 56.2 56.2 

na, not applicable; IQR, interquartile range; TOM, Therapy Outcome Measure; Primary TOM, Primary TOMs scale selected.

aSex: missing data in 4,881 patients; excluded from analysis.

Patients were 55.1% male, with a median age of 71 years old (interquartile range [IQR] 40–83). Of these patients, 56.1% were rated with a primary TOMs scale of dysphagia indicating the reason for referral to SLT. In the general database population, there was a decrease in the number of referrals during the COVID-19 pandemic, and the numbers recovered from 2021. The age and sex ratio did not change throughout the study period. The time on the SLT caseload appears to have increased over the years from a median of 14 days (IQR: 0–56) in 2018 to 20 days (IQR: 3–81) in 2022.

Figure 2 shows the trend in number of SLT referrals and the ratio of referrals for swallowing as opposed to communication disorders (e.g., dysphasia, dysarthria, dyspraxia). Generally, there were more referrals for dysphagia than for non-swallowing reasons. In the general database population, there was a decrease in cases being referred during the COVID-19 pandemic, after which cases increased. In ages 40 and above, the decrease during the pandemic appears smaller than the general database population, and there was a more prominent increase of cases over the last year. However, the swallowing versus non-swallowing ratio of referrals remains around 70%, as shown in Table 2.

Fig. 2.

Trend in average number of SLT referrals for swallowing and communication per Trust in the general population and >40 years between 2018 and 2022. a SLT referrals in all ages. b SLT referrals in ages 40 and above. Swallowing impairment was the predominant reason for SLT referral throughout the study period. There was a decrease in cases being referred during the COVID-19 pandemic, after which cases increased.

Fig. 2.

Trend in average number of SLT referrals for swallowing and communication per Trust in the general population and >40 years between 2018 and 2022. a SLT referrals in all ages. b SLT referrals in ages 40 and above. Swallowing impairment was the predominant reason for SLT referral throughout the study period. There was a decrease in cases being referred during the COVID-19 pandemic, after which cases increased.

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Table 2.

Trend in referrals of patients aged 40 and above

All20182019202020212022
All referrals of ages 40 and above 29,391 5,676 5,517 4,889 5,516 7,793 
Primary TOMs: dysphagia, % 70.2 71.0 69.9 66.5 71.8 71.3 
All20182019202020212022
All referrals of ages 40 and above 29,391 5,676 5,517 4,889 5,516 7,793 
Primary TOMs: dysphagia, % 70.2 71.0 69.9 66.5 71.8 71.3 

IQR, interquartile range; TOM, Therapy Outcome Measure; Primary TOM, Primary TOMs scale used.

Next, we analysed the subgroup of patients aged 40 years old and above, with a primary diagnosis of stroke. The number of referrals of these patients showed a similar trend of dipping during the pandemic and rising again towards pre-COVID levels. In those referred for dysphagia, there appears to be a large increase of those with an initially severe impairment, though the mildly impaired and normal swallow groups have showed an increase over the years (Table 3; Fig. 3). Importantly, less than 5% of referrals were assessed as having a “normal swallow” when first seen by the SLT (Table 3).

Table 3.

Characteristics of stroke patients 40 and above

20182019202020212022
Number of referrals, n 1,311 1,126 560 907 1,350 
Primary TOMs: dysphagia, n 528 507 210 397 581 
Primary TOMs: dysphagia, % 40.3 45.0 35.9 43.8 43.0 
Impairment at referrala of patients referred for dysphagia 
 Severe (0–1.5), % 25.0 17.8 16.9 25.5 31.0 
 Moderate (2.0–3.0), % 46.8 42.6 33.8 37.4 36.3 
 Mild (3.5–4.5), % 25.6 35.3 45.3 34.8 28.9 
 Normal swallow (5.0), % 2.7 4.3 4.0 2.3 3.7 
20182019202020212022
Number of referrals, n 1,311 1,126 560 907 1,350 
Primary TOMs: dysphagia, n 528 507 210 397 581 
Primary TOMs: dysphagia, % 40.3 45.0 35.9 43.8 43.0 
Impairment at referrala of patients referred for dysphagia 
 Severe (0–1.5), % 25.0 17.8 16.9 25.5 31.0 
 Moderate (2.0–3.0), % 46.8 42.6 33.8 37.4 36.3 
 Mild (3.5–4.5), % 25.6 35.3 45.3 34.8 28.9 
 Normal swallow (5.0), % 2.7 4.3 4.0 2.3 3.7 

aImpairment at referral: TOMs score of impairment at initial rating date.

