{
  "lane": "services",
  "compiled": "2026-10-16",
  "definition": "A breakpoint is a point in the UK stroke/aphasia pathway where provision documented as required either fails to happen for a sizeable group, or happens unevenly in a way that depends on something other than need. Each entry separates what is DOCUMENTED in a source from what is INFERRED from the pattern or from an absence.",
  "breakpoints": [
    {
      "id": "BP1",
      "name": "Acute SLT assessment missing for over half of patients",
      "stage": "Inpatient stroke unit, first 72 hours",
      "documented_or_inferred": "documented",
      "evidence": [
        {"claim": "Only 46.8% of stroke patients assessed by an SLT within 72 hours of clock start [UNVERIFIED at primary source]", "source": "vault source-ssnap-apt-synthesis-2026; indicator definition confirmed in [1][10]", "access": "vault full text; indicator definition full text"},
        {"claim": "7.6% receive no assessment for organisational reasons [UNVERIFIED at primary source]", "source": "vault source-ssnap-apt-synthesis-2026", "access": "vault full text"},
        {"claim": "Guideline requires early assessment by an SLT", "source": "[4] National Clinical Guideline for Stroke 2023, communication and language chapter", "access": "full text"}
      ],
      "inference": "The gap arises before therapy dose is even in question: the audited gateway itself is missed for over half. This is stated, not inferred.",
      "confidence": "high (guideline and indicator definition); medium (exact percentage, not re-derived)"
    },
    {
      "id": "BP2",
      "name": "Inpatient SLT therapy dose below the guideline standard, and uniquely declining",
      "stage": "Inpatient stroke unit therapy",
      "documented_or_inferred": "documented",
      "evidence": [
        {"claim": "Only 35.4% receive the NICE target total therapy dose (128 min/day) [UNVERIFIED at primary source]", "source": "vault source-ssnap-apt-synthesis-2026", "access": "vault full text"},
        {"claim": "There has been a decline in the standard of receiving 45 minutes of therapy five days per week since 2022/23 in speech and language therapy, whilst the other disciplines remain unchanged", "source": "[10] SSNAP Therapy Spotlight Report; [8] Stroke Association 10 Year Health Plan response", "access": "full text"},
        {"claim": "SSNAP SLT coverage benchmark is 50% of caseload vs OT 80% and PT 85%", "source": "[19] BMJ Open ethnography of SSNAP therapy-intensity auditing", "access": "abstract/full text page"}
      ],
      "inference": "Because SLT alone is reported to be declining while OT and PT hold, the shortfall is SLT-specific rather than a general therapy capacity shortfall, though both may share causes.",
      "confidence": "high (direction); medium (magnitude)"
    },
    {
      "id": "BP3",
      "name": "Hospital discharge without a stroke-specific community rehabilitation service",
      "stage": "Transition, hospital to community",
      "documented_or_inferred": "documented",
      "evidence": [
        {"claim": "66.6% discharged to a stroke/neurology specific community rehabilitation service in 2024/25, so about one third are not", "source": "[1] SSNAP State of the Nation 2025", "access": "full text"},
        {"claim": "23.1% of discharges went to a combined ESD-CRT team", "source": "[1] SSNAP State of the Nation 2025", "access": "full text"}
      ],
      "inference": "The residual third is a population of stroke survivors, including people with aphasia, who leave hospital without specialist community rehabilitation. The aphasia-specific share of that third is not measured (that is an inference).",
      "confidence": "high (headline); low (aphasia-specific split)"
    },
    {
      "id": "BP4",
      "name": "ESD not universally available",
      "stage": "Early supported discharge",
      "documented_or_inferred": "documented (charity claim)",
      "evidence": [
        {"claim": "Around one fifth of hospitals in England, Scotland and Wales do not yet offer an ESD service", "source": "[8] Stroke Association 10 Year Health Plan response, citing a 2020 evidence review", "access": "full text; underlying count not verified"}
      ],
      "inference": "Absence of ESD forces some patients into either a longer hospital stay or a discharge with no specialist home rehabilitation. Stated by the source; not independently counted here.",
      "confidence": "medium (interested-party claim, basis a 2020 review)"
    },
    {
      "id": "BP5",
      "name": "Community teams under-resourced against recommended staffing and discipline access",
      "stage": "Community rehabilitation (ICSS)",
      "documented_or_inferred": "documented",
      "evidence": [
        {"claim": "Only 17% of community-based services have appropriate access to all the core disciplines (physiotherapy, occupational therapy, speech and language therapy)", "source": "[8][11] Stroke Association response; SSNAP Post-acute Organisational Audit 2021", "access": "full text"},
