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Internal working evidence base, not a published report
Verdict: the problem is a dose and access problem, not a missing-intervention problem, and there is essentially no UK effectiveness evidence for any strategy proposed to fix it.
55 of 70 items confirmed at source 3 distinct corrections applied 1 claim killed 10 residuals carried 56 barriers documented, 8 inferred
Of about 76 distinct works, 42 are peer-reviewed papers and reviews (roughly a seventh read at abstract or metadata level only), 10 are national audit, guideline or official statistical sources, 5 are professional-body workforce surveys, 15 are charity self-report or provider pages, and 4 are implementation-taxonomy sources; and of the 64 barriers mapped to strategies, none has effectiveness evidence in a UK aphasia context. The composition split is this synthesis's own classification, made from the lanes' own access-level labels; the access labels themselves (full text, abstract only, metadata only) are the lanes' and are preserved per source.
Reading note. This is a consolidation, not new research: it adds nothing to the three lanes and the verification wave beyond assembly, and it was bound to the sources they delivered. Absolute numbers below are reproduced as the lanes stated them; where the verification wave changed a figure, the corrected figure appears and the change is recorded in the limits section.
Scope: adults with aphasia after stroke in UK services. Primary progressive aphasia is included only where a UK service explicitly covers it, and that is stated each time. Evidence about stroke aphasia only is labelled as such. Each treatment carries the lane's access level: full text, abstract only, metadata only, registry record or provider page.
Impairment-focused SLT (semantic and phonological therapy). The default UK model: therapy targeting the language impairment directly, usually word retrieval. Delivered by qualified speech and language therapists, sometimes with assistants undertaking practice, one-to-one and face-to-face. Guidance supports individualised impairment-focused therapy [1] [2]. Monnelly 2023, an e-survey of 227 UK SLTs, found impairment-based therapy delivered by 70 per cent and functional language therapy by 85 per cent [8]. Comparative head-to-head evidence on semantic versus phonological approaches is thin and mixed: one 2025 analysis of 63 participants reported differential effects, but it was read at abstract level only and its direction is [UNVERIFIED] [26]. The lane recorded no standalone manualised protocol for either package.
Constraint-induced and intensive language action approaches (CILT, CIAT-Plus, ILAT). High-intensity practice in which non-verbal communication is discouraged. The evidence base is contested: descriptive reviews report positive effects, but the systematic reviews that ran meta-analyses found CILT effects often did not surpass comparison treatments, concluding that intensity may be the potent factor rather than constraint itself, and the 2016 Cochrane review found no evidence of a difference between constraint therapy and conventional SLT [24] [5]. A Phase II trial nested in COMPARE found low-moderate intensity CIAT-Plus and M-MAT feasible and acceptable with preliminary efficacy [25]. No UK national rollout was found.
Comprehensive and high-dose programmes (ICAPs and CHAT). A systematic review included 21 studies covering 13 comprehensive programmes (485 participants), of which only 8 used an experimental design suitable for synthesis [9]; the guideline position is a strong recommendation for at least 20 hours rather than fewer than 20 (low-quality evidence) [3] [4], and the RELEASE individual-participant analysis behind it found the greatest language gain at 20 to 50 hours [6]. UK provision here is capacity, not delivery: 50 per cent of surveyed SLTs were aware of comprehensive programmes, 15 had been involved in provision, and only 16.5 per cent felt their service could be reconfigured to deliver one [8]. No fully commissioned NHS programme was found. The registry record for the first UK randomised trial reports a 4-week, 100-hour programme in 334 people, not yet recruiting, primary completion 2030 [30].
Conversation and communication partner training (CPT). Better Conversations with Aphasia is a UK, conversation-analysis-based programme delivered to the person with aphasia and their partner, free to SLTs through the UCL resource [17] [18]. The 2026 intensive group programme delivered 26 hours over two weeks in groups of four or five family dyads; its authors state plainly that there is no research evidence about optimal intensity or dosage for CPT [15]. BCPPA plus is a UK NHS-embedded telehealth protocol for primary progressive aphasia and other rare dementias, the only intervention found that explicitly covers PPA; it delivers four to six one-hour sessions, the number jointly decided by the person, their partner and the treating therapist, and it is delivered by a research assistant who is a highly specialist HCPC-registered SLT (over 80 per cent of delivery) or by a local collaborator SLT, under supervision [16].
