Provision of communication equipment and support: guidance

Part 3

Section 1. Introduction

Part 4 of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 on the Provision of Communication Equipment and Support commenced on 19 March 2018.

This gives children and adults across all age ranges and care groups, who have lost their voice, or have difficulty speaking, a right to be provided with communication equipment and support in using that equipment, as necessary to meet all reasonable requirements.

Communication equipment is frequently referred to, and is one part of Augmentative and Alternative Communication ( AAC).

The best equipment will support the person to achieve their personal outcomes and will be unique to each individual and personalised to suit their individual needs. The best equipment for one person may not be the best for another person.

Beyond the scope of this Act, are unaided communication systems, which do not require the use of equipment, such as signing, gestures, and facial expressions.

AAC provision is delivered across Scotland by Health Boards, Education and Integration Joint Boards ( IJB’s) often in collaboration with the third sector (voluntary) as appropriate to the needs of the individual.

A Definition of Communication

Communication is the exchange of information between one person (the sender) and another person or people (receivers).

It relies on the language skills of both sender and receiver, which includes the ability to understand and express meaning. Meaning can be conveyed nonverbally (e.g. facial expression, body posture) and by using language (e.g. through speech, sign, written word or via communication equipment).

Communication may be face to face or at a distance, such as via text, email, or social media and may take place in a range of settings i.e. home, school/college, work, leisure, day care, hospital and any other community settings and with many different people (family, friends, carers, professionals).

Section 2. Definition Of Communication Equipment

Outcome: Everyone with an interest in communication equipment will have a shared understanding of what that includes.

Communication equipment is any equipment that enables a person to communicate by conveying a message to support or replace speech.

It may be used by people who have no speech, or whose speech is not sufficient to meet their everyday needs. The purpose of this equipment is to support a person to communicate in their daily life and help them achieve personal outcomes.

Communication equipment is either ‘low tech’ (unpowered) or ‘high tech’ (powered) and people may use a combination of these. The equipment required may change over a person’s lifetime. It will always include a communication aid, which is used to generate a message in place of speech, and any of the following:

• Software to provide the language content and structure (such as apps, language programmes or symbol sets).
• Adaptations and Access equipment or software which may be required for two reasons:
  i. to ensure the person can see, hear or touch the communication equipment, especially if they have a sensory impairment.
  ii. to ensure the person can interact with the communication equipment, especially if they have a physical impairment.

• Accessories such as screen protectors and cases, mounting or positioning equipment to support and hold the communication equipment or other components in the appropriate position.
• Equipment to maintain the power supply of the communication aid while in use, for example, mobile power packs, hot-swappable batteries, or extra mains adaptors.
• Accessories or software to allow the equipment to communicate remotely, such as, email and SMS text messaging.
• Appropriate warranties, servicing or maintenance required to ensure maximum availability and continued safe operation of the communication equipment.

2.1 Low Tech Communication Equipment relates to any type of equipment used specifically for communication that does not require batteries or electricity to work. Low tech equipment can be simple or complex, depending on the needs of the individual, and should be personalised and fully adaptable to suit their needs.

Low tech equipment may include physical resources, which can be paper based and printed. Simple communication equipment is usually used for a specific activity and has a finite amount of vocabulary. More complex equipment may include a large amount of vocabulary, organised in a pre-set format with structured guidance. This framework may be designed for speech and language development, as well as functional communication needs. Learning to use low tech equipment can be as difficult as learning a new language, which requires to be taught.

Some examples of low tech communication equipment include:

• Pen and paper or dry wipe board.
• Flash cards.
• Communication books with letters, words, pictures and/or symbols (which may include a multi-page communication book with the vocabulary arranged in topics).
• Tangible symbols (e.g. real objects, miniature objects or parts of objects).
• A communication board with the alphabet or pictures arranged in a grid format.
• Colour coded eye pointing frame.

Creating personalised low tech communication equipment which is fit for purpose often requires skill, time and access to, for example: specialised software, colour printer, laminator. It also requires identifying and organising personal vocabulary to meet the individual’s needs. Where this has been developed electronically, this should be stored for future updates or necessary access and sharing at points of transition. Colour coding of vocabulary may also be involved and can enhance the individual’s efficient and effective use of the low tech system.

2.2 High-Tech Communication Equipment is electronic equipment with a power source (battery or charger with mains adapter) that provides a means of communicating with others either face-to-face or at a distance. It usually has a voice output, which may be supported by text and/or images/symbols, and is usually portable. High tech communication equipment can be simple or complex.

