Case study provided by Hazel Ferreira (Speech and Language Therapy (SLT) Service Lead) and Rachael Bilton (Consultant GI Radiographer) at North West Anglia NHS Foundation Trust
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Summary
This case study outlines how diagnostic imaging and speech and language therapy (SLT) created a novel out-patient barium swallow (BaSw) pathway to reduce delays and ensure timely SLT review for those with suspected oro-pharyngeal dysphagia. The project achieved a reduction in mean time from BaSw to SLT review from 41 days to 8 days.
This work directly supports Getting it Right First Time and the NHS Long Term Plan’s ambition to modernise outpatient services, strengthen multidisciplinary working and improve early diagnosis through streamlined, data driven pathways.
Organisation
Diagnostic Imaging and Speech & Language Therapy, North West Anglia NHS Foundation Trust.
What was the problem?
The existing pathway relied on referrers actioning radiographer recommendations on BaSw report to refer to SLT. This created significant delays and inconsistency and increased risk of dysphagia related complications, such as aspiration.
Key issues identified:
- Delays of up to one year in referrals reaching SLT identified prior to project, instigating initial pathway review.
- No evidence of best practice pathways addressing this issue.
- Lack of understanding of pathway. Patients sometimes sent to community SLT instead of outpatient SLT, adding further delay.
- Lack of standardised terminology in radiographer descriptions of the oropharyngeal phase.
- No direct pathway between BaSw findings and SLT outpatient review.
- 40% of patients needing SLT review were not referred.
- Process inefficiency
What was done?
The project leads redesigned the pathway to create a direct, standardised, and efficient process:
- Co‑produced standardised terminology for describing oropharyngeal dysphagia in BaSw reports.
- Introduced a direct referral process from radiographers to SLT.
- Created a designated virtual SLT clinic for BaSw review.
- Implemented ongoing data capture and case reviews.
- Engaged stakeholders across imaging, SLT, ENT, gastro, respiratory, rheumatology, surgery, and community partners.
- Refined pathway referral criteria from Radiographers to SLT, based on early PDSA findings.
Challenges
The project encountered several challenges and identified future potential risks:
- Variability in Advanced Practice Radiographers training and backgrounds resulting in inconsistent terminology which needed standardisation through consultation and coproduction.
- Risk of over‑referral – monitored via PDSA.
- Reduced visibility of SLT BaSw review in patient pathway – utilised addendum task to add direct SLT review to BaSw report.
- Resources & skill mix – Risk of “single point of failure” as only one SLT working at this advanced level in dysphagia diagnostics.
- Processes and human error – early errors where radiographers did not use the addendum referral task.
- Recognition of the pathway – Need for consistent communication with referrers and community SLT partners.
- Cross system working between Trust and Community settings – provision of individual access to designated community SLTs.
Impact
Timeliness
- Time from BaSw to SLT review improved
| Range (Days) | Mean (Days) | |
| Pre pathway | 1-168 | 41 |
| Post pathway | 0-22 | 8 |
Process reliability
- Missed referrals eliminated (previously 40% not referred).
- Standardised terminology improved clarity and diagnostic consistency.
Efficiency
- Steps reduced from 5 → 3.
- Removal of delays caused by letter transcription and postal systems.
Referral volume
- Proportion of BaSw requiring SLT review remained stable at 11%, confirming no over referral.
Learning points
- Co-production between SLT and radiographers is essential for shared understanding and pathway improvement.
- Direct referral pathways reduce risk and delay.
- Standardised terminology improves diagnostic accuracy.
- Early PDSA cycles help identify and correct process errors.
Next steps and sustainability
- The pathway is now embedded as “business as usual”, supported by updated SOPs, training, and workflow integration.
- Ongoing monitoring through 6‑month PDSA cycles.
- Incorporated BaSw case review through established Radiographer & SLT meetings following a REALM (Radiology Events and Learning Meeting) format.
- Dissemination to professional group of novel pathway.
Alignment to the 4 pillars of advanced practice
1. Clinical practice
Advanced-level autonomous practice and clinical expertise in dysphagia diagnostics.
2. Education
The project demonstrates teaching, capability-building and system-wide education.
3. Research and evidence-based practice
The project uses data, audit, and iterative improvement cycles to drive change.
4. Leadership and management
The project required cross-system leadership, stakeholder engagement and service transformation. It demonstrates strategic leadership, service improvement, governance and cross-disciplinary coordination.
Contact
Project Leads:
Hazel Ferreira, SLT Service Lead: hazelferreira@nhs.net
Rachael Bilton, Consultant GI Radiographer: rachael.bilton@nhs.net
Reference list
- NHS England. Getting It Right First Time – GIRFT [Internet]. Getting It Right First Time – GIRFT. 2023. Available from: https://gettingitrightfirsttime.co.uk/
- NHS England. NHS England – NHS Long Term Workforce Plan [Internet]. NHS England. NHS England; 2024. Available from: https://www.england.nhs.uk/long-read/nhs-long-term-workforce-plan-2/
- Health Education England. Multi-professional Framework for Advanced Practice in England [Internet]. Advanced Practice. 2025. Available from: https://advanced-practice.hee.nhs.uk/multi-professional-framework-for-advanced-practice/