Technology and telepractice. Big CACTUS, a UK multicentre randomised trial in 278 people across 21 NHS SLT departments, found a word-finding improvement of 16.2 percentage points over usual care (above the pre-specified 10 per cent clinical importance threshold) but no improvement in conversation or quality of life [12]. Remote LUNA met all feasibility criteria (20 hours over ten weeks, 85 per cent consented, 86 per cent retained, 92 per cent treatment fidelity) with medium to large preliminary effect sizes [11]. TeleCHAT delivered 50 hours over eight weeks in Australia (14 hours each of impairment, functional and computer-based therapy plus 8 hours of psychosocial group therapy; nine of twelve participants received the full dose); no UK equivalent was found [13]. Guidance supports computer-based word-finding programmes alongside face-to-face therapy [1] and states that telerehabilitation should not be used as an alternative to in-person rehabilitation [2].
Adjuncts: befriending, self-management and mood. SUPERB, a UK feasibility trial, delivered six one-hour peer-befriending visits over three months plus two optional transition sessions; ten peer-befrienders were trained for 4 to 6 hours; a pilot economic evaluation estimated about 57.24 pounds per visit, cost-effective in 39 to 66 per cent of simulations [21] [22] [23]. Aphasia ASK, an Australian cluster randomised trial built to prevent depression, was null for mood and only 41 of the 171 who received treatment met the prescribed minimum dose; no UK equivalent was found [19] [20]. The Stroke Association communication support service is a provider description only, with no independent evaluation of dose or outcome [27] [28]. StarStep, a supported self-management protocol, is at protocol stage with no outcome results [34].
Twelve-item TIDieR rows were completed for the twelve interventions with a retrievable description. Table 1 shows, for every treatment, whether each TIDieR item was reported (Y), partly reported (P) or not reported (N) in the retrieved source. Table 2 shows the load-bearing items in full. The complete answer, source and reported flag for every cell sit in the machine-readable base.
Table 1, TIDieR item completeness. Columns 1 to 12 are the TIDieR items: 1 brief name, 2 why, 3 what (materials), 4 what (procedures), 5 who provided, 6 how (mode), 7 where, 8 when and how much, 9 tailoring, 10 modifications, 11 fidelity planned, 12 fidelity actual.
| Treatment | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Impairment-focused SLT: semantic therapy | Y | P | N | P | P | N | N | Y | N | N | N | N |
| Impairment-focused SLT: phonological therapy | Y | P | N | P | P | N | N | Y | N | N | N | N |
| Constraint-Induced Language Therapy (CILT / CIAT-Plus / ILAT) | Y | Y | Y | Y | Y | Y | N | Y | N | Y | N | N |
| Intensive Comprehensive Aphasia Programme (ICAP), generic model | Y | Y | P | P | Y | Y | P | Y | Y | N | N | P |
| Remote LUNA (Language Underpins Narrative in Aphasia) discourse therapy | Y | Y | Y | Y | P | Y | Y | Y | Y | Y | Y | Y |
| Better Conversations with Aphasia (BCA) communication partner training | Y | Y | Y | Y | P | Y | N | Y | Y | N | N | N |
| Better Conversations intensive conversation groups (non-progressive aphasia and PPA) | Y | Y | P | Y | Y | Y | Y | Y | Y | P | N | N |
| BCPPA plus (Better Conversations with Primary Progressive Aphasia and other rare dementias), telehealth | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | Y | N |
| Self-managed computerised speech and language therapy (Big CACTUS / StepByStep) | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | Y | P |
| SUPERB peer-befriending | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | Y | Y |
| Aphasia ASK (Aphasia Action Success Knowledge) | Y | Y | Y | P | Y | P | Y | Y | P | N | Y | Y |
| Stroke Association Communication Support Service (incl. Northern Ireland 8-week groups and AOL) | Y | Y | N | Y | Y | Y | Y | P | Y | N | N | N |
Table 2, TIDieR load-bearing items.