        {"claim": "Fewer than one third of community-based teams meet recommended staffing levels per patient; fewer than 50% of inpatient services do", "source": "[11] SSNAP Post-acute Organisational Audit 2021", "access": "full text"},
        {"claim": "Recommended SLT establishment in community teams is 0.4 WTE per unit", "source": "[11] SSNAP Post-acute Organisational Audit 2021", "access": "full text"}
      ],
      "inference": "Even where a patient reaches a community stroke team, the SLT input available depends on that team's staffing, so aphasia therapy reach depends on postcode. Stated by sources plus direct inference.",
      "confidence": "high (structure); the exact SLT ratio proportion is provisional (two unreconciled tabulations in [11])"
    },
    {
      "id": "BP6",
      "name": "Persistent SLT workforce vacancy constraining supply",
      "stage": "Whole pathway (workforce)",
      "documented_or_inferred": "documented",
      "evidence": [
        {"claim": "14% of SLT posts vacant across NHS and independent sectors; 14% in NHS adult services; 23% in the independent sector", "source": "[3] RCSLT Workforce and Vacancy Survey 2025", "access": "full text"},
        {"claim": "21% overall vacancy with adult services at 23% in an earlier survey wave", "source": "[27] RCSLT news item", "access": "full text"},
        {"claim": "32% of non-NHS SLT services turned down new or extended contracts because of recruitment problems (spring 2024 survey)", "source": "[7] House of Commons Library CDP-2025-0010", "access": "full text"}
      ],
      "inference": "The workforce shortfall is a supply-side constraint on any expansion of aphasia therapy, and cannot be closed by pathway redesign alone. This inference is mine; the vacancy figures are documented.",
      "confidence": "high (figures); caveat: voluntary self-selecting surveys, not a census"
    },
    {
      "id": "BP7",
      "name": "Six-month review decline, far below the national ambition",
      "stage": "Long-term follow-up",
      "documented_or_inferred": "documented",
      "evidence": [
        {"claim": "35.1% of applicable patients received a six-month review in 2024/25, down from 39% in 2023/24", "source": "[1] SSNAP State of the Nation 2025", "access": "full text"},
        {"claim": "National Stroke Programme target was to raise six-month reviews from 29% to 90%", "source": "[13] NHS England stroke programme page", "access": "full text"},
        {"claim": "Approximately one fifth of patients report moderate to severe mood issues at six months", "source": "[1] SSNAP State of the Nation 2025", "access": "full text"}
      ],
      "inference": "The review is the only structured checkpoint after community rehabilitation, so the decline removes the main detection route for unmet aphasia and mood need. Documented direction plus inference.",
      "confidence": "high"
    },
    {
      "id": "BP8",
      "name": "No structured checkpoint after six months; long-term support is voluntary-sector dependent",
      "stage": "Long-term / life after stroke",
      "documented_or_inferred": "inferred (from an absence of infrastructure, corroborated by qualitative evidence)",
      "evidence": [
        {"claim": "SLTs report the lack of long-term community support as a particular concern and that knowing there was no long-term support made discharge difficult", "source": "[25] Northcott et al. UK SLT survey (n=124)", "access": "abstract/metadata"},
        {"claim": "Charity provision is welcomed but variable across the country, with little available in some areas at the end of rehabilitation", "source": "[25] Northcott et al.", "access": "abstract/metadata"},
        {"claim": "50% of people with aphasia in Scotland said there was support they needed but were unable to access; 24% of that unmet need was more speech and language therapy", "source": "[24] CHSS 1 in 5 Aphasia Report (n=250, summer 2023)", "access": "full text"}
      ],
      "inference": "That the UK has no national long-term aphasia pathway artefact is an inference from its absence, not from an audit of pathway documents. The comparator (82 Australian best-practice statements across eight care areas) is evidence about Australia, not the UK.",
      "confidence": "medium (absence-based; the Australian comparator is not UK evidence)"
    },
    {
      "id": "BP9",
      "name": "Provision varies by geography (waiting times, vacancies, commissioning)",
      "stage": "Whole pathway",
      "documented_or_inferred": "documented",
      "evidence": [
        {"claim": "Waiting over 12 weeks for adult SLT: London 37.8%, South East 37.2%, East of England 18.7%", "source": "[7] House of Commons Library CDP-2025-0010", "access": "full text"},
        {"claim": "SLT vacancy: England 17%, London 21%, Scotland 12%, Northern Ireland 13%, NHS Wales 6%", "source": "[3] RCSLT Vacancy Survey 2025", "access": "full text"},
        {"claim": "Thrombectomy access 9% in Thames Valley vs about 2% in parts of the North East and North Cumbria and West Yorkshire (different pathway stage, shown as the general access pattern)", "source": "[8] Stroke Association 10 Year Health Plan response", "access": "full text"},
