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Pamela Enderby On Therapy Outcomes, Leadership, And Professional Scopes Of Practice

Image credit: RCSLT

Pamela Enderby, Emeritus Professor of Community Rehabilitation at the University of Sheffield, is a pioneering and distinguished speech and language therapist who has dedicated over 40 years to therapy focused research, particularly in outcome measurements. Her academic journey includes mentoring 30 doctoral candidates, leading 40 research initiatives, and contributing to scientific literature with 14 books and over 250 articles.

She founded The Bristol Speech and Language Therapy Research Unit (BSLTRU), which continues to conduct research and development aiming to improve the care and management of people with speech, language and communication disorders. Pamela has also held leadership positions in various professional bodies, including the Royal College of Speech and Language Therapists; currently, she is Past President of the International Association of Communication Sciences and Disorders (IALP).

In 1986, Pamela spearheaded a legal battle for equal pay within her field, contrasting the significant pay discrepancy of female-dominated health service roles in the National Health Service (NHS) like senior speech therapists against male-dominated counterparts. Her 15-year pursuit culminated in a systemic pay review, significantly impacting women’s compensation in health service roles.

Pamela’s distinguished career has earned her numerous accolades, including the Jacque Parisot Medal, two honorary Doctorates of Science, the Tavistock Award for Aphasia, and recognition from the Society for Research in Rehabilitation, The British Society of Rehabilitation Medicine and the Stroke Association. Her contributions were officially honoured with an MBE in 1984 and an OBE in 2018.

We are very pleased that Pam was able to join us for a chat about her career and her ongoing work contributing to the implementation of therapy outcome measures for numerous healthcare professions across the NHS.

Could you talk about the early days of your career, and your initial forays into research?

One of my very first jobs was in the first stroke unit within the UK, it was an acute and rehabilitation unit. Before that time, there had not been such specialist services for patients with stroke, so I was very lucky to be recruited. I worked with colleagues who were keen on looking at, ‘well, we’ve never done this before. So what evidence is there that we’re going to do better’. And they kept on looking at me and saying, ‘what’s speech therapy got to offer?’

At that time, decades ago, we had very little research to underpin what we were doing, so my first emphasis was, ‘how do we actually know what the patients have, with regard to aphasia, the severity of it, the nature of it’—if we can’t describe that, we can’t then see whether it changes over time.

It was  a clinically driven requirement to get more information on the patients that we were seeing in a more objective fashion, so that I could discuss it with the multidisciplinary team in a more concrete and objective manner than just giving them a vague description.

I had the opportunity to do my master’s and my PhD which, of course, really give you the skills to conduct measurement, which was essential. I had never thought  I was a person that was particularly fascinated by numbers and statistics. But it was then that I became interested in numbers and statistics and the value they brought to clinical practice.

 There was nothing ‘quick and easy’ which could be done not just by speech and language therapists, but by others.

So we developed and standardised an aphasia screening test, which is called the Frenchay Aphasia Screening Test, that could be done by a broad range of disciplines to look at the types and severities of aphasia. That allowed us to really say that if the speech therapist wasn’t in, because at that time they were often part timers, that other people could take the case forward—and that’s led to the real interest I have in making sure that we can work and be able to gather information as a team which, I believe, facilitates team cohesion.

So often the professions are very keen on keeping their professionalism sacrosanct, rather than trying to knit it together with others around the patient. A lot of the things that come out: that only a physio can do, or only a speech therapist can do, or only a nurse can do, or only a doctor can do—and yes, there are parts of their jobs where that’s right—but there’s an awful lot that’s generic, where we should be sharing and facilitating that team work, rather than working in parallel.

Let’s talk about your current work at the University of Sheffield

I’m emeritus (retired) now, but I’ve still remained very actively engaged, and one of the things that has really occupied my mind for the last 35-odd years is outcome measurement, for all the disciplines working together.

We’ve now got to a point where speech and language therapists have a national database to collect outcomes in a particular way, called the Therapy Outcome Measures (TOM), and we have data on a national database held by RCSLT (ROOT) of more than 80,000 people who have received speech and language therapy in the UK; I know that physios and OTs and others also use TOM, but unfortunately they haven’t, as yet, got a national database.

But what’s fascinating is that in the UK we have the National Health Service, which is meant to give equal access and equal treatment to all in the UK. But by gathering national data, we actually find  that there is a lot of variation, and we are learning a lot about how to deal with positive deviance—services that do better—as compared to negative deviance—services that do less well—just by gathering everyday information. This is the value of real world evidence.

