RCSLT - Royal College of Speech and Language Therapists

Health inequalities and their impact on speech and language therapy

April 11, 2022 The Royal College of Speech and Language Therapists Season 4 Episode 6
RCSLT - Royal College of Speech and Language Therapists
Health inequalities and their impact on speech and language therapy
Show Notes Transcript

In this episode we explore the complex topic of health inequalities which are being exacerbated by the pandemic and cost of living crisis. We discuss the social and economic impacts as well as some ideas about how these inequalities can be addressed. 

Interviewees:

  • Michelle Morris, Consultant Speech & Language Therapist 
    SRO, Greater Manchester Early Years Pathway for Speech, Language & Communication.
  • Sahar Nashir, specialist speech and language therapist - CCPNR (Cambridge Centre for Paediatric Neuropsychological Rehabilitation)
  • Berenice Napier, Policy Adviser, The Royal College of Speech and Language Therapists


Useful links from RCSLT:


The interview was produced by Jacques Strauss, freelance digital producer.



Welcome to another RRCs LT podcast. My name is Jacque Straus. For today's episode, we've assembled a panel to talk about health inequalities, which is a pressing topic. As one of the panelists pointed out, even though in the UK we are very lucky to have a publicly funded world class health system that is free at the point of use, that does not mean we do not have significant health inequalities. The NHS may treat us when we are sick, but that doesn't equate to health. There are a number of complex factors at play, including income and education. This is exacerbated by the cost of living crisis, and of course, the ongoing impact of the pandemic. We now have a large cohort of children who have missed out on education, not at the same language exposure they would've had, or for some SLT interventions and so forth. And many of these children may well need additional care in the future. We have something of a perfect storm on our hands. So in this podcast, we'll be looking at the issue and what we can do to mitigate some of the impacts, including a new tool that rcs l t has made available. I started by asking the panel to introduce themselves. Um, I'm Michelle LA and I'm a consultant speech and language therapist, and my consultant role is in population health. Hi, I'm Sahar Nashir I'm a speech and language therapist in acquired brain injury, and I work with, uh, children and teenagers. Hello, I'm Bernice Napier. I'm a policy advisor here at rcs l t, and I've, um, worked on the Health in Qualities resource that we're gonna be talking about today. Michelle, do you think we can start by, um, defining what we mean by health inequality? That's a, that's a really good question, and the answer is it's very complex. Um, but to kind of summarize it, I, I guess one would say that they are the unjust and avoidable differences that, um, ex people experience in their health across the country and between specific population groups. So we know that there's, in, in the UK for example, that there are wide variations, um, in population health. And the kind of, for me, the most, one of the most scary statistics is that if you are born in London, if you were born in London in 2020, um, you have a life expectancy, which is on an average eight years longer than if you're born in Manchester or Liverpool. Okay. So that's sort of horrifying. And, uh, as, as, uh, a non-expert, I guess my respons would be, but we've all got the nhs I mean, we, we, we we're all using a publicly funded healthcare system. Why are there these disparities? Because health doesn't derive from the nhs. The amount of benefit the NHS provides in terms of, of people's overall health and wellbeing is relatively small. So the things that are big factors are things like, um, income, uh, about where people live, clean water, housing, whether they have access to transportation and all these other factors, um, that are called the wider determinants of health are much bigger hitters, if you like, that actual access to health services. Right. It's so interesting when you say that, when you say, Oh, things like access to clean water, that's not, not something that we tend to think about in like, go, whats the first world we don't think about clean water? Yeah, you're right. But in America, it's the first world and actually many millions of people don't have a secure access to, to clean water. So, you know, I I, there's lots of different areas, but in access to education, good quality education, uh, access to resources like shops and, and libraries, all these things have an impact, particularly on children's and health and wellbeing. I. Wonder if you could tell us a little bit more about why this is a topic that we need to care about. So, so from my perspective, I, I am, I will be focusing sort of largely on the economic aspects of how that impacts on children's development. And, and what we know is that there are intergenerational issues that transfer. So depending on how people were parented themselves, that then transfers through to those, their children. And we are talking specifically today about language and communication and, and that is a really intergenerational thing, if you like, unless there is intervention. And that kind of brings me nicely on to talk about two concepts that are really important, and one of those is equality. And we talk about health inequality, inequality, but actually equality in the true sense of the word means equalness. So actually everybody gets the same. So for example, everybody who's a school age in the