| Treatment | 5 Who provided | 6 Mode | 7 Where | 8 When and how much | 11 Fidelity planned | 12 Fidelity actual |
|---|---|---|---|---|---|---|
| Impairment-focused SLT: semantic therapy | Speech and language therapist | Not reported | Not reported | Three weeks of semantic treatment in the comparison trial (63 participants with chronic aphasia) | Not reported | Not reported |
| Impairment-focused SLT: phonological therapy | Speech and language therapist | Not reported | Not reported | Three weeks of phonological treatment in the comparison trial | Not reported | Not reported |
| Constraint-Induced Language Therapy (CILT / CIAT-Plus / ILAT) | Speech and language therapist | Group, face-to-face | Not reported (Cochrane description) | About 30 h over 2 weeks (classic); COMPARE 15 h/week x 2 weeks; low-moderate 6 h/week x 5 weeks | Not reported | Not reported |
| Intensive Comprehensive Aphasia Programme (ICAP), generic model | Interdisciplinary team | Multiple formats (individual and group) | Varies (research clinic or healthcare setting); no standard | Commonly 3-5 h/day over 2-6 weeks; ESO specifies >=20 h total, >=3 h/week, >=4 days/week | Not standardised across programmes | Not standardised; only 8 of 21 studies had a design suitable for synthesis |
| Remote LUNA (Language Underpins Narrative in Aphasia) discourse therapy | Speech and language therapist | One-to-one, remote via Zoom | Participant's home (remote delivery) | 20 h: 2 sessions/week of 60 min for 10 weeks | Fidelity assessed; 92% adherence to manual | 87% of sessions delivered as scheduled; 79% completed >=80% of programme; fidelity 92% |
| Better Conversations with Aphasia (BCA) communication partner training | Speech and language therapist (programme delivered to the dyad) | Dyadic one-to-one sessions with video feedback | Not reported | 8 x 1-hour sessions, once weekly | Not reported | Not reported |
| Better Conversations intensive conversation groups (non-progressive aphasia and PPA) | Two student SLTs, four qualified SLTs, one artist-researcher | Group; 4 days face-to-face and 4 days remote synchronous (Zoom) | University clinic | 26 h total; 2.5-3 h/day, 4 days/week over 2 weeks | Not reported | Not reported |
| BCPPA plus (Better Conversations with Primary Progressive Aphasia and other rare dementias), telehealth | Delivered by a research assistant who is a highly specialist HCPC-registered SLT (over 80% of delivery) or by a local collaborator SLT, under supervision from the... | Dyadic; telehealth | NHS sites; remote delivery to participants | 4-6 x 1-hour sessions over 4-6 weeks; session number decided by person, partner and SLT | Fidelity rating planned (consent to video recording for fidelity rating) | Not reported (protocol stage) |
| Self-managed computerised speech and language therapy (Big CACTUS / StepByStep) | Qualified SLT sets the plan; volunteers or therapy assistants visit to support | Self-managed computer practice at home, supported by occasional in-person visits | Participants' own homes | 20-30 min practice daily over 6 months; volunteers/assistants visit >=1 h once per month | TIDieR template used to describe the intervention | Self-managed practice enabled increased therapy amounts; adherence reported as feasible and acceptable |
| SUPERB peer-befriending | 10 peer-befrienders, >=1 year post-stroke, trained 4-6 h | One-to-one, in person, at home | Community / participant's home | Six 1-hour visits over 3 months, plus two optional sessions | Fidelity evaluated across all areas of the Behaviour Change Consortium framework | Fidelity reported; median 14 of 25 group supervision sessions and 7.5 of 8 individual sessions attended |
| Aphasia ASK (Aphasia Action Success Knowledge) | Speech pathologists trained 5-6 h (in person or online) by trial managers; trained to deliver one intervention only | Not fully reported; delivered at a location convenient to participants, usually hospital or home | Usually hospital or home | Manualised over 6-8 weeks followed by monthly telephone calls | Fidelity protocol developed; sessions video-recorded and reviewed by a fidelity monitor; dose set a priori | Only 41 of 171 who received treatment met the prescribed minimum dose |
| Stroke Association Communication Support Service (incl. Northern Ireland 8-week groups and AOL) | Communication support coordinators; NI service SLT-led | One-to-one, group, workshop, online (Zoom) | Community; home visits, group meetings, online | Not reported in full; NI 8-week groups; AOL fortnightly | Not reported | Not reported |
| Treatment | Delivered dose found | Source |
|---|---|---|
| Impairment-focused SLT (routine) | Mean 128 min/week across services; median 6.3 h per 3 months in the community | [8] [7] |
| Remote LUNA | 20 h over 10 weeks, 2 sessions of 60 min per week | [11] |
| Big CACTUS computerised therapy | 20 to 30 min daily for 6 months, plus at least 1 h/month volunteer support | [12] |
| Better Conversations with Aphasia (CPT) | 8 sessions of 1 h, once weekly | [15] [17] |
| Better Conversations intensive groups | 26 h over 2 weeks, 2.5 to 3 h/day, 4 days/week | [15] |
| BCPPA plus (PPA) | 4 to 6 sessions of 1 h over 4 to 6 weeks | [16] |
| SUPERB peer-befriending | 6 visits of 1 h over 3 months | [21] |
| Aphasia ASK (Australia, no UK equivalent) | Manualised over 6 to 8 weeks, then monthly telephone calls | [19] |
| TeleCHAT (Australia, no UK equivalent) | 50 h over 8 weeks | [13] |
Read against the ESO threshold of at least 20 hours total and at least 3 hours per week [3], routine UK impairment-focused provision sits below the intensity threshold at about 2.1 hours per week [8], and the total dose over three months is closer to a tenth of the guideline figure [7]. The delivered UK interventions that do reach 20 hours or more are single studies with defined protocols, not routine provision. The professional body welcomed the increase in recommended daily therapy in the 2023 national guideline but warned that the three-hours-a-day target may be unachievable within current staffing [32].
