The impact of the Covid-19 virus changed the way the Outpatient Voice Therapy service operated. Since April 2020, the service has significantly reduced face-to-face (F2F) appointments, which were the service’s primary mode of delivering treatment prior to the pandemic.

The primary method of delivering therapy has been via telephone and/or video consultation out of necessity, with a significant reduction in the number of outpatient clinics which are available for therapists to use. (Please see Appendix A for an outline of the therapy modes that are possible in this format).

Where remote appointments are not suitable or if progress is not being made via remote therapy, a F2F appointment will be offered (currently at either Fleet Community Hospital or Wexham Park Hospitals). (See Appendix B for a list of patient groups where remote therapy is not appropriate).

1.1 Referrals for the treatment of dysphonia and upper airway disorders are made by referral letter (via the medical records system - Epic) or via email (then uploaded into Epic). Referrals come from the following sources:

• An ENT consultant, associate specialist or registrar.

• A GP following a prior ENT assessment (within 6 months).

• An ENT Consultant working for the Slough Outpatient Service team (SOPS clinic)

• A GPwSI (GP with Special Interest) in ENT.

1.2 Referrals for treatment of patients with a chronic cough and upper airway disorder can be made by a respiratory consultant without an ENT assessment, or an AHP working with respiratory disorders or long Covid providing the patient has access to the care of a respiratory consultant.

1.3 Referrals will be accepted for adults and children over the age of 7 years old. Advice may be provided for under this age.

1.4 Referrals must contain adequate diagnostic information to allow an appropriate course of therapy before they can be accepted.

1.5 If a referral is rejected (if it is deemed inappropriate or unsuitable), this will be communicated typically via Epic or email, depending on whether the referral is external to the Trust.

Please Note All patients must have an ENT or Respiratory assessment before referrals can be accepted. Requests for second opinions from other SLTs will be accepted if they already have a referral from a doctor. Internal referrals will only be accepted via an order raised on the EPIC online medical records system. External referrals will be triaged by the voice therapists and uploaded into EPIC by the booking team. Referrals will not be accepted if they are direct from GP without any ENT/Respiratory assessment or other specialities.

2.1 On receipt of referral, patients will be triaged onto the waiting list by the Voice/Upper Airway team. The outpatient booking team will contact the patient to arrange an appointment (see Appendix C Booking Routine Referrals Pathway).

2.2 Urgent referrals will be contacted via telephone directly by the booking team or therapist depending on whether a remote or F2F appointment is required. We aim to see urgent referrals typically within two weeks of receiving the referral letter.

2.3 Initial appointments will be conducted remotely or f2f depending on need. Patients will be offered a telephone or video consultation, unless they meet the criteria set out in Appendix B.

2.4 The treating SLT will use a variety of methods of therapy and will use clinical judgement to determine if a patient requires a F2F appointment, in accordance with the specifications laid out in Appendix B.

2.5 Video appointments are currently being conducted using Microsoft Teams via EPIC.

2.6 The therapists arrange all follow up appointments with new appointments being booked by the booking team.

3.1 If a patient misses a remote or F2F appointment, the treating clinician should use their clinical judgement as to whether to apply the Trust’s policy of discharge on non-attendance, or to contact the patient and offer another appointment. This contact may be in the form of a phone call, email or DNA/RTB letter to the patient.

3.2 If a patient cancels two consecutive appointments (remote or F2F), the discharge policy should be applied unless in exceptional circumstances, as judged by the treating SLT.

3.3 The policy for missed appointments and cancellations will be communicated to the patient verbally at the start of therapy, it is also re-iterated on appointment letters.

4.1 During the initial phone conversation to book an appointment, the booking team will explain the process for remote appointments and consent to progress with therapy will be obtained.

4.2 Email correspondence will not be used for communicating sensitive or confidential information.

4.3 If a patient does not have an email address, or does not consent to its use, then communication will be via post and telephone.

4.4 If a patient does not consent to SLT remote intervention and is unable to attend F2F appointments, this will be recorded in the patient’s medical records, a letter will be written to the referrer, and the patient will be discharged.

5.1 During an initial voice therapy consultation, the treating SLT will complete the following:

• 'Voice Clinical History and Speech and Language Therapy Assessment – Case History’ form on EPIC.

• Voice Handicap Index-10 (VHI-10)

• If clinically relevant: Reflux Symptom Index (RSI) or Vocal Tract Discomfort Scale.

5.2 During an initial cough or upper airway therapy consultation, the treating SLT will complete the following:

• ‘Upper Airway Clinical History and Speech and Language Therapy Assessment – Case History’ form or Cough Clinical History and Speech and Language Therapy Assessment – Remote Appointment’ form and a range of the following if clinically relevant:

• Newcastle Laryngeal Hypersensitivity Questionnaire

• Vocal Tract Discomfort Scale

• Pittsburgh VCD Index

• Reflux Symptom Index (RSI)

5.3 At present, audio recordings of the patient’s voice will not be made, due to the complexity of doing this remotely.

5.4 After assessment, the treating therapist will write an ‘Initial Report’ within EPIC and copies will be sent to the referring ENT doctor, the GP and the patient automatically by the system.

6.1 Treatment format, as far as possible, will not differ from if therapy was being delivered F2F, with the accepted limitations as documented in Appendix A.

