Waiting list management: Professionals’ perspectives and innovations

3.1.1 Negative feelings

Most SLTs’ comments described negative feelings about their waiting lists. SLTs described feeling “bad” (28), “frustrated” (4), “anxious” (32), “overwhelmed” (164), “stressed” (250), “concerned” (260), and “embarrassed as a professional” (276) regarding their waiting lists. Most negative responses involved comments about waiting list duration, which SLTs felt was “far too long” (13). SLTs described their waiting lists as “enormous” (119), “horrendous” (16), and “a disgrace, but we can’t speak about it” (10). Negative comments also related to being “understaffed” (172), “system level roadblocks” (4) and “business/money focused” organisations (166), or waiting lists being “poorly managed” (1). SLTs also described experiencing conflict between evidence-based practice and reality as their waiting lists went “against the intention of early intervention” (119) and that “if advocating the benefits of early intervention . . . [I] should be able to ‘walk the talk”’ (276). SLTs described their waiting lists as “unethical” (181), particularly when they had “opened a duty of care to the clients” (220). The negative personal toll of waiting lists on SLTs was highlighted by comments about “feeling stressed. . . because parents become anxious about waiting” (190), or feeling “a sense of having let others down” (260), meaning waiting lists had the “biggest negative impact upon. . . job satisfaction” (260).

Similar negative feelings have previously been reported with regards to SLTs’ management of large caseloads in services with resource constraints, which had negative implications for workforce retention and the care provided to clients (Edgar & Rosa-Lugo, 2007; Kenny & Lincoln, 2012; McLaughlin et al., 2008). Conflict between practice and professional/personal values or ethics has also been found to impact job satisfaction and retention within the workforce (Byng et al., 2002; Lincoln et al., 2014). Key ethical principles guiding SLTs’ practice include beneficence (doing good for others), nonmaleficence (doing no harm), and justice (fair and equitable access to care) (Fletcher et al., 1997). Waiting lists can delay provision of care for clients who would benefit from support, and factors associated with the practice context (e.g., resource limitations, organisational policies) may contribute to service delivery decisions that conflict with best practice recommendations or clients’ needs, for instance, regarding the timing, type, and intensity of intervention (Hoffman et al., 2017). The findings may illustrate the moral and ethical challenges for SLTs posed by a “philosophical conflict between desired and allowable practices” (Byng et al., 2002, p. 90). More must be done to address the constraints facing SLTs in their practice contexts, and support and retain SLTs in the workforce to enhance quality and continuity of care for clients.

3.1.2 Neutral feelings

There were also neutral responses from SLTs about their waiting lists. Some SLTs indicated they had “mixed feelings about the waiting list” (234) or felt their waiting list was “not too bad” (137), “okay” (169), or “adequate” (238). Others felt that although their waiting list “could be better. . . prioritising helps get in more urgent patients” (178). Some SLTs displayed a sense of acceptance that “long waiting lists seem to be the nature of community health” (163) with “no available alternative” (246) and “it is unfortunate to have a waitlist; however, it is necessary” (244). These perspectives are consistent with previous research indicating that health professionals view waiting lists as a “normalized” aspect of health care “culture” (Rittenmeyer et al., 2014, p. 194).

3.1.3 Positive feelings

Some SLTs reported positive feelings, including feeling “generally OK” (26), “fortunate” (184), or “good” (204) about their waiting lists. Most positive responses involved comparisons with waiting lists in other organisations or reflections on how their waiting list had changed over time. For instance, some SLTs described their waiting list as “a big improvement” (212) or “better than it was” (58), while another felt “a shorter waiting list would be better but compared to other public services it isn’t that bad” (182). These perspectives may indicate that some form of waiting list management strategy had been in place within the workplaces. Some SLTs felt their waiting list was “manageable” (251) and felt “proud that we can respond to requests for service in a timely way” (154). Being proactive by “actively working towards NOT having a waiting list” (176) may have provided a more positive perspective for SLTs regarding their waiting lists, perhaps due to feeling like they were doing something to address the issue.