That’s exciting because most research in all of the allied professions are on specific conditions with quite small cohorts of clients, and they exclude 90% of the people who have perhaps more than one condition—complex clients are rarely included in research. So having data on everybody we see gives us a much better picture of what’s really going on. For example, in some places, you have to have a much more severe speech, language or physical problem to be referred to therapy as compared to another part of the country, and that may be to do with the bias or knowledge of the referrer or resources. If we don’t get data on this, we will never know that there are these sorts of anomalies in service provision.

Let’s talk about your equal pay activism in the 1980s

It was between three different professions really. I was comparing speech and language therapy, 98% female, with psychology that was about 80% male at that time, and pharmacy which was 90% male—it took fifteen years to go from beginning to end of this case.

We had to go through different review processes, and then it ended up in the EU in Strasburg. …Which was a fascinating experience in its own right, because of all the interpreters—you’d want to listen to the Italian interpreter because she had so much passion, so much more convincing than all the others!

We had to go through a lot of reviews of what we did in our week.  I was terribly lucky to have good colleagues who were Heads of Department of Pharmacy and Psychology, and who allowed people to traipse around and look at the meetings they went to and their professional  judgments, etc. In a lot of places I think the friendship would have broken down, if you were saying ‘please do all this for me and for my profession’, so I always take my hat off to them.

In previous decades speech and language therapy had developed as an occupation for ladies doing good work and to earn pin money, and the career structure never moved on into ‘this is a profession, and needs professional pay’. Whereas pharmacy and psychology, having started as more male orientated professions, had those career structures. So it took a lot of time, it took a lot of effort on the part of people other than myself—it was the right thing to do, we needed a career structure and, in the end, it affected the grading system for the NHS, and influenced physiotherapy and occupational therapy as well.

There are still some problems even now with career structures, but it was a big step in the right direction.

I could write a book about just the involvement in an equal pay case; the taxi driver wouldn’t take me to the court because he didn’t believe in equal pay for women, I was chucked out of his taxi! He was coming down to the court and there were a lot of women outside with placards and he said ‘what’s all that about? You’re going for that?’ I said ‘it’s about equal pay for women.’ And he said, ‘you can get out here’.

What does leadership in allied health mean to you?

Leadership is not management; both are terribly important.

I think management is making sure that the administrative aspects are correct, all the issues to do with personnel, support, etc. Leadership is having some vision, motivating people to look to that vision, and encouraging individuals to develop themselves but in line with the vision for the service.

I think sometimes we forget that people who are employed—whether it’s a private company or a public funded company—they are employed by people who have a purpose, and they want that purpose to be shared and worked towards. So coming along and thinking, ‘I just want to develop my career’ isn’t sufficient. You have to actually think, what does the employer, who’s paying me good money, also want from me? And how can my career align with that?’ Now, one of the issues, is that our training doesn’t necessarily align with what employers want and need.

For example, we may be doing a good job regarding the education on communication disorders in our undergraduate training, as you would expect—but a lot of employers are wanting newly qualified speech and language therapists to also be able to cover clients with swallowing disorders, and yet that is not necessarily covered in all our training programs. We constantly should be looking at, ‘what do patients require, what does evidence tell us we need to be doing? Do the employers know about this? How can we do better? And how can we work with employers and patients to get an appropriate service?’

So again, it requires communication between an employer, the leader, the manager and the team but keeping the needs of the patient at the heart. I would say that it’s [within those] five levels, that sometimes there is a breakdown. Sometimes the leader and the employer don’t really align their views. Sometimes it’s the leader and  manager who may not align their views—we all have different views, but if we can get all that together, we’re really on the winning team.”

What advice would you have for clinicians who are contemplating a career in research?

What lights your fire is terribly important—what are you really interested in?

Because research is (you’ve probably heard this so often), 99% perspiration and 1% inspiration. You’ve got to be inspired, and well-motivated, in order to do the graft. So the important thing is to really be interested in what you want to do and take forward. ‘Why do you think it’s necessary? What is your viewpoint?’

Some of the work that I’m doing now—and why I’m actually still working—is work that started 40 years ago, but it’s just beginning to pay off. Getting this database set up in the Royal College has taken a lot of time of a lot of people to build up, to get the data, but now we’re seeing some patterns of data that can really make a difference to the way that we provide speech and language therapy, and to interdisciplinary teams working. The awful thing with this database is I have disproved a lot of my heartfelt theories. How bad is that at my age? I’ve had these long-term theories, and now they’re being disproved. That’s dreadful!