UK is offered a school placement that's equality of access. But what I'm talking about actually, what makes the difference is equity and equity is actually getting everybody to the same place. So for example, if you, um, start off and, and you are, uh, two or three years old and you have a really restricted vocabulary, what interventions need to happen to get you to the right, the same place as other children who are starting school at, at a at statutory school age. So it's about the difference you have to make. And that's really, um, the kind of key concepts that stand behind that inequalities issue. Okay. So that's, that's really interesting. Let me make sure I've, I've understood this. So the, the, the, the equality, we will say, well, everyone technically has access to speech and language therapy services, for instance, but if we're not sure that the, the speech and language therapy service is being used at the appropriate time by the target population, then better quality is kind of hollow, really. Correct. That's exactly right. And actually, so many things impact on that. So for example, if we think about Maslow's hierarchy of needs where we talk about the physiological needs or the sort of bottom level, and then the next level up is safety. If you haven't got secure, um, access to food, if you have issues with heating, uh, if you have issues with income, um, then actually all those issues are gonna impact on how, how you can focus your time as an adult on the child's development. Because actually you've got these really fundamental things, these fundamental needs that need to be met before you can actually think about the, the actualization of child development. What. What are the, the main drivers of, of, of these inequities? What we're talking about here is actually keeping people healthy and well. And actually education at the level of education that people, um, experience is a very significant driver in how healthy they remain. And part of that is to do with how they can access the information that's provided, how they will seek out health services. Um, but you know, things like people's aspirations make a big, big difference to how people will, will see themselves in relation to the world and health services that they can access. And one of the things that I, I was always struck by, this was actually before I started doing, um, my masters in public health, but we insulted were launching a clinic in an area that actually historically, that had the, any health services in that area were closed because, um, people just didn't attend. So we, we ended up launching a new clinic, new new setting, uh, and had this massive, massive event, and it was to encourage children through the schools. It was to encourage, we had, um, we had local celebrities, we had the fire service, we had all sorts of people who used talking and language as part of their job. And that was a big draw for people. And an older lady came up to me at the end of it and said that she had been, she'd lived in that area for 20 years and she'd never set a foot into the previous clinic now. Really. So in the previous clinic were all the different health provisions, but that wasn't for the likes of her. That's what she said. These facilities were the not for the likes of her. And if it hadn't been for her child being the driver of getting her into the building, she probably wouldn't have come again. But it's kind of understanding people's view of life and circumstances that when you kind of really have a good understanding of that, then you can start to build, um, on those inequities and actually start to support to get people to the same place. If. I'm hearing you saying people that, that one of these, these drivers is that people are not accessing the services because they, they think it's not not for them. Yeah, yeah. Or they're intimidated. You know, we, we will take for granted going to an appointment, but actually speaking to the receptionist, remembering when you, you, when you, your appointment is, um, if there's a problem sorting out that problem, uh, if there's an issue talking to the professional that you're meeting, all those things are potential, um, barriers to, to people accessing services. And so actually what we need to do is kind of understand our communities in a lot of depth to really kind of drill down on what the, the barriers are, because they will be different to every community. So. On the one hand, obviously there's this moral imperative, um, that, you know, we want to give everyone the best life they possibly can, the healthiest life we possibly can, and the longest life we possibly can. So there's that. But then there's this interesting issue that you said. There's, there's, there's an economic issue around why, um, health equality matters. Okay. So, so just going back to, let's, let's take it sort of, um, antenatally. If you are, um, in, uh, a family where there is fuel insecurity, food insecurity, you are less likely to eat well, you are, um, more likely to be exposed to stress. Um, and these things have impact on the developing features. Um, and you also less likely to, um, engage with services. Um, so for example, we know there is a direct correlation between low birth weight infants and poverty. Um, so right from the start, even before you're born, you are experiencing inequalities. And that's very, very different. And that will then continue, I'm gonna sound jump from from Antenatally, uh, but, but then perinatally, there'll be issues about whether you access services to support you and your child. If you are experiencing postnatal depression, do you seek out