SLTs’ feelings may have reflected caseload size, which can contribute to perceptions of caseload manageability –a construct interconnected to job satisfaction (Katz et al., 2010). SLTs who expressed neutral or positive views may have had smaller caseloads than those who reported negative feelings. Caseloads exceeding 55 clients have been reported by school-based SLTs to be unmanageable (Katz et al., 2010).

3.2.1 SLT service delivery

Many SLTs described existing or aspirational service delivery strategies in their workplaces to manage waiting lists and support those who are waiting for speech and language therapy. SLTs described assessment practices such as screening, intake/triage, single session models, and drop-in services. An SLT emphasised the importance of families receiving a timely assessment, even if they subsequently waited for therapy: “I believe that assessment is the greatest priority. . . Assessments take away parental anxiety when no problems are found. Even if therapy cannot be offered for a long time, processes are ‘in motion’ once an assessment is done” (160). In a recent community-based randomised controlled trial (RCT), provision of an assessment following referral to families on a speech and language therapy waiting list led to similar improvements in child outcomes and caregiver satisfaction to those who received both an assessment and access to an evidence-based speech and language website while waiting (McGill, McLeod, Ivory et al., 2021). However, Ruggero et al. (2012) found that parents were dissatisfied with long waits between assessment and commencing therapy.

SLTs described providing group therapy, intensive therapy programs, and therapy blocks, including “shorter block therapy sessions followed by home program and review” (195). Group therapy was described by many SLTs as a way to “decrease waiting times” (193) by seeing multiple clients at once with “similar needs” (60) and offering “places. . . to children on the wait list” (1), as well as encouraging active waiting by offering “group [therapy] while waiting for individual [therapy]” (255). However, a study by Ruggero et al. (2012) found that most parents preferred one-on-one therapy for their children instead of group therapy and few preferred home programs or parent training. Alternatives to one-on-one therapy were considered acceptable to “fill a gap” (p. 346) rather than replace direct face-to-face support; however, it is possible that greater transparency between SLTs and families regarding service delivery options may alter these perspectives (Ruggero et al., 2012).

SLTs also identified the need for a greater focus on prevention through health promotion or embedding speech and language therapy services within universal services (e.g., nurseries/early childhood education centres, child health services, playgroups), such as having SLTs as “part of mothers’ groups so early fundamental language teaching can be taught” (33). Historically speech and language services have aligned with a rehabilitative framework and services have typically been provided in one-on-one, clinic-based settings with children diagnosed with speech and language disorders (Law et al., 2013). However, there is an increasing awareness of the social and environmental influences on children’s speech and language development, and a growing focus on and need for prevention, health promotion, and whole population approaches (Law et al., 2013). Such approaches may enable SLTs to expand their reach and provide support earlier to greater numbers of children, both with existing speech and language difficulties and those who are at risk.

SLTs also discussed the use of technology in service delivery, such as “using teletherapy to provide services” (43) or as a way of disseminating information and training to families through “webinars” (1), “moderated online support groups” (1), “SMS messages with tips” (237), a “parent coaching app” (232), “a website to direct them to with appropriate strategies” (273), and “online parental videos for support strategies family can use in interim until they are able to seek help” (64), which have shown promise in other research studies (e.g., Wales et al., 2017). Many technology-based strategies were innovative ideas that SLTs aspired to implement in their workplaces, and fewer SLTs were already using such strategies.