What this means (the lane's own inference, not an observation): the gap is delivery and dose, not absence of a describable intervention. Every treatment a UK commissioner might buy, except the generic comprehensive model and the charity group service, has a published protocol with a dose attached. The missing link is not a treatment description; it is a commissioned UK pathway that delivers one at the guideline dose.
Sources cited in this section: [1] [2] [3] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35]
The audited scale of the pathway: SSNAP covered 92,414 stroke admissions across 250 hospitals, 195 community services and 184 six-month follow-up providers in 2024/25 [36]. The pathway is nationally specified and locally commissioned. There is no ringfenced central funding for speech and language therapy; integrated care boards and local authorities decide local spend [41], which is the structural reason provision varies by geography.
Acute assessment is the audited gateway, and it is missed for over half. The 2023 national guideline requires early assessment by a speech and language therapist [2]; SSNAP operationalises it as assessment within 72 hours of clock start. On the figures carried from the vault and not re-derived at primary source, 46.8 per cent are assessed within 72 hours, 24.8 per cent within 24 hours, and 7.6 per cent receive no assessment for organisational reasons (all [UNVERIFIED at primary source]: definitions confirmed, point values not) [36] [44] [53].
Inpatient therapy intensity is modest and, uniquely in SLT, declining. Only 35.4 per cent of patients receive the NICE target total therapy dose (128 minutes a day) [UNVERIFIED at primary source] [36]. The SSNAP therapy spotlight report finds a decline since 2022/23 in the standard of receiving 45 minutes of therapy five days per week in speech and language therapy, while the other disciplines were unchanged [44]. Reporting is shaped by a measurement convention: the audit weights the caseload as 50 per cent requiring SLT, against 80 per cent for occupational therapy and 85 per cent for physiotherapy [53].
Discharge to specialist community rehabilitation has grown but is incomplete. In 2024/25, 66.6 per cent of patients were discharged to a stroke or neurology specific community rehabilitation service, 23.1 per cent of those to a combined early-supported-discharge and community-rehabilitation team, up from 41 per cent in 2013/14 [36]. About one third leave hospital without a stroke-specific community rehabilitation service; the aphasia-specific share of that third is not measured. The intended destination is the Integrated Community Stroke Service model: a seven-day service carrying early supported discharge, high-intensity needs-based community rehabilitation, disability management, six-month reviews and longer-term support [40].
Community teams are frequently under-resourced against recommended staffing. Fewer than one third of community-based teams met recommended staffing levels per patient, and fewer than 50 per cent of inpatient services met recommended levels [45]. Only 17 per cent of community-based services had appropriate access to all the core disciplines of physiotherapy, occupational therapy and speech and language therapy [42] [45]. The recommended SLT establishment in community-based teams is 0.4 whole-time equivalents per 100 patients (corrected on verification; the lane had written "per unit") [45].
Long-term review is the last formal checkpoint, and it is moving the wrong way. In 2024/25 only 35.1 per cent of applicable patients received a six-month review, down from 39 per cent in 2023/24, continuing a decline since 2019/20 [36]; delivery was 14.7 per cent in person, 18.8 per cent by telephone and 0.4 per cent by post, with no online follow-up recorded [36]. The national target was to raise six-month reviews from 29 per cent to 90 per cent [47]. After six months the UK has no further structured checkpoint, and long-term support is voluntary-sector dependent [59]. The two charity and audit figures for the same measure disagree (the Stroke Association's response states 39 per cent for 2024-25 against SSNAP's 35.1 per cent); the lane flags the contradiction and does not average it, and verification agrees with that treatment [36] [42].
Each breakpoint separates what the source documents from what the lane inferred from the pattern or from an absence. The split is preserved here: 11 rows carry a documented label and 4 an inferred label, two of them both, so the partition is 9 documented only, 2 inferred only and 2 both, with the sub-labels the lane applied.