Fig. 3.

Trend in severity of TOMS impairment at referral in stroke patients referred for swallowing impairment. The initial severity of impairment in patients with stroke referred to SLT for swallowing impairment appears to have increased over the study period.

Fig. 3.

Trend in severity of TOMS impairment at referral in stroke patients referred for swallowing impairment. The initial severity of impairment in patients with stroke referred to SLT for swallowing impairment appears to have increased over the study period.

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The trend in swallowing versus communication referrals in ages 40 years and above with a diagnosis of stroke is shown in Figure 4. While swallowing impairment was the most common reason for an SLT referral in 2018–2019, communication was the dominant reason for referral from 2020 onwards. After 2021, referrals for swallowing returned to pre-pandemic levels but a notable finding was that referrals for communication continued to increase beyond that of pre-pandemic levels.

Fig. 4.

Trend in number of swallowing/communication referrals in ages 40 and above, with a primary diagnosis of stroke. The predominant reason for referral to SLT in patients with stroke was swallowing impairment in 2018–2019, but it has changed to communication impairment from 2020.

Fig. 4.

Trend in number of swallowing/communication referrals in ages 40 and above, with a primary diagnosis of stroke. The predominant reason for referral to SLT in patients with stroke was swallowing impairment in 2018–2019, but it has changed to communication impairment from 2020.

Close modal

This ROOTs database study showed a U-shaped decrease and recovery in SLT referrals in relation to the COVID-19 pandemic, while there was a recent increase in time on caseload which may be associated with increased evidence and related guidance regarding the positive impact of prolonged SLT intervention on patient outcomes [9]. In the stroke subgroup, the ratio of referrals related to communication disorders is now higher than swallowing impairment, since 2020. Points for discussion arise from these trends.

Changes in Referral Patterns to SLT over Time

The general stability of the number of cases referred (aside from during the COVID-19 pandemic) and age/sex distribution shows the reliability of these data. The decrease in referrals during the pandemic is similar to other reports [12] and in occupational therapy [11]. The particular change in referrals to SLTs may be due to a number of reasons including a difficulty in performing swallowing interventions (which are often aerosol generating procedures) in an attempt to avoid the spread of infection, and changes in criteria for admission to hospital for stroke and other conditions to make room for COVID-19 admissions [14, 26]. This dip in the number of referrals may have been less pronounced in those aged 40 years old or above due to there being an increase in hospital admissions of the older population related to COVID-19, the nature of how patients were affected by COVID-10 in terms of respiration and dysphagia, in addition to workforce issues.

Increased time on caseload i.e., between referral and discharge may be due to multiple reasons including the possible increase in the complexity of care due to comorbidities, increased treatment/rehabilitation options, increasing evidence for longer duration of rehabilitation [27] particularly in SLTs compared to physiotherapy and occupational therapy [28], changes in referral patterns (possibly more community/non-acute referrals), and changes in criteria for “discharging” from caseload.

Changes in Swallowing and Communication Ratio

As expected, swallowing impairments dominated the reason for referral to SLTs in the overall population. However, in patients 40 years old and above diagnosed with stroke, referrals for communication impairments are increasing over the past few years. A possible reason for this shift may be increased awareness of communication impairment in stroke and the increased evidence of the benefits of early referral on improved outcome [27]. The introduction of the Sentinel Stroke National Audit Programme (SSNAP) may also have contributed to increased awareness by bringing forth systematic changes in screening and identification methods which are now being used regularly on stroke units.

A further consideration when comparing stroke referrals against other diagnoses in the UK is the Sentinel Stroke National Audit Programme which measures the quality and organisation of stroke care in the NHS [29]. For the targets to be achieved, the resourcing on specialist stroke services is significantly greater than general acute wards. The National Clinical Guideline for Stroke outlines 0.5 whole time equivalent SLTs to 5 beds (acute and rehabilitation wards). Although staffing levels still vary across stroke units, it is likely that they are better staffed to respond to communication and swallowing referrals in a more timely manner than when compared to stroke patients situated in general acute wards [9].