SLTs also described collaboration with parents and professionals as a common strategy. Many SLTs reported providing advice and training to parents, with some providing “phone support” (36), “parent training programs” (207) or “one-off advice sessions to families at time of referral” (196) or soon after intake to “provide parent education to support active waiting while on the wait list for an initial assessment” (215). Some SLTs provided home programs, “general information” (103), and “‘harm-free’ resources to parents” (104), which have been implemented by SLTs for many years. Others were not currently offering these supports but suggested ways that services could support families on waiting lists, such as providing “parent friendly resources” (167) for “parents to use during wait times or for mild diagnoses” (165), “[an] accessible website for families to use, including some video clips on how to put these [strategies] into practice at home” (206), an “information package for families or. . . a parent information group to present generic strategies for communication support that could be used while waiting” (182). It was unclear whether the parent education strategies implemented by SLTs involved direct parent training and high doses, which has been recommended for home therapy programs (Tosh et al., 2017). McLeod et al. (2020) conducted an RCT to evaluate provision of three types of support to children aged 3–6 years on a speech and language therapy waiting list: (1) 12 sessions of immediate face-to-face therapy; (2) a tailored advice session; and (3) provision of a purpose-built website containing information and parent-friendly strategies for stimulating children’s speech and language skills. The results indicated that provision of advice sessions or a website to caregivers were not as effective as face-to-face therapy for improving children’s speech production or caregivers’ satisfaction, but there was little difference in outcomes across groups regarding children’s intelligibility, language, and early literacy, and caregivers’ feelings of empowerment (McLeod et al., 2020). A concurrent RCT by McGill, McLeod et al. (2021) compared two waiting list conditions: (1) provision of the same purpose-built website to caregivers; and (2) a control group involving provision of assessments only. The findings indicated that provision of a website was no more effective at improving children’s and caregivers’ outcomes than receiving an assessment only while waiting, suggesting families may require more than a generic website alone while waiting (McGill, McLeod, Ivory et al., 2021).

SLTs suggested “strong links and sharing of knowledge” (65) with other health and education professionals would assist with managing speech and language therapy waiting lists and supporting those on waiting lists through “training of health visitors [regarding] appropriate referrals” (146), training “educators and. . . early childhood providers. . . in providing language rich environments and in strategies for modelling and eliciting language” (123), and implementing “school/preschool based programs” (21). Interprofessional collaborative practice can enhance access to health care and coordination of services, improve clients’ outcomes, and increase clients’ and caregivers’ satisfaction with care (World Health Organization, 2010). Collaboration between professionals, such as in education settings, can have many benefits for children’s communication development (Hadley et al., 2000). For children with disabilities, interprofessional collaborative practice can enhance progress toward goals and provide “more seamless care” (Sylvester et al., 2017, p. 206). However, collaboration can be time consuming and has been associated with SLTs’ perceiving their caseload to be unmanageable (Katz et al., 2010), potentially impacting their work with children and, subsequently, the outcomes of children and families.

Additionally, relying on non-SLTs in service delivery was suggested, including “recruiting AHAs [allied health assistants] to do the bulk of group work” (166) to “allow the SLTs to see the higher priority clients” (166). Speech and language therapy assistants or allied health assistants work with children and families under the supervision and guidance of SLTs, carrying out therapy plans, completing routine-based tasks, or preparing resources and materials (SPA, 2014). Speech and language therapy assistants may assist with reducing SLTs’ workloads and free up time for other non-delegable complex tasks such as assessment and therapy planning; however, training and supervising assistants also takes time and resources (Goldberg et al., 2002).

3.2.2 Workplace processes and policies

The second theme related to workplace processes and policies. SLTs’ responses related to funding, administrative strategies, referral processes, organisational strategies, and evidence-based practice. With regards to funding, many SLTs indicated that “increased funding” (126) would help with management of waiting lists as “funding is the main issue” (229). However, researchers have recommended that provision of additional resources and funding occurs in combination with other initiatives for effective long-term management of waiting lists (Sanmartin et al., 2000). Many comments about funding were linked with the ability to “increase staffing levels” (165) among the SLT workforce. Others described a need for “bulk funding for health promotion/carer training” (129), “primary health care initiatives” (131), and “communication workshops and training” (129) for early childhood education services. Some SLTs made use of alternative funding models to manage their waiting lists, including encouraging families to access government rebates for private services, or making referrals to disability/medical insurance schemes. However, such funding is not available in all countries. In countries where funding and government subsidised sessions are available, not all children are eligible, and children who are eligible often require more than their allocated amount of support to make significant improvements in speech and language (Law & Conti-Ramsden, 2000). Privately-funded services were not an affordable option for many families (McGill et al., 2020).

SLTs also reported implementing administrative strategies such as failure to attend policies, cancellation lists, registration forms, limits on advertising, waiting list audits, and templates for documentation to increase efficiency. Some SLTs used scheduling to manage their waiting lists by “reserving assessment appointments to ensure that new referrals are assessed promptly” (212) “regardless of the number of discharges to ensure throughput of clients” (260), and keeping “a full schedule” to “see as many kids as possible” (241). SLTs also suggested strategic caseload allocation processes could help, including having “allocated teams, within current staffing, to manage each priority level” (237) of clients.