| ID | Breakpoint | Stage | Documented or inferred | Confidence as stated |
|---|---|---|---|---|
| BP1 | Acute SLT assessment missing for over half of patients | Inpatient, first 72 hours | documented | high (guideline and indicator); medium (exact percentage) |
| BP2 | Inpatient SLT dose below the guideline standard, and uniquely declining | Inpatient therapy | documented | high (direction); medium (magnitude) |
| BP3 | Hospital discharge without a stroke-specific community rehabilitation service | Transition to community | documented | high (headline); low (aphasia-specific split) |
| BP4 | Early supported discharge not universally available (around one fifth of hospitals; charity claim) | Early supported discharge | documented (charity claim) | medium (interested-party claim) |
| BP5 | Community teams under-resourced against recommended staffing and discipline access | Community rehabilitation | documented | high (structure); SLT ratio provisional |
| BP6 | Persistent SLT workforce vacancy constraining supply | Whole pathway | documented | high (figures); voluntary surveys, not a census |
| BP7 | Six-month review decline, far below the national ambition | Long-term follow-up | documented | high |
| BP8 | No structured checkpoint after six months; long-term support is voluntary-sector dependent | Life after stroke | inferred (from an absence) | medium; the Australian comparator is not UK evidence |
| BP9 | Provision varies by geography (waiting times, vacancies, commissioning) | Whole pathway | documented | high (variation); medium (aphasia-specific) |
| BP10 | No aphasia-specific tariff, commissioning currency or ringfenced funding located | Commissioning | inferred (from absence) | low to medium (absence-based) |
| BP11 | Psychological and emotional support almost absent for people with aphasia | Whole pathway | documented | medium to high (Scotland); unknown elsewhere |
| BP12 | Care-home residents are a distinct and under-measured access problem | Residential care | documented (existence) inferred (size) | low (size); the audit section exists |
| BP13 | Aphasia-specific inequity by ethnicity and deprivation is not measured | Equity | documented (general) inferred (aphasia-specific) | medium (general); low (aphasia-specific) |
Two context findings the lane recorded rather than smoothed. First, an SSNAP-linked analysis found non-White patients were significantly more likely to attend a six-month review (Black patients odds ratio 1.29, Asian patients 1.10) while still experiencing worse outcomes, whereas a separate analysis found ethnic-minority patients received less therapy than white patients [49] [54]; the two point in different directions and are not averaged. Second, the six-month review figure of 35.1 per cent and the charity's stated 39 per cent for the same year cannot both be right on the same denominator, and the audited figure is preferred [36] [42]. Aphasia-specific prevalence is claimed as "1 in 3 stroke survivors"; the underlying work puts the baseline in the 30 to 35 per cent band depending on ascertainment, so treat "1 in 3" as a round figure, not a measurement [58].
Sources cited in this section: [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61]
Sixty-four barriers were mapped to implementation strategies. The map preserves the lanes' vocabulary exactly: each row names a CFIR domain and the construct as the lane coded it, states the barrier, marks it documented or inferred, and names one ERIC strategy and its ERIC cluster, with an evidence_standing column. The lane's own vocabulary is used throughout; where a construct name is a CFIR 1.0 or 2.0 label or a COM-B label, that is how it appears, not normalised.
| evidence_standing | Count | What it means, in the lane's definition |
|---|---|---|
| validated_uk | 0 | effectiveness evidence for this strategy in UK aphasia or a closely comparable UK context |
| validated_other | 8 | effectiveness evidence exists, but not in UK aphasia (mostly generic implementation-strategy trials in stroke rehabilitation) |
| mapped_only | 47 | in the published matching set; no effectiveness evidence found (search recorded) |
| untested | 9 | no evidence located; mapping is plausible reasoning only |
Documented 56, inferred 8. By CFIR domain: Inner Setting 16, Outer Setting 15, Implementation Process 13, Individuals 12, Innovation Characteristics 8. Distinct ERIC strategies used: 40; distinct ERIC clusters: 9.
This distribution is the finding, not a failure of the work.
None of the 64 mapped strategies carries effectiveness evidence in a UK aphasia context. The map can be produced but cannot be backed by a body of evaluated UK aphasia implementation strategies. It is the local shape of the CFIR-ERIC validation deficit: a scoping review of 53 studies using the matching tool found that 96.23 per cent formulated strategies from the tool but only 15.69 per cent validated them and 7.84 per cent evaluated whether they worked [69]. Anyone reading the map as a menu of proven fixes would be misreading it. It is a set of defensible hypotheses about what to try, ranked only by whether the strategy has any effectiveness evidence anywhere.
The "Doc / inf" column preserves the lane's documented-versus-inferred split. The "Evidence standing" column preserves validated_uk / validated_other / mapped_only / untested exactly. No categories have been merged.