support? Um, you know, and this is about how, how services have to, to shape round families because actually health visiting services and, you know, with Covid have moved online. Um, and, but then we are talking about people who potentially have, have it poverty. So for example, we know that in greater Manchester, one in three people, um, either doesn't have the hardware, the software, the connection or the skills to, to access online learning of any sort. That's really frightening. So we're talking about children's dev development. So at services from schools moved online with Covid, but one in three families in Greater Manchester would've had difficulty accessing that. It's really interesting listening in and sort of hearing it from a, a different perspective as a different part of the UK as well. I think for me as well, it's really important to consider how health inequality sort of impact on the access to our services. And it's, for me, I always remember, okay, how do different communities even understand how understand, you know, how to attend appointments? And for example, you know, families might receive a letter in the post that says, Your appointment is this day and, and this time and not understanding, you know, exactly what I'm, I'm being asked to, to come for and where I'm being asked to go. There's immediately a huge sort of language barrier So for me, that's a huge part of this topic as well. But I think that during the pandemic it's also just been exacerbated because you've got, you know, we've re we've really understood as a community and as a profession how kind of the racial disparities have just evolved hugely. And we are really now only understanding how it's impacting on our services now because I think we're talking about it more and we are looking at what are, you know, what are our biases with different communities and and how do we understand our service users? So I think that's such a huge part of this topic as well. And I, I think that's why I feel really passionate about thinking about how do we support our service users. If you don't understand the system, you're not gonna access it the same level as everyone else. So if there's a migrant community or a migrant family, they're probably not going to have the same understanding of speech language therapy or different healthcare services. As a family living in the uk. I consider myself sort of a reasonably informed person. I have a number of family members that work in healthcare, but the truth is, until I started working with, um, rcs l t I don't think I really had any genuine understanding of what speech and language therapy was. You wouldn't be alone amongst the general population in, in not having that wider kind of awareness of speech and language therapy. We tend to find that, you know, people have an awareness if they have a family member perhaps who's, um, experienced it. But in terms of sort of the why now, um, I think following the, the, um, horrific events around the killing of George Floyd and the Black Lives Matter, um, movement afterwards, um, we, we had been sort of looking at our existing guidance for speech and language therapists and thinking actually we need to do something, you know, to pull this together into one place to make it easier, um, to support SLTs in, in finding that, um, easily on the website. And then, you know, I think with the, the pandemic as well as Saha said, it's really highlighted, um, those health inequalities, um, in, in a much more stark way than, than has ever been done before. And mean, you know, we've seen continued research as we've gone through the pandemic, um, rcs LT has, has has looked at, you know, the impact of the pandemic on speech and Manus therapy and on service users, a, a and then, you know, you've seen other reports, so from the NHS race and Health Observatory report very recently too. So all of those things have come together and we have really made us think hard about, you know, know how do we support SLTs in the context of their practice. Talking specifically around the issue of, of race, what, what, what, what, what are the disparities? And, and do we, do we have any understanding as to why, why it may be? Um, I think there are, there is understanding about it. I think a lot of the work is done at a local level. Um, so it's really important to have that data and that information that's held by public health and to work with public health to really understand the needs of communities. Uh, and what we've done is really drill down in grace of Manchester, and I'm giving you a, a kind a live example if you like, but this is just one of many, many, many, um, is that we have looked at things like, for example, a two year take up in, in the, um, the early years offer. And what we know is that in, in certain communities that's not, not, um, not taken up very highly. So we've actually put behavioral analysts, behavioral insight people into that area and to kind of really identify what are the barriers for people. And then once we've identified what those barriers we that worked with communities to, to do, to address some of those barriers. So I think race is a, is a huge issue in terms of inequalities. I think physical, uh, and mental and disabilities are also, you know, we, we must not forget about our, of the populations as well. There are other groups who are significantly healthcare. We've seen very, very significant cost delivering increases, um, that are happening incredibly fast. I, I can't remember things getting that much more expensive that quickly in an awfully long time. Is is the concern that this is gonna continue