There is a scope of practice review currently underway in Australia—is there an equivalent discussion or dialogue around scope of practice in the UK?

Yes, there is, and particularly between nursing, medicine, and some allied health and consultant allied health professionals. I think what we miss out is the change in technologies that support professions, so that some things that could only be done if you were trained, now can be done with less training because of technological advances.

The other thing is, it’s very easy to look at keeping your profession beautifully ring fenced, rather than what does the patient need. I think there’s an awful lot of generic work that could be interdisciplinary, but that means we’ve got to have more interdisciplinary training.

I think we ought to be looking at trained assistants and trained carers, generic carers, particularly in rehabilitation. It’s extraordinary to me that some of the basic rules in speech therapy are not used by speech therapists, let alone other members of the profession. For example, you don’t have to be trained that much to say, ‘do not give a drink to a patient after a stroke when they’re lying down’. That is such a given, you would think, and yet it’s still not done, because it is not an agreed shared rule.

There are so many bits and pieces within each of the professions that are very basic, but are still not shared and not done—because we’re so enamoured with the high tech, the unusual, the unique thing, rather than looking at ‘what’s the foundation of good basic care?’ We really need to look at this from a patient perspective and from a whole rehabilitation perspective, rather than each profession’s perspective.

One of the examples would be that in some of the courses, there are people who are employed to teach specialist topics, but actually that specialist topic is no longer so central to practice but that lecturer is employed and hasn’t moved their teaching on. So how do you change the course in that area? You can’t just say, ‘well, bad luck, you’re out of date go away’. How do you actually move the training on into more modern forms of training which perhaps includes modules on, for example, ‘how does technology assist you with this?’; learning how to use different artificial intelligence techniques; different technological approaches; different diagnostic equipment which are now required.

What are your thoughts on COVID being an inadvertent catalyst for innovation in health care?

We did a lot of work during COVID, and what’s fascinating is that there were such benefits as well as dis-benefits in that time. The benefits were, for example, people became much more comfortable with Zoom/virtual online meetings which could be held more regularly facilitating case and professional outcomes.

We learned to incorporate such technology in different rehabilitation programs. About 15 years ago, it was shown with very sound research that providing computerised therapy to aphasic patients following stroke to support their face-to-face therapy was efficacious and improved outcomes. It also proved that a majority of patients liked using computer therapy for aphasia, and went on doing it even after their face-to-face therapy was completed. They enjoyed the challenge of it, they enjoyed the ability to see that they were progressing, et cetera. And yet we hadn’t adopted it broadly until COVID came along.

COVID meant that therapists began to adopt newer technological approaches in practice. There were other things, to do with screening and providing advice, that we only adopted, despite the fact that they had been shown to be very efficacious whether it was on computer or by telephone, that had not been adopted until COVID came along; now these are more frequently embraced by people working in the allied health professions. Yes, there are always going to be some groups where you have to see patients, but that mixture of face-to-face and computerised therapy, I think has really moved on.

We reviewed the national database ROOT to look at what the outcomes were like before COVID, and what the outcomes were like during and after COVID. We were able to get some very strong data to demonstrate to the government that far fewer children were being referred to speech therapy during COVID, because health visitors weren’t going out et cetera, and that allowed quite a lot of services to get extra resources for ‘catch-up’. Now, without having that national database to really show its impact on referral patterns, we could not have gone to our local governments and national governments to say, ‘we need catch-up money’.

That was, again, a plus to demonstrate to people that we need national data on: who’s being referred to speech and language therapy; what are they like; what are their conditions; how do they change over time? Another example: we see a lot of people at the end of life and people think, ‘why would you get outcome measures on people at the end of life?’ Well, you do need it, because you want to see whether you do actually maintain some degree of quality of life for as long as you can, in the deterioration of their condition: can you maintain communication for longer; can you improve the wellbeing of the family, all very important considerations.

Until we can get basic information on what we’re doing now, in addition to research, we will be unclear regarding context. We need to know what we’re doing NOW!


Find out more about Therapy Outcome Measures | Follow Pamela on LinkedIn | We host a number of career forums and communities of practice that provide discussion around career pathways for allied health professionals. Please visit the Allied Health Academy to find out more. 

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