| Domain | Construct (as the lane coded it) | Barrier | Doc / inf | ERIC strategy | ERIC cluster | Evidence standing |
|---|---|---|---|---|---|---|
| Innovation | Relative Advantage | CPT / conversation-focused therapy is not recognised in workload or as direct intervention; 'gold standard but not essential', deprioritised against dysphagia. | documented | Inform local opinion leaders | Develop stakeholder interrelationships | mapped_only |
| Innovation | Relative Advantage | Current community provision is below any effective dose (~6.3 h per 3 months; mean 128 min/week against a 45 min/day x 5 day guideline), so the innovation's advantage is not demonstrable in the status quo. | documented | Promote adaptability | Adapt and tailor to context | mapped_only |
| Innovation | Complexity | No standardised approach: 'different SLTs mean different things by CPT'; no structured manual; conceptual confusion about what CPT is. | documented | Develop a formal implementation blueprint | Use evaluative and iterative strategies | mapped_only |
| Innovation | Complexity | ICAP/comprehensive therapy is operationally difficult to configure within mainstream services; only 16.5% of services felt able to deliver an ICAP. | documented | Promote adaptability | Adapt and tailor to context | mapped_only |
| Innovation | Cost | Cost-effectiveness of intensive/comprehensive aphasia therapy is not established; a 100-hour multidisciplinary programme is resource-intensive. | documented | Fund and contract for the clinical innovation | Utilize financial strategies | untested |
| Innovation | Evidence Strength and Quality | Uncertainty about the effectiveness of comprehensive models weakens the case for investment (first definitive ICAP RCT reports 2030). | documented | Capture and share local knowledge | Develop stakeholder interrelationships | mapped_only |
| Outer Setting | Policy and Incentives | Lack of national and/or local funding due to ICB deficits is the top reported challenge to delivering stroke rehabilitation. | documented | Access new funding | Utilize financial strategies | untested |
| Outer Setting | Policy and Incentives | Only one third of ICSs prioritised stroke in their Joint Forward plans; ISDNs are not consistently funded by their ICB. | documented | Involve executive boards | Develop stakeholder interrelationships | mapped_only |
| Outer Setting | Policy and Incentives | CPT is invisible in the national stroke audit (SSNAP does not distinguish CPT from impairment-based therapy or dysphagia), so there is no national measurement or feedback loop. | documented | Develop and organize quality monitoring systems | Use evaluative and iterative strategies | mapped_only |
| Outer Setting | Policy and Incentives | Aphasia is undercounted nationally: SSNAP records presence/absence on NIHSS item 9 (~72% sensitivity) with no severity, type or standardised screener. | documented | Develop and implement tools for quality monitoring | Use evaluative and iterative strategies | mapped_only |
| Outer Setting | Policy and Incentives | The six-month cliff-edge: only 35% of stroke survivors received a six-month review in 2024/25 (39% in 2023/24), leaving ~60,000/yr with no formal review. | documented | Change record systems | Change infrastructure | mapped_only |
| Outer Setting | External Pressure | Resources are skewed towards acute provision, leaving community rehabilitation under-resourced; there is variation in access and some survivors pay privately. | documented | Alter incentive/allowance structures | Utilize financial strategies | untested |
| Outer Setting | Local Conditions | Geographical variation in therapy intensity (c.60-180 min/week by region) and in service capacity raises equity concerns. | documented | Tailor strategies | Adapt and tailor to context | validated_other |
| Outer Setting | Local Conditions | Transport and geography (rural/remote access) restrict face-to-face attendance; pre-pandemic UK data show ~1 h 23 min/week post-discharge in the North West. | documented | Change service sites | Change infrastructure | untested |
| Outer Setting | Local Conditions | Digital exclusion: telehealth access depends on a carer/relative being present and capable, excluding people with aphasia who live alone. | documented | Prepare patients/consumers to be active participants | Engage consumers | mapped_only |
| Outer Setting | Patient Needs and Resources | Half of people with aphasia (50%) report support they needed but could not access, the top unmet need being more speech and language therapy (24%). | documented | Conduct local needs assessment | Use evaluative and iterative strategies | mapped_only |
| Outer Setting | Patient Needs and Resources | Two thirds (67%) of people with aphasia report some difficulty accessing services. | documented | Involve patients/consumers and family members | Engage consumers | mapped_only |
| Outer Setting | Local Attitudes | Cultural and linguistic barriers: only 23% of the national workforce feels confident adapting CPT for non-English speakers; materials are absent in other languages and interpreters are unreliable. | documented | Tailor strategies | Adapt and tailor to context | validated_other |
| Outer Setting | Local Attitudes | Societal attitudes and stigma: 48% of people with aphasia report loneliness (vs 34% of all stroke survivors); friends disappear. | documented | Use mass media | Engage consumers | untested |
| Inner Setting | Structural Characteristics | Fewer than a third of community-based rehabilitation teams meet recommended staffing levels; less than 50% of inpatient services meet any core-discipline level. | documented | Revise professional roles | Support clinicians | mapped_only |