to, to drive up, um, inequities if we are not very, very careful and proactive about it? It's inevitable. Um, it's inevitable that it will, if you think about the amount of money, and just, just take for an example, um, a work through example, and this is a pre covid example, and the difference in the percentage of spend on food and drink, um, between the people who are, um, more ad advantaged and people who are less advantaged. Uh, and there was an 8.4 difference percent difference, right? So actually it costs more to be poor. Um, so that was preco. So we're talking now that, that, that gap is going to just widen. And I think that is, is in, in many societies, you look at sort of the gap rather than actually what the, the top income earners earn and what the low income earners earn. It's that gap between the two that actually makes a, a, a, a less equitive society. So people who have, have got sufficient money are going to feel the pinch a little bit. Um, with the cost of living rises, people who are already in f in economic, um, disadvantage are going to be blindsided by it. What, what are, what are some of the things that we can do to begin to turn the situation around? And I'll, I'll go around and ask each of you. I don't know. Do you wanna start, Michelle? Yeah, I, I think you are. I mean, it is a bad news story. However, I do think there are some really positive things that we can do. And, and that is, as, as health professionals, it's about understanding our data, understanding our communities, and working with communities to facilitate their access to help them. So they, they don't, we don't, we don't, we don't access for them, but actually so that people feel it empowered to, to access what is available. Um, and it's understanding the communities from the community's point of view. It's not about with us kind of designing something and then say, What do you think about this? It's about starting right at the very beginning and saying, This seems to be a problem. Tell us about it, and how do you think we might manage that problem? And if services were developed in that way, they would be, they would look very different to how they look now. They would look very different indeed. And actually that would mean that people were able to access. So yeah, right. We can't do anything about fuel and about food, but what we can do is make access, uh, easier. And I think in pediatric brain injury, because brain injury does not just impact on one area, it's a, you know, it's the whole thing and it's the community, it's the family, it's education and all the services around that person. I think that's why I've even seen it more in, in since being in the, in this field. And, um, I think that's kind of spurred on my, my interest and my passion for this. But, um, I think aside from that, I really agree with what Michelle's saying about how do we kind of support and use the community, uh, services to help us understand more as clinicians. But we, we really do need more data. We re we really need clear data to show us, okay, you know, we need this at a, at a huge level of what are the issues in even accessing a, a service user group, for example. So, you know, are there going to be families that have a really tight work schedule or they have really, um, they have a lot of childcare, um, responsibilities, you know, how how are they going to be able to access the same things as other families? So that's something we've been thinking about in our team. And because, um, I'm the speech and language therapist as part of an interdisciplinary team, I've been thinking about how do we then involve other professions in thinking about this? So how do I involve our occupational therapists in thinking about physical access and how do we then think about language and making it accessible? But I mean, the, the brilliant thing that we really have access to is community advocates. So we can look through, you know, interpreters for example. We can look at different professions to help us and help us really like explain what is going on for, um, you know, a different kind of different community. So learning more about culture and the religion, it's even at that base level, isn't it, of thinking about how do we create a safe, um, service and how do we kind of develop that within a team. Um, but I think it's really, I think a speech and Irish therapist, we always have that hat on of thinking about language obviously, but I think pulling out bits of information from other really does help, um, in developing our understanding. I think when we, we deliver health services, we, we, We don't, we don't even think about it, but we kind of work on, on a, a deficits model. So now what's wrong with this person? What is, what do we need to do to make it right instead of looking at an assets based approach? And when you start thinking about what assets are in the family, what assets are in the community, it's a completely different mindset. Could you. Gimme a practical example of that? Um, so an example of an assets based approach, um, I'll give you a real life example from, from where I work. Uh, and that as part of the early language and communication process that we have in greater Manchester, in my particular locality, um, we were looking at putting on a stay and play. So this was to, to encourage families to come in and to, um, work with a member of the speech and language team. Uh, and so just have a fun time with their children and kind of build on those early social interaction, um, skills. So we're put on the stay and play, advertise it really widely. No one pitched up <laugh>, and then we did