6.2 Patient Information Leaflets will be sent to patients by email, or by post if email is not available/consented.

6.3 Therapy videos may be sent to the patient to supplement their treatment.

6.4 Additional written information, directions, etc., can be sent to the patient via email or post.

6.5 At any stage of the agreed treatment programme the treating SLT may seek a second opinion from another SLT, from an ENT consultant, or the Joint Voice Clinic (JVC). Referrals into the JVC can be made via the ENT booking team.

6.6 In cases of a chronic cough a referral to ENT should be made if voice or upper airway problems persist after the cough resolves.

6.7 Any compliant patient who does not make expected progress should be referred back to ENT – either to the referring doctor or to the JVC - using the clinical judgement of the SLT.

7.1 Digital record keeping via Epic was implemented across the Trust in July 2022. All documentation relating to the patient will be recorded in this system.

7.2 Each therapy session will be documented in the patient chart and their outcome recorded with the appropriate RTT status. The session notes are available to view by EPIC users under the ‘Encounters’ tab in the patient chart.

8.1 Patients who do not make contact to book, who do not attend appointments (DNA) or who cancel multiple appointments will be discharged, and their Consultant/GP will be informed by letter.

8.2 Patients will be discharged when it is agreed they have benefitted maximally from SLT at that time, or at their own request.

Effective therapy techniques via telephone/video consultation

There are a number of therapy techniques / advice that can be delivered effectively and easily via telephone or video consultation, with supporting therapy leaflets distributed via email or post. They include:

• Vocal hygiene advice

• Reflux management strategies

• Cough control strategies

• Inducible laryngeal obstruction emergency breathing strategies

• Post-operative vocal health

Therapy that may have limited effectiveness when delivered remotely

There have been variable results when delivering the majority of our therapy techniques with patients thus far, with limitations as to how effective we can be. Observation and adjustment of the patient’s technique is critical to success, and phone/video consultations do not fully substitute face to face contact in this regard, due to reduced quality of sound and the ability to pick up on the subtleties of phonation.

The success of therapy also depends on the patient’s own level of self-awareness, their co-morbidities, language barriers, hearing impairments, mental health issues and prior experience of therapy, all of which are easier to manage face to face. The therapy techniques which may have limited effectiveness when delivered remotely include:

• Vocal exercises (semi-occlusion, oral resonance, twang, SOB, deconstriction, straw phonation, glottal pops)

• Breath support and teaching diaphragmatic breathing

• Postural realignment

• Mindfulness and meditation

• Head, neck and shoulder stretches

• Laryngeal self-massage (only via video)

• Counselling

Therapy which can only be delivered face to face

‘Hands on’ techniques cannot be delivered remotely. The techniques include:

• Laryngeal palpation and massage

• Alexander (semi-supine) technique

• Relaxation techniques

Patients with aphonia or severe hyperfunction

Rationale: Verbal communication over telephone or video may be extremely difficult for these patients, and thus limit the effectiveness of remote assessment/treatment. These voice disorders also constitute the most severe/urgent voice disorders, especially as they may be hindering the patient’s ability to work.

Patients who are hard of hearing

Rationale: Again, verbal communication over telephone or video may be extremely difficult for these patients.

Patients with significant mental health difficulties

Rationale: Voice disorders in this population can be complex and are often intrinsically linked with their mental health. Relaxation and counselling techniques are often a core part of their treatment. For some patients with mental health difficulties, phone or video consultations can exacerbate feelings of anxiety or stress which often serves to increase their levels of dysphonia.

Patients with no/limited English (and no access to translation)

Rationale: Therapy with this patient group often relies on non-verbal communication (i.e., facial and hand gestures) and may be more weighted towards hands on techniques that do not require language, such as laryngeal massage and relaxation techniques.

Patients who do not have access to the internet

Rationale: Patients without internet access and/or the appropriate technology will not be able to access video therapy. These patients are generally elderly and may have hearing impairments making phone consultations difficult.

Patients who have not made progress with remote therapy

Rationale: For some patients, the limitations of delivering therapy remotely may mean that their progress is minimal due to individual patient factors such as self-awareness and self-monitoring. The treating SLT may feel that, in order for the patient’s voice disorder to improve, they require some F2F sessions to deliver therapy more comprehensively.

Referral received and triaged by SLT. If accepted, patient is added to waiting list.

The SLT will determine whether the patient is Urgent/High Priority, or Routine; and whether the patient is for remote or F2F initial assessment.

Urgent patients

Will be contacted by telephone to arrange a telephone, video or F2F appointment.

F2F patients

Will be contacted by telephone to arrange a F2F appointment.

Routine patients

Will be offered a telephone appointment.

During periods when the wait list is long, all patients either contacted by telephone or letter if unable to be reached.

A ring to book letter is sent out during periods when the wait list is short.

Telephone appointment

• Time/date set and recorded in SLT diary

• Preferred phone number taken and documented

• Confirmation letter sent

Video Appointment

• Time/date set and recorded in SLT diary

• Confirmation letter sent

• MS Teams invite sent by email

Face-to-Face appointment

• Time/date set and recorded in SLT diary (in allocated session for F2F)

• Confirmation letter sent

• Instructions for attending F2F appointment sent