| Inner Setting | Structural Characteristics | Only 17% of community-based services have appropriate access to all core disciplines (PT, OT, SLT). | documented | Recruit, designate, and train for leadership | Develop stakeholder interrelationships | mapped_only |
| Inner Setting | Structural Characteristics | SLT workforce shortage: 14% overall vacancy, 14% in NHS adult services, 21% in London; 23% in the independent sector. | documented | Access new funding | Utilize financial strategies | untested |
| Inner Setting | Structural Characteristics | Under-represented disciplines (psychology, dietetics, social work, family/carer support) and a lack of band-4/assistant staff in stroke rehabilitation teams. | documented | Create new clinical teams | Support clinicians | mapped_only |
| Inner Setting | Networks and Communications | No standardised referral pathway for CPT; inconsistent referral/recruitment (ImPACT recruited 41 of 504 pooled dyads). | documented | Build a coalition | Develop stakeholder interrelationships | mapped_only |
| Inner Setting | Networks and Communications | Interpreters are not always available for the critical first session and lack aphasia training. | documented | Develop resource sharing agreements | Support clinicians | mapped_only |
| Inner Setting | Culture | Competing priorities and deprioritisation: CPT is not recognised in workload and is squeezed by dysphagia and impairment targets. | documented | Conduct local consensus discussions | Develop stakeholder interrelationships | mapped_only |
| Inner Setting | Culture | Staff moral injury: clinicians experience distress and overwhelm at knowing the standard but being unable to deliver it. | documented | Provide ongoing consultation | Train and educate stakeholders | mapped_only |
| Inner Setting | Implementation Climate | Time and caseload pressures are the most frequent barrier to delivering psychosocial/family work (72% of surveyed UK SLTs). | documented | Facilitation | Provide interactive assistance | validated_other |
| Inner Setting | Implementation Climate | Staff turnover and loss of a local champion derailed implementation in some teams; change fatigue reported. | documented | Identify and prepare champions | Develop stakeholder interrelationships | mapped_only |
| Inner Setting | Implementation Climate | Poor 'fit' between the innovation and the team's organisational structure; simultaneous delivery of other systems (e.g. parallel goal-setting tools) impeded adoption. | documented | Model and simulate change | Develop stakeholder interrelationships | mapped_only |
| Inner Setting | Readiness for Implementation | Limited leadership engagement from team leaders/managers is a documented barrier to implementation. | documented | Recruit, designate, and train for leadership | Develop stakeholder interrelationships | mapped_only |
| Inner Setting | Readiness for Implementation | Practice changes were not sustained: short-term CPT provision improved but gains were not maintained due to organisational barriers. | documented | Purposefully reexamine the implementation | Use evaluative and iterative strategies | mapped_only |
| Inner Setting | Resources (Access to Knowledge and Information) | Only 23% of community-based teams offered stroke-specific training for all disciplines. | documented | Conduct ongoing training | Train and educate stakeholders | mapped_only |
| Inner Setting | Resources | Funding, printing and materials constraints: most SLTs lack access to resources; no time to prepare materials. | documented | Develop resource sharing agreements | Support clinicians | mapped_only |
| Individuals | Deliverers: Knowledge and Beliefs | Most SLTs had received no CPT training at all; knowledge gaps about the intervention. | documented | Conduct educational meetings | Train and educate stakeholders | validated_other |
| Individuals | Deliverers: Knowledge and Beliefs | The video-feedback component is rated essential by almost all SLTs but very few use it: the largest single evidence-practice gap. | documented | Make training dynamic | Train and educate stakeholders | mapped_only |
| Individuals | Deliverers: Self-efficacy and Confidence | Only 42% of surveyed UK SLTs felt confident addressing clients' psychological needs. | documented | Provide clinical supervision | Provide interactive assistance | mapped_only |
| Individuals | Deliverers: Self-efficacy and Confidence | Just over half of SLTs feel they have the skills to manage emotional/relationship issues; fewer than half are confident using video. | documented | Provide ongoing consultation | Train and educate stakeholders | mapped_only |
| Individuals | Deliverers: Capability (COM-B) / Knowledge | 77% of the workforce does not feel equipped to adapt CPT for non-English speakers. | documented | Conduct ongoing training | Train and educate stakeholders | mapped_only |
| Individuals | Deliverers: Capability / Skills | SLT scope is heavily oriented to impairment-level work (naming, repetition, comprehension) with little family involvement, psychosocial support, employment or participation work. | documented | Work with educational institutions | Train and educate stakeholders | mapped_only |
| Individuals | Deliverers: Motivation / Personal Attributes | Existing clinician knowledge shapes how training is 'heard'; operationalisation drift means the same strategy is enacted differently by different clinicians. | documented | Conduct local consensus discussions | Develop stakeholder interrelationships | mapped_only |
| Individuals | Recipients (Patients/Clients): Characteristics | Many people with aphasia have no consistent communication partner; family attendance at therapy is often low. | documented | Involve patients/consumers and family members | Engage consumers | mapped_only |