the same the next week and nobody pitched up. So what we tried to do then do is think, actually, let's go right back to the beginning here. And what we worked out with, there were a com there were a number of people in that community who were influencers and they weren't people in positions of authority, but actually they were very influential people in their community. Um, and they, so what what we actually did was went and talked to them and we said, this is, this is what we want to do. We, we, we feel we know another areas this works, but actually we're really struggling to get people in helpers. You tell us how we might go about doing this. And, and we worked with them. They came up with some great ideas, um, including employing somebody from the community to help run it right. Um, and, you know, they became a champion. And so actually when they were out, you know, shopping or they were picking their kids up from school, they could say to the mums, You know, I've been to this, it's absolutely great. You need to go try it out for yourself. And it was kind of increasingly week on week after that. And, you know, it was, it took time. I'm not saying it was an overnight success, but it took time. And actually now we've had to put a second group on in that local, local area. There's such demand for it. The college is thinking about a lot of stuff, obviously, you know, there's, there's the issue around race and there's the issue around how the, I CSL t's becoming more representative, but in terms of health inequalities, what is the college doing to, to try and address some of these issues? Yeah. Thank you. So, uh, I think of a, our response in two different ways, really. So firstly, our role is to support SLTs in, in this mm-hmm. <affirmative>. Um, you know, there's, it's one of those areas where, you know, everybody could look at it individually, but actually if we can support SLTs, bring together all the information into one place and provide helpful needs through which they can think about it, talk about it within their teams, um, then that's something that, that we want to do. And I think that's why we've developed, um, our healthy inequalities resource, which I can come along to talk about more. But before I do that yet, the other way, um, that, that we would res we are responding is to influence the wider systems. So in terms of us trying to influence governments about the impact of health inequalities on speech and language therapy, um, how to influence NHS systems, you know, so, you know, we are trying to influence those different wider public systems about the impact of health inequalities too. You. You mentioned there's this inequalities toolkit. I wonder if you could tell us what it is and how we hope people are going to use it. Yeah. Cool. So, um, our health inequality is resources sort of broken down into a few sections. So, you know, firstly we might, we are looking more widely at what health inequalities are, you know, what are the links to the social determinants of diversity and inclusion agenda. And then we're also looking at what it means for SLTs in, in their practice. Um, so in a pr more practical way and what resources that they can use to help identify what those health inequalities are in their services. And then as part of that, we developed a self audit tool, um, and that offers a practical way to think about health inequalities in your team, and you might discuss and record what you might want to do in practice. You know, we know that not all parts of the tool will be relevant for everyone. Now, you know, from some feedback we've had already, we know that you could consider it differently if you were an individual or whether you were a part of a team or in a wider multidisciplinary team. So, you know, we know also too in universities that are, are looking at it with their students, uh, and slt who's used it to influence the work of a wider local authority youth offending team. So, you know, I think I would, I, my message is that you can use it flexibly. You know, you can download the audit tool as a Word document and then just change it. Okay. So there's a couple of things. Firstly, I think it's really important to make friends with public health, um, because they have lots of local data, uh, but there are lots of other things available, uh, widely anyway. So things like the public health observatory gives you really good, uh, fit what for the fingertip tools on there give you really good, um, broad data on, on your local area. But public health can certainly, um, provide much more detailed, um, information that's available. And then I think it's a case of, of looking at what that data tells you, looking at things like the joint strategic needs assessment, the GS a in your local area, and kind of gathering all that information. I don't think we as SLTs are necessarily in a position to be able to collect it ourselves, but we be, you know, what we need to do is tap into what's already being collected. And that's, that's, and there is lots of it out there, but then once you've got all that data, it's kind of understanding it and under interpreting the data and then developing action plans on the basis of what the data tells you. I then ask Michelle to tell us a bit more about the greater Manchester language and communication pathway. So the greater Manchester Early Language and Communication pathway is, um, uh, a pathway that runs across the 10 local authorities that make up greater Manchester. And it sets out how we as a conation are going to explore language and communication and support language and communication in different communities. So