2.2.1 Simple High-Tech Communication Equipment has limited features and recorded speech output. It can range from a single spoken message aid to one with a limited number of messages. It may have printed images/symbols or text linked to the messages, allowing the individual to select the chosen message to speak. This category also includes equipment providing a sound source as a substitute for voice e.g. an artificial larynx or a voice amplifier.

2.2.2 Complex High-Tech Communication Equipment is based on computer technology with a screen display showing communication vocabulary, images, symbols, text and/or an on-screen keyboard. They are multi-featured, often with synthesised voice output, alternative access options, add-ons, accessories and mountings.

All complex high-tech communication equipment consists of:

• Hardware – internal computer/ tablet, battery, screen display, sound amplifier.
• Software – operating system and specialised communication software / apps.

Some complex communication equipment has optional features such as:

• A wide range of alternative access options e.g. eye gaze camera, head tracker and switches.
• Internet Wi-Fi or Bluetooth connectivity, enabling social networking and emailing.
• Phone and video calling, camera and SMS text messaging.
• Basic environmental controls e.g. light switches, television controls.

Some mainstream hardware and software widely available, such as a tablet device may be appropriate to use as communication equipment in certain situations.

In order to make the most of the communication equipment, access to Wi-Fi is necessary if required for setting up equipment, intervention, update and back up for complex high-tech communication equipment.

2.3.3 Communication Equipment Management

Outcome: People using communication equipment which is safe, effective and fit for purpose should receive the communication equipment in a timely manner.

Agencies providing support for people using communication equipment should have a robust system for equipment management for both high tech and low tech communication, in accordance with appropriate regulatory guidance. This may include an online or electronic catalogue of available equipment and a record or database of the people supplied with the communication equipment. Items for access to, and or mounting equipment should be included within this catalogue.

Equipment management should include procedures for:

• Procurement of equipment.

• Safe and secure storage.

• Ongoing monitoring and maintenance and any changes to regulation or safety alerts.

• Safety checking in accordance with relevant health & safety legislation, this should also include the Equipment Coordinators in all health boards and local authorities who are part of the arrangements for reporting incidents and cascading safety alerts.
• Decontamination and infection control.
• Retrieval/recycling/re-issue of equipment.
• Decommissioning of equipment.
• Loan, both short-term and long-term.
• Maintaining and updating software as required.
• Backing up and saving personalised vocabularies.

The knowledge and skills required to fulfill these tasks are set out in relevant specialist and generic competency frameworks which may be developed locally such as the IPAACKs (Individual Profiling of AAC Knowledge and Skills) developed as part of the Right to Speak Scottish Government national guidance. Other frameworks may be developed locally.

All procedures should be compliant with current and future regulations and guidance.

Section 3. Definition Of Support In Using That Communication Equipment

Outcome: People who need and use communication equipment, the commissioners of services, professionals and carers will understand how the type of support is determined, what this looks like, the range and responsibilities of people delivering that support and how to access it, within the scope of the legislation.

Support is the help that is given to allow the person to achieve their communication potential and their personal outcomes. Securing support for a person who has lost their voice or has difficulty speaking may involve working with the person’s family, friends, carers and wider circle of communication support to work with the person to ensure the person is able to effectively use the communication equipment.

Support should be provided to the person using the communication equipment with advice, information and training available for anyone else who the person interacts with including but not limited to family, friends, formal and informal carers, and staff working with them.

Support provided should be delivered to match the person’s particular needs and outcomes for wellbeing. This may be provided at different levels: universal, targeted and specialist in different ways and at various stages depending on the needs of those involved and is particularly important at times of transition.

The person will require support to:

• Participate effectively in the assessment process.
• Ensure they receive the most appropriate communication equipment following assessment and identification of communication needs.
• Ensure the communication equipment is prepared, adapted, and updated appropriately.
• Ensure they develop the skills to operate their communication equipment.
• Ensure they maximise their language and communication potential.
• Use their communication equipment to achieve their personal outcomes and what matters to them.
• Help them meet their continuing communication needs and aspirations, also taking responsibility for letting it be known when changes occur and with access to an appropriate review process.

Family, carers and friends may require support to learn:

• How to communicate and interact with the person using the communication equipment.
• How to set-up and maintain the communication equipment on a daily basis.
• How to help the person develop their communication skills using the communication equipment.
• Who to contact in the event of any difficulties.