Study Implications

These results have clinical and academic implications. In clinical practice, it is useful to keep real-world evidence and large data in mind when considering trust protocols and recommendations on referrals to the SLT service. Comparison of local data with the national data may help guide appropriate distribution of SLTs within a service. An increase in time on caseload required for better outcomes and growth of those with more severe health conditions has workforce implications with a greater requirement for SLTs in acute hospitals. A further study implication is the importance of continuing to increase the awareness of the public and healthcare workforce about communication and swallowing needs and to work with those who refer patients to improve referral rates of appropriate patients. An interesting positive finding is that among the swallow referrals, less than 5% had a “normal swallow,” implying that the screening process in referring to SLTs is effective. These data highlights the value of the ROOTs database, and the need for services to contribute to such clinical databases. This real-world data indicates the value for studies to extend over longer periods of time, in order to identify changes over time and make evidence-based predictions and workforce analysis on changes that may occur.

This up-to-date data will also be crucial in reforming the education and training curriculums of SLTs. Real-world data is important when reviewing work demands and current service provision which should inform the needed staff competencies. Currently SLTs are appropriately prepared to assess, diagnose and determine the management of those with acquired communication deficits on graduation. Swallowing impairment has become an increasing part of SLTs profession for over 30 years, and there is an awareness towards increasing undergraduate dysphagia training [30]. However, not all universities prepare SLTs to the same level of proficiency for the management of patients with acquired dysphagia necessitating further postgraduate training. This gap in what is needed in clinical practice and what is taught or detailed in guidelines, has been reported internationally [31‒35].

Another clear learning point from this study is that SLTs must understand the importance of maintaining the integrity of data that they are recording and should make every effort to record as many data fields as possible (including important core data such as age and gender) so that as much data can be included in analyses to inform health policies and education.

Strengths and Limitations

There were several limitations associated with this study, mainly due to its nature as a retrospective database study. First, there was a high amount of missing data, reducing the final numbers. Secondly, results must be interpreted with caution as variables unknown to us may have affected how each service records their cases. Additionally, participating Trusts have increased over the years, and while we have designed the study so the effects of these changes are minimal, they cannot be ignored. Data on severity of impairment, in particular, warrants further investigation and statistical analysis. It must also be mentioned that less than 20% of the NHS Trusts took part in ROOT at the time of this study.

However, to our knowledge, this is the first study to provide real-world data facilitating consideration of the optimal distribution of SLT resources workforce and time-appropriate education and training for SLTs. This study included a large number of real-world data across the UK NHS Trusts, over a critical period before, during and after the COVID-19 pandemic where staff allocations and referral patterns tended to change. It would be beneficial to repeat this study in the future to continue monitoring and contributing to health policies and education curriculum. The data would also benefit from further statistical analyses to assess changes over time, differences across Trusts and changes in severity in more detail. It is also important to consider referrals that may not have happened due to a lack of awareness, particularly considering the lack of increase in referrals in an increasingly ageing society. This topic warrants further research into data that cannot be attained from the ROOT database alone. Investigating trends in referrals to other professions during a similar timeframe before, during and after the pandemic would also be valuable.

Real-world data implies that the needs for SLTs are changing over the years to include more complex and severe patients requiring more time for therapy, with a demand in both swallowing and communication impairments. These results will benefit staff allocation and remodelling of education/training of SLTs to better accommodate clinical and public health needs.

The protocol was reviewed and approved by the RCSLT Governance Committee on June 22, 2023. Ethical approval and written informed consent were deemed unnecessary by the RCSLT Governance Committee due to there being no identifiable information on the database and due to the retrospective nature of the study.

The authors have no competing interests to declare.

Yuki Yoshimatsu is supported by The Japanese Respiratory Society Fellowship Grant. The funder had no role in the design, data collection, data analysis, and reporting of this study. The authors received no other financial support for the research, authorship and publication of this article.

P.M.E. had the conception of the work and all authors contributed to the study design. Y.Y. analysed and interpreted the data and wrote the first draft of the manuscript, and P.M.E., D.H., and D.G.S. critically reviewed and edited the manuscript. All authors approved the final version for submission. All authors are in agreement to be accountable for all aspects of the work.

All data are applicable in the paper. Further enquiries can be directed to the corresponding author.

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