we have a, an enhanced system of identification. Um, and then we have different types of intervention that are offered. Uh, and even though it's obviously delivered in individual localities, it's reported up to greater Manchester at a strategic level, which means it's got that oversight, it's got that governance. And that really has driven the change in practice because we don't specify how individual localities will deliver things, but we do specify the outcomes we want 'em to deliver. Uh, and so actually we know that if you will in Oldham or you live in tra, you will have a very different, um, means of delivering something, but actually you'll be achieving the same outcomes. And the whole points of it is to make sure that children, um, who are disadvantaged in any way, um, are able to start school with as, as, as close to their more advantage peers as possible, um, with the same level of skill. Um, and what we know pre Covid was that, again, this is where data is so absolutely essential, is that across Greater Manchester, we track the data and we know that we, with closing that gap between, um, more affluent families and less affluent families, um, and it was actually starting to come down, that gap was starting to close. And of course, Covid has blown that out the water. I do really think that if, if a team prioritizes this work, and now that we have things like this tool from the Royal College, I really do think that it just takes one person as part of a team to champion this. And just to say, Look, if we, if we have time as part of, you know, a team meeting or a clinical day that we, um, that we lead on, that we spend, you know, half an hour looking at the tool and we look at, okay, what's our population? What's the data looking like at the moment? What kind of, uh, issues are we having in terms of, you know, appointments and all that kind of stuff. And thinking about readdressing our own kind of viewpoints on this as well because it's, it really varies from clinician to clinician. And I do think as well that we are really lucky to have many, many trusts and universities that will fund for this work. It's just about that same person saying, actually, let's, I'm gonna make an application or I'm gonna speak to someone and say, we've got this part of money, how do we use it for this? And how can we further the research? The panel made the point that we need to look at all the data, but also all the policies and the nomenclature when thinking about health inequalities. For instance, Michelle made an interesting point about DNA or did not attend, how that has now referred to as was not brought, which is really more appropriate Coding when talking about children, how we use language really frames how we think about things. So even seemingly trivial things can be very important. Finally, the panel turned to the question of how Covid has impacted health inequalities. And given that the first five years of the child's life are most important for language acquisition and development, two and a half to three years have been severely disrupted. So, so I think we've always had, uh, we've always known that there is an issue between, uh, language and communication skills and educational access. That's, that's not a new thing. Mm-hmm. <affirmative>, and there's loads and loads of research which backs that up. But I think, and I am going back to the Covid issue again because I think that there were two things that happened. One is that rcc lt, you know, produced some really, really helpful data during Covid address identifying the inequalities. Um, but I think also now we are, um, potentially in the so-called post covid world, um, although I'm not sure about you, but everybody I know seems to have got covid. Um, a lot of covid going around. Yeah, yeah. Um, and there's, there's kind of very recent, um, information coming out which is, is confirming what we know out anecdotally. And so the education select committee that met last week, um, talked about the devastating impact of the pandemic and how that widened inequalities for children. And again, there are massive regional variations in that. Uh, and uh, a recent study showed that, um, this is again, post covid, they asked teachers across primary and secondary, uh, and over half of the children on free school meals, um, were identified that that school had a significantly, um, negative impact on their, their language and communication skills. Now, free school meals is a proxy indicator of poverty. Yeah. Uh, and so when we talk about free children being on free school meals, what we're talking about is, is, um, social disadvantage. So those children, up to 50% of those children, um, had an impact on their communication skills and their education as opposed to 20% of those children who were in from more affluent families. So the gap has widened again significantly. Um, and we need to do things to help catch up. And I think actually what we're going to have, we're going to potentially have a whole generation of, of, um, children and growing into adults that have asked basically scar developmentally by Covid. Um, and I think we need to think as speech and language providers how we are supporting that systemic, um, language and communication development, try and accelerate children's development because of those gaps that exist. And if you think about that on, on, on a neurodevelopmental um, trajectory, actually the first five years are the most important years in the child's life in terms of the, the speed and rate of learning. So actually, if three of those five years have been disrupted, then we are talking about