Professionals may require support to:

• Maintain and develop relevant knowledge and skills in relation to communication equipment and support.
• Ensure the necessary steps take place to confirm relevance and cost effectiveness when introducing newly developed equipment.
• Be able to communicate and interact with the person.
• Know how to set-up, prepare, adapt and update the person’s communication equipment.
• Know how to help the person develop their language and communication skills using the communication equipment.
• Ensure there is a process in place to manage and maintain the communication equipment and carry out appropriate risk assessments.
• Be alert to any safety messages from regulatory bodies and ensure these are acted upon.

The pathway of support for the person starts with the recognition of their communication needs, followed by assessment, trialing and provision of equipment and recommendation of support strategies, which may include appropriate intervention, training and review.

All agencies can contribute to providing support at all levels.

3.1 Approaches to supporting people who use communication equipment

Outcome: People with communication difficulties who use or need communication equipment will benefit from timely support provided by competent staff.

For many people support for communication equipment involves working with agencies who have a shared duty of care (i.e. health, social care, housing, education and third sectors). Support is based on and in response to the complexity and needs of the individual in meeting their wellbeing outcomes.

The person who will be using the equipment, their families and carers will be an integral partner and involved throughout the support process to ensure the communication equipment provided meets their needs and supports achievement of personal and wellbeing outcomes.

3.1.1 Universal Support

Universal support includes workforce development, access to appropriate information, and creating communication friendly environments. Universal support may be provided to the wider community to raise awareness of communication needs and give advice on how to communicate with any person using communication equipment. This may involve giving support towards breaking down any societal attitudes, practice and policy barriers that could limit the participation of people who use communication equipment.

3.1.2 Targeted Support

Targeted support is provided to people in other agencies and environments who have specific involvement with people using communication equipment. Targeted support does not focus on the specific communication equipment needs of an individual. This support may be delivered by developing the skills of individuals who directly interact with people who use communication equipment, and may involve providing or teaching strategies for supporting communication.

3.1.3 Specialist Support

The person who uses communication equipment is supported by a local team who may be in direct and regular contact with them. That team may then contact a local specialist (e.g. teacher, Speech and Language Therapist, technician) when the person’s needs are complex and beyond their level of competence. This may result in onward referral to a specialist multi-disciplinary team which may be at a regional or national level.

Specialist support is provided directly to the person with a communication equipment need, to help them reach their communication potential. Specialist support is personal and individual to the needs and abilities of the person using communication equipment. They and their families and carers, will be consulted and involved throughout the support process, so that the communication equipment appropriately meets their needs.

Specialist support is delivered by the local team working in partnership and across agencies (health, education, social care and the third sector).

3.1.4 Support Competencies

Support to use communication equipment should be provided by staff with necessary competencies, making use of the best available evidence and competency frameworks. A range of staff with higher level competencies should exist locally, with access to staff with expert level competencies to provide support to people requiring the use of communication equipment. Four levels of competency are set out in the IPAACKs competency framework that is based on learning needs as prioritised by people who use communication equipment.

3.2 Recognition of Need

Outcome: A person’s communication difficulties are recognised at an early stage to enable access to timely assessment of their communication equipment support needs.

It is necessary to recognise when a person has communication needs and that communication equipment may be required. This may be identified by the person with communication support needs or anyone within their support network.

3.3 Assessment

Outcome: The person who uses communication equipment and the services providing support have all the information they need to make a joint decision about the most suitable communication equipment and the support necessary to use it.

The purpose of assessment is to identify the most appropriate communication equipment to meet the person’s communication goals and aspirations, taking into consideration the skills and strategies required.

The views and preferences of the person who will use the communication equipment are central to the assessment process as well as those of people connected to their support or care. Assessment is usually multidisciplinary, with the initial assessment carried out by staff having the necessary competencies from the local team, involving specialists where required.

The assessment may take place in the different environments and activities that the person experiences e.g. home, school/college, work, day care, hospital or wider community.

People providing support will understand that successful communication depends on a range of skills and other factors. Any communication equipment assessment should consider the person’s skills and abilities in the following areas, and the support required to develop them:

• Current methods of communication, and use of any existing equipment.
• Cognitive, physical, learning and sensory abilities.
• Understanding and use of language.
• Reading and spelling abilities.
• Awareness of the rules of communication and social interaction.
• The ability to use different methods and strategies available to communicate efficiently and effectively.
• Coping with the demands and challenges of communicating in everyday life using communication equipment.
• Operation of the communication equipment.

