What is prioritisation?

Prioritisation: the paediatric caseload

Prioritisation is about deciding who you are going to provide assessment and intervention to first. This may mean that you see clients who have only been waiting a short time before other clients who have been waiting longer. Understandably this can be frustrating for clients and carers, and you therefore need to have a sound rationale to justify your prioritisation decisions. 

There are a number of factors to consider when prioritising your case load, which include:

• Legal requirements
• Contractual obligations
• Presence and level of clinical risk
• Timing
• Predicted outcomes in current context

Below is an explanation of the each of the above five headings, with suggested questions to help explore them further.

Legal requirements in the context of speech and language therapy are specific and legally enforceable details of what input an individual must receive.

• Is the child subject to a child protection plan detailing the necessary care and provisions required to protect them from harm?
• Does the individual have an education, health and care plan (EHCP) detailing the speech and language input required?

Contractual obligations in the context of speech and language therapy relate to the provision expected according to the agreement between the commissioner/s and the speech and language therapy service.  

• Is your service commissioned to provide speech and language therapy to the individual in question?  (E.g. a service level agreement between a school and a specific speech and language therapy service may specify that SLTs only provide assessment (and not intervention) to children without an EHCP.)

Clinical risk is the foreseeable physical, psychological or functional harm that can be reduced by SLT.

• What are the individual’s needs and are they needs that are best addressed by SLT or by an alternative service? (e.g. the child’s attention and listening difficulties are associated with sensory difficulties rather than language difficulties, for which  OT support may be more appropriate)
• If SLT is required and it is not provided, what is the likely harm to that individual? E.g.
  • Physical (increased impairment): The child whose swallowing needs are not addressed is at risk of dehydration and malnutrition.
  • Psychological (decreased wellbeing): The child who cannot talk about past events risks becoming socially isolated and unhappy.
  • Functional (increased disability/decreased access): The child who cannot understand basic instructions is at risk of missing out on educational opportunities.

The presence and level of clinical risk varies from client to client, and two children who present with seemingly very similar SLCN may have very different levels of clinical risk. For example, one child might attend a school that has already had training on how to support children with SLCN, which mitigates their risk. Another child might have a highly anxious parent who prevents the child from attending social events to avoid embarrassment, which impacts on the child’s wellbeing. 

Timing refers to a medical emergency, significant life events and the optimal time for intervention.

• Is the individual facing a rapidly deteriorating condition which requires immediate intervention? (e.g. a child with a recent head injury which is impacting on their swallowing and needs immediate intervention)
• Is the individual about to transition from one environment to another? (e.g. reception to year 1, primary to secondary school, college to employment)
• Are there other factors which need to be considered/addressed before speech and language therapy would be effective (e.g. does the child require grommets, or their teeth to grow in before starting speech work)

Predicted outcomes in the current context considers additional factors which might impact on the individual being able to access intervention and make progress at the current time.

• Does the individual or their carer/s want to engage with the intervention? Will they attend the sessions and carry out the work as is necessary for progress to occur?
• Is speech and language therapy a priority for the individual and/or their family at the current time? Do they have additional and more pressing concerns e.g. is a family member unwell and the family are focusing on them? Is the individual known to a number of professionals and the family are more concerned about other health needs? Have the family experienced a recent change in circumstances e.g. new baby, housing crisis etc. which is more of a priority for them?
• What has been the individual’s previous response to intervention? (e.g. if they responded well before, would it be beneficial to prioritise them for another block of intervention in the hope that it might be possible to discharge them? If they didn’t respond well would they benefit from alternative intervention (e.g. whole school approach) or do they need to be at a more advanced developmental stage to access the necessary intervention (see timing above)?

Information taken and adapted from:

RCSLT guidance - see website

Anderson, C., & Van Der Gaag, A. (Eds.) (2005) Speech and Language Therapy: Issues in Professional Practice. Whurr Publishers Ltd. London