SLTs also described strategies involving referral policies to assist with waiting list management. Some SLTs preferred to “refer excess clients on to others and will not accept clients if they have to wait more than 2-3 weeks” (176) while others referred potentially eligible children to other services to access alternative funding (e.g., disability insurance schemes) as it “is the only way most of these children will access regular and ongoing. . . intervention” (163). Referrals were a way to “assist in starting processes for further assessment” (113) as well as encourage active waiting through linking families with other “adjunct services. . . community-based group programs. . . parent courses and parent support groups” (176) while waiting for speech and language therapy.

Organisational strategies for waiting list management related to both standards and restrictions imposed on services. Some SLTs described having “state mandated timelines” (238) for seeing clients and “strict benchmarks for different ages to be assessed by” (165). Benchmarking is consistent with recommendations from Rvachew and Rafaat (2014). There were many restrictions imposed on the services provided by SLTs, including closing the books, discharge protocols, “strict criteria for acceptance onto waiting lists” (126), and “strict caps on session numbers to help reduce wait times for other clients” (165), which have implications for continuity of care, client satisfaction, and efficacy of interventions (Law & Conti-Ramsden, 2000; Ruggero et al., 2012).

SLTs reported “prioritisation based on outcome evidence” (190) to be an effective waiting list management strategy. Many SLTs used prioritisation to ration the services provided based on factors such as “age, disorder type” (21), “severity, impact on education. . . impact on daily functioning” (225), or “vulnerable” (149) and “disadvantaged groups” (167). Some SLTs described formal prioritisation guidelines in their workplaces such as a “clinical prioritisation tool” (167), while others described “a vague prioritisation policy which is not consistently implemented” (206) and thought that “a clear pathway for prioritisation” (206) with greater “consensus” (187) was needed to help manage waiting lists. Prioritisation of children for services based on child and service factors is consistent with previous research (McCartney, 2000; McGill, McLeod, Crowe et al., 2021; Roulstone, 2007). Prioritisation can be problematic as some children considered low priority may never receive support, despite the ability to benefit from therapy (McCartney, 2000).

SLTs’ responses also commonly related to evidence-based practice. Some SLTs experienced feelings of conflict regarding their current waiting list management strategies as they felt they were “unable to offer best practice” (250) and were “not providing a good service for children” (126) which was “not good for the reputation of the SLT profession” (126). Speech and language therapy should be evidence-based and person-centred in order to promote optimal outcomes for children, which involves integration of evidence from research literature, clinical experience and expertise, client values and preferences, and the practice context (Hoffman et al., 2017). Incongruency between strategies implemented in services and evidence-based practice is consistent with prior studies (Hersh, 2010; Ruggero et al., 2012). Although the practice context is important to consider in professional practice, the SLTs’ responses may highlight a heavily service-centred focus within their workplaces, rather than achieving balance between the constraints of practice contexts and a person-centred focus. SLTs’ responses also suggested a lack of control or autonomy over the decision-making processes regarding some aspects of client care. This could conflict with SLTs’ professional and ethical values, ultimately impacting children’s care (Keane et al., 2012).

Being able to “empower” families “to do proper research” (240) was another innovative solution identified. SLTs suggested “evidence making” (141) through “more research into group service delivery” (149) and the “most effective time to treat particular disorders” (149) would help with waiting list management. SLTs identified a need for “evaluation of ‘while you are waiting’ resources” (129) “that are easy to integrate into home routines” (60). Some SLTs acknowledged that although they were “yet to explore” if the resources provided to families to encourage active waiting have “an impact on the referral condition,” it “allows parents to have heard the information before when I start to introduce it all during the assessment” (192). Development and evaluation of resources and information for supporting children and families on waiting lists were often identified as aspirational solutions rather than strategies the SLTs were already implementing in practice, and are consistent with recent research (McGill & McLeod, 2019; McGill, McLeod, Ivory et al., 2021). People on waiting lists have been found to “long for information” but seldom receive it from health care services (Rittenmeyer et al., 2014, p. 218).