        {"claim": "No ringfenced central SLT funding; ICBs and local authorities decide spend", "source": "[7] House of Commons Library CDP-2025-0010", "access": "full text"}
      ],
      "inference": "Because funding is local, geographic variation in aphasia provision is expected; the waiting and vacancy figures corroborate it. The waiting figures are all-adult SLT, not aphasia-specific.",
      "confidence": "high (variation exists); medium (that it is aphasia-specific)"
    },
    {
      "id": "BP10",
      "name": "No aphasia-specific tariff, commissioning currency or ringfenced funding",
      "stage": "Commissioning",
      "documented_or_inferred": "inferred (from absence)",
      "evidence": [
        {"claim": "There is no ringfenced central funding for speech and language therapy; ICBs and local authorities decide", "source": "[7] House of Commons Library CDP-2025-0010", "access": "full text"}
      ],
      "inference": "No aphasia-specific tariff or commissioning currency was located in this run. That aphasia therapy has no separate line in the money is my inference from not finding one, and is weaker evidence than finding an explicit statement. Search was limited to the sources listed; a national tariff document would settle it.",
      "confidence": "low-medium (absence-based)"
    },
    {
      "id": "BP11",
      "name": "Psychological and emotional support almost absent for people with aphasia",
      "stage": "Whole pathway, worst after rehabilitation",
      "documented_or_inferred": "documented",
      "evidence": [
        {"claim": "52% of people with aphasia said their condition affects their mental health, but only 8% had accessed psychological or emotional support", "source": "[24] CHSS 1 in 5 Aphasia Report (Scotland, n=250)", "access": "full text"},
        {"claim": "Mental health services are often inaccessible to those with moderate to severe communication disability and are seen as under-skilled in working with aphasia", "source": "[25] Northcott et al. UK SLT survey", "access": "abstract/metadata"},
        {"claim": "SLTs reported time and caseload pressures, feeling under-skilled, and lack of specialist ongoing support as the main barriers to delivering psychosocial support", "source": "[25] Northcott et al.", "access": "abstract/metadata"},
        {"claim": "The guideline requires monitoring and assessment for depression and other mood disorders using validated tools, with tailored psychological interventions", "source": "[4] National Clinical Guideline for Stroke 2023", "access": "full text"}
      ],
      "inference": "The 52% vs 8% gap is the clearest quantified unmet-need finding in this lane, though it is Scotland-only and from a charity survey (interested party for CHSS services).",
      "confidence": "medium-high (Scotland); unknown for England, Wales, NI"
    },
    {
      "id": "BP12",
      "name": "Care-home residents are a distinct and under-measured access problem",
      "stage": "Long-term / residential care",
      "documented_or_inferred": "documented (existence of the problem); inferred (its size)",
      "evidence": [
        {"claim": "The SSNAP Post-acute Organisational Audit 2021 devotes a section (4.5) to treatment of patients in care homes", "source": "[11] SSNAP Post-acute Organisational Audit 2021", "access": "full text (section located, figures not extracted)"}
      ],
      "inference": "A dedicated audit section is evidence that care-home provision was recognised as a separate problem in 2021; the size of the gap today is not established here.",
      "confidence": "low (size); the section's existence is documented"
    },
    {
      "id": "BP13",
      "name": "Aphasia-specific inequity by ethnicity and deprivation is not measured",
      "stage": "Whole pathway (equity)",
      "documented_or_inferred": "documented (the general inequity); inferred (the aphasia-specific part)",
      "evidence": [
        {"claim": "People from all ethnic minorities received less therapy than white patients; men received more physical and speech therapy than women", "source": "[20] Imperial College therapy-predictor analysis", "access": "abstract/metadata"},
        {"claim": "Non-White patients were significantly more likely to attend a six-month review (Black OR 1.29, Asian OR 1.10) but still had worse outcomes and lower secondary prevention use", "source": "[15] PLOS ONE ethnicity and six-month care", "access": "full text abstract"},
        {"claim": "People from poorer backgrounds have their first stroke about seven years earlier", "source": "[9] Stroke Association accessible 10 Year Health Plan summary", "access": "full text"}
      ],
      "inference": "No source located measures aphasia-specific provision by ethnicity or deprivation; the general inequities are documented, the aphasia-specific ones are inferred. The two ethnicity findings point in different directions and are not averaged.",
      "confidence": "medium (general); low (aphasia-specific)"
    }
  ]
}