Other factors will need to be considered during the assessment process, including:

• The person’s communication goals and aspirations.
• Perceptions and expectations of what success would look like.
• Opportunities for communication in different environments, and the wider support available.
• Potential or existing barriers to effective use, of the communication equipment.
• The need for multiple pieces of communication equipment, to meet a variety of needs.
• Future changes or transitions.
• How the communication equipment will be made available, carried, and accessed, including the potential need for it to be mounted, for example; on a wheelchair, floor, or desk mount.
• Safe transportation of the communication equipment.

The assessment should include a process for information gathering, observation, consultation and discussion with the person and with key people, in a co-ordinated way.

3.3.1 Equipment Trial

The trial of communication equipment is an integral part of assessment, and this should be accessed in a timely manner.

The duration of the trial should be based on the needs of the person and allow enough time for them to learn the essentials of how to operate the equipment and begin developing skills in everyday life, with a variety of communication partners.
Support and training may be required at this point to ensure a successful outcome

In some cases, it may be necessary for a person to trial several items of equipment, before the most effective system can be identified.

3.3.2 Communication Equipment Specification

Outcome: People receive all the necessary communication equipment to ensure that their needs are met.

Once the assessment is complete and the most effective communication equipment has been identified for the person, a member of the team should provide a detailed specification of the recommended equipment, as well as the level and nature of support needed and share with relevant professionals, where appropriate.

3.4 Provision and Intervention

Outcome: People who need and use communication equipment will be provided with suitable equipment and support to achieve their personal outcomes and to ensure effective, safe and sustained use of the equipment, where necessary through multi-agency intervention.

3.4.1 Preparation of communication equipment

Outcome: People receive communication equipment that is tailored to meet their needs.

Preparation is required before the communication equipment is ready to be provided to the person. This may involve setting up the equipment, programming and vocabulary personalisation. Time and resources required will vary depending on the complexity of the equipment and needs of the person.

Situations where the time and resource demands may be greater include those where, symbol-based vocabulary is needed, alternative access methods are used, mounting and positioning is involved, or integration with other technologies is required.

3.4.2 Intervention and training to use communication equipment

Outcome: People using communication equipment along with their support networks receive the intervention and training they need to make their communication successful.

3.4.3 Intervention Goals and Measurement

Learning to use communication equipment for effective communication is a complex process which takes time to teach and learn, both for the person and their support networks. The person should be consulted regarding priorities, preferences and aspirations and involved in agreeing short and long term intervention goals. Expectations from all parties should be set out and effectively managed. An outcome measurement should be in place to inform the effectiveness of the communication equipment and support. For example, one outcome measure that has been adapted for AAC is the TOMS (Therapy Outcome Measure) which was adapted following trial use by teachers, speech therapists and other social care staff and funded as part of the Right to Speak Scottish national guidance.

3.4.4 Intensity and Delivery of Intervention

Different levels of intervention may be appropriate (universal, targeted and specialist) to enable the person to learn and practice skills for effective communication.

The intensity of intervention and support required is likely to vary over time. It may need to be increased when a person is starting to use new equipment and developing skills, or is in a new environment. Less intensive intervention may be required when the person becomes more skilled in using the communication equipment across different environments and is effectively supported by communication partners.

Intervention and support may also take place within differing environments e.g. home, school/college, work, leisure, day care, hospital and any other community settings during everyday activities to allow the person to practice using the communication equipment functionally, in real life situations.

Periodic indirect intervention may be required for the person using communication equipment. This may include programming, updating vocabulary and layouts, and updating staff skills.

3.4.5 Training

Professionals working with communication equipment play a key role in ensuring that the person, their family/carers and key workers have the necessary knowledge and skills required to make using communication equipment effective and to develop their capacity for ongoing support. This can be through signposting and training, which may be provided by a range of agencies.

Families/carers may require instruction and support in how best to support the person to use their communication equipment. This may involve developing knowledge and skills in relation to:

• Awareness of the communication challenges and different ways to communicate and overcome these.
• Developing the person’s use of communication equipment, including identifying personalised vocabulary and communication opportunities.
• Expanding personalised vocabulary to a person’s communication equipment.
• Maintaining, charging, setting up and backing up communication equipment.
• Being a good communication partner and supporting people to use their equipment to participate in different aspects of everyday life.
• Identifying and creating new opportunities for the person to use their equipment to communicate independently.

Professionals supporting the person using communication equipment (the local team/key workers) may require instruction and support in how best to support the person to use their equipment. This may involve developing and maintaining knowledge and skills in relation to:

• Strategies for communicating with people who use communication equipment.
• Preparing, adapting and updating communication equipment.
• Developing language and communication competence via the use of communication equipment.
• Identifying and creating opportunities for the person to use their equipment to communicate independently.
• Managing and maintaining the communication equipment.