significant deficits. Hearing you talk, Michelle makes me think about kind of just this sheer amount of trauma that so many people have gone through, not only in the last sort of two years just thinking about kind of racial trauma, but also the pandemic. Um, there's just been so many events and kind of from a social perspective, but also, you know, for many people personally, you know, people have been grieving, um, and people have had to deal with, you know, war and um, poverty. So there's so much trauma into LinkedIn, all of this. But there's also, we obviously know that trauma has a huge impact on development and communication and um, I think it's really, it's great that we have more research into this area and we sort of understand it a bit more. And I think a lot of the research from America in particular has really shown us, um, that, you know, many black and ethnic minority groups and children and not accessing the same level of care and then maybe being missed for speech and language therapy support compared to their, compared to white children. Um, so it's knowing that and thinking about how does that impact on child development and how does that impact on, Michelle was saying, you know, on the, the trajectory. In, in, in many homes where language and communication, as you said it was, you know, was, was, was, was okay, it was fine. Uh, you know, if you put a bereavement into that, so, or as I said, trauma, then actually that alters that language and communication model in the family and children are not exposed to the same amount of and quality of language. And I think that's really important. It's those two things. So it's not just how much, but it's also the quality of the language that's used. So, I mean, would it be fair to say that we probably still haven't actually got our head around, potentially have the, the, the fallout from Covid? I don't think we have got our head around it at all. I absolutely don't. And then money has been made available, um, but it's like all these things is, I guess it, it's, it's probably not, it's not enough and it's probably targeted in the wrong place. So we need to, so what, what we need to come to terms with that, it's, it's not just a question of, okay, we have massive backlog in the NHS cuz of Covid, which is gonna cost a vast amount of money to fix. We have a whole new set of problems totally separate from long covid or any of those things. With, with with, with, with, with childhood development and stuff, which, yeah, now that you mention it, we, we can't imagine people having been locked inside for two years having far less social contact and they ordinarily have, and we are gonna be dealing with this fallout for a potentially a very, very long time. I think so, and I think, and the children are going back into settings. Um, but actually the impact is, is still incredibly visible just in terms of interaction skills. I'm not talking here about language at all, just in an interaction. Little ones are not interacting with each other in a typical way because they actually, many children had never seen other people outside their family. Um, so, so it's very, very different topography out there at the moment. I think speech and language therapists have got the skills, so we kind of rod's seeing things to that sort of medical lens of health services. We, we operate across a number of different, uh, modalities if you'd like. So in terms of education, we have the skills to support schools and settings to think about those developmental models and how we, how they can really enhance children's learning in, uh, you know, in, in a restricted amount of time. Buries gave us a useful summary of some planned activity that addresses the question of health inequality and a reminder to check the show notes for links to all the resources. Okay. So we're also planning some further development work on the tool this year. So both to respond to the feedback we've had and to try and help speech and language therapist with that local analysis of the patients and matching that with what we know about outcomes, prevalence, um, and incidents of clinical conditions. So, uh, in addition we've got the RCS LT route tool, um, and there that tool is being developed to enable SLTs to collect diversity data. So they're all helpful things that we'll be added to over the course of the year. Um, also, uh, if you would like to look out for our tweet chat that we'll be having on health inequalities on the 27th of April from one o'clock to two o'clock, uh, in the afternoon, and that'll be on the, at our CSL t policy, Twitter, uh, feed, and that be a first speech and language therapist just to chat together about how they're using the resource or to ask questions about, you know, how others are are doing. So, um, we're also planning a webinar for the autumn, uh, about health inequality. So anyone would like to share their work on health inequalities for that webinar. Then please do get in touch and we'd also love to hear from anyone about how you've used the resource. Um, we are looking for more case studies to, to put onto the website. I think this is one of those things where sharing experience is gonna be really valuable for others. A very big thank you to all of our panelists for their time. We do ask that if you found the podcast interesting, you rate it on Apple Podcasts or whatever your preferred podcast provider is, why not send your favorite episode to three of your colleagues? Personal recommendations really do matter. It helps us grow the audience and advocate for speech and language therapists and their patients. Until next time, keep well.