3.2.3 SLT workforce

The third theme identified in SLTs’ responses about waiting list management related to the SLT workforce. SLTs described strategies related to recruitment, stating that more publicly funded SLT positions were “desperately” (119, 164) needed since there are “not enough positions to meet demands” (26). For some workplaces, there had been “no increase in staffing in almost 20 years despite marked growth in population” (164). One SLT described spending “40 years coping with waiting lists” and reported: “There are not enough SLTs in the public health system. Not then; not now. . . So much angst. So much discussion. So many years. Employ more SLTs - that is how we can manage paediatric waiting lists” (160). Despite trying “many strategies”, SLTs reported “the only factor that has helped is when we have had periods of increased staffing, but when this ceases, the waiting lists grow again” (167). Recruiting “casual” SLTs to “conduct additional assessments when the waitlist starts to grow too quickly” (224) was reportedly effective in some workplaces. SLTs described the need for not only increased numbers of SLTs and positions, but for recruitment and retention of “skilled” (131), “well-trained” (39) SLTs “with experience” (225). Whilst many SLTs suggested recruitment and retention of SLTs were key waiting list management solutions, few identified specific strategies to recruit and retain skilled SLTs in the workforce such as “more training” (127) and “ongoing professional development opportunities” (184). The shortage of SLTs and other health professionals is a well-documented issue impacting children’s access to services (Keane et al., 2012; Lincoln et al., 2014).

Traditionally, speech and language therapy services for children have been provided on weekdays and most often within clinics. However, flexibility of the SLT was another waiting list management strategy identified by SLTs, which included “being flexible with work hours” (102), “scheduling options” (251), and “location options for service delivery” (176). Increased flexibility of service delivery, including location and session times, was one of the most common suggestions from parents for improving speech and language therapy services (Ruggero et al., 2012).

Increasing managerial support for the SLT workforce was identified as an aspirational idea which would help manage waiting lists, as “the worst examples of large waiting lists. . . are where there is chronic understaffing, appalling management support. . . and unreasonable workloads” leading to “subsequent staff retention issues” (184). SLTs who felt “overworked, overwhelmed and unsupported” with “little time or energy for inspirational ideas” just kept “continuing on with mostly the same processes and programs”, rather than feeling supported to implement innovative actions to manage their waiting lists (250). Employees require a positive workplace environment in order to “flourish” and be innovative, which includes managerial support, provision of resources, enhanced autonomy, and reduced workloads (Colligan & Higgins, 2006, p. 95).

Changes to SLT higher education were also suggested to help manage waiting lists. These included an “increase” in “the number of spaces in graduate programs” (227), and having a “better understanding of workforce need” (40) by teaching “aspects of managing a caseload, prioritisation and how to explain these to others” (270) as well as “service delivery models. . . taking into consideration telehealth” (270). SLTs also described implementing “university clinics and groups” (260) and having SLT students “carry out assessments” (21) to manage waiting lists. Involving students in the workplace may enable larger numbers of children to be seen or facilitate greater therapy doses for children already on SLT caseloads.

3.2.4 Inaction

Some SLTs described inaction or passive strategies regarding waiting lists, although this was less common among the respondents. One SLT attributed their inaction to being “just a casual” and “I turn up, see the clients, and leave” (1). Some described facing challenges or barriers in their workplaces preventing them from taking action, including having “not enough staff” (227) and “little time or energy” (250), finding it “too difficult to set aside enough time” (21), or because actions were “not billable services” (42). Another challenge was incomplete or unclear referrals, and since “each child has individual needs and not all strategies are appropriate for every child” (236) it can be “difficult to provide ‘blanket’ strategies for parents” (236). SLTs also described a lack of control leading to their inaction. Some SLTs reported their waiting lists were “out of my hands” (62) and “entirely in the hands of managers” (181). Other challenges were blocks to collaboration with other organisations at a “systems level” (133) which were “quite depressing” (133) or restrictions on service delivery, including how telehealth was “not yet allowed at our facility” (221). A lack of control and autonomy in the workplace can lead to distress, whilst the ability to influence and contribute meaningfully to decisions in the workplace has been found to reduce work stress, improve performance, and enhance job satisfaction (Colligan & Higgins, 2006).