| Individuals | Recipients: Motivation / Beliefs about Consequences | Family and client preference for direct therapy; CPT can be read as 'giving up' or 'no hope for improvement'. | documented | Intervene with patients/consumers to enhance uptake and adherence | Engage consumers | mapped_only |
| Individuals | Recipients (Families): Characteristics | Carer burden and unmet carer need: 81% of people with aphasia are cared for by a family member or friend; communication partners are not assessed at all. | documented | Prepare patients/consumers to be active participants | Engage consumers | mapped_only |
| Individuals | Recipients: Opportunity (COM-B) | Equity gap: people without an advocate 'fall by the wayside'; access is shaped by financial and cognitive capacity to push for services. | documented | Increase demand | Engage consumers | mapped_only |
| Implementation Process | Planning | Training is not coupled to implementation planning: staff were prepared to deliver the innovation but not to plan, monitor and tailor its local implementation. | documented | Develop a formal implementation blueprint | Use evaluative and iterative strategies | mapped_only |
| Implementation Process | Planning / Assessing Context | No formal context/readiness assessment before implementation: services adopt innovations without evaluating inner/outer setting readiness. | documented | Assess for readiness and identify barriers and facilitators | Use evaluative and iterative strategies | mapped_only |
| Implementation Process | Planning | Delays between training and implementation (staged referral, waiting lists) let momentum dissipate before delivery begins. | documented | Stage implementation scale up | Use evaluative and iterative strategies | mapped_only |
| Implementation Process | Engaging | No co-design or coproduction with people with aphasia and families in service design; recipients are consulted late or not at all. | documented | Involve patients/consumers and family members | Engage consumers | mapped_only |
| Implementation Process | Engaging | Information and education gaps: aphasia education is delivered but the purpose and value of CPT are not understood by communication partners. | documented | Develop educational materials | Train and educate stakeholders | validated_other |
| Implementation Process | Engaging | Goal-setting difficulties: goal tools 'don't get to the heart of it'; families want to be told what to do; goals change between sessions. | documented | Conduct local consensus discussions | Develop stakeholder interrelationships | mapped_only |
| Implementation Process | Executing | SLT assistants are underutilised: 88% of SLTs deliver CPT alone; Band 3/4 staff lack CPT-specific training and supervision. | documented | Revise professional roles | Support clinicians | mapped_only |
| Implementation Process | Executing | Follow-up and continuity are not executed: no long-term follow-up pathway exists after the six-week block; ~3 h total therapy over 6 weeks. | documented | Change service sites | Change infrastructure | untested |
| Implementation Process | Reflecting and Evaluating | Lack of ongoing local monitoring, evaluation and tailoring of implementation; no site-specific performance feedback. | documented | Develop and organize quality monitoring systems | Use evaluative and iterative strategies | mapped_only |
| Implementation Process | Reflecting and Evaluating | The CFIR-ERIC cascade: across 53 studies using the matching tool, 96.23% formulated strategies but only 15.69% validated them and 7.84% evaluated effectiveness. | documented | Purposefully reexamine the implementation | Use evaluative and iterative strategies | mapped_only |
| Implementation Process | Reflecting and Evaluating | Matched strategies are selected from a taxonomy without mechanism specification, so failure is undiagnosable and nothing specific is validated. | documented | Audit and provide feedback | Use evaluative and iterative strategies | validated_other |
| Innovation | Cost | INFERRED: the true economic case is likely understated because SSNAP's health-economics methodology was not built around communication outcomes. | inferred | Fund and contract for the clinical innovation | Utilize financial strategies | untested |
| Outer Setting | Local Conditions | INFERRED: outer-setting funding and inner-setting capacity interact non-linearly (a funded service still fails without staff), a pattern CFIR's interaction deletion cannot represent. | inferred | Tailor strategies | Adapt and tailor to context | validated_other |
| Outer Setting | External Pressure | INFERRED: commissioning cycles and contract durations may be misaligned with intervention timeframes, sustaining a revolving-door pattern of short programmes. | inferred | Alter incentive/allowance structures | Utilize financial strategies | untested |
| Inner Setting | Implementation Climate | INFERRED: deprioritisation and time pressure compound, so the constraint is not any single barrier but their conjunction ('deal breakers' interact). | inferred | Conduct cyclical small tests of change | Use evaluative and iterative strategies | mapped_only |
| Individuals | Recipients: Motivation | INFERRED: patient and carer readiness is dynamically shaped by relationship and timing, not a fixed trait, so a single pre-implementation assessment will misclassify dyads. | inferred | Assess for readiness and identify barriers and facilitators | Use evaluative and iterative strategies | mapped_only |
| Implementation Process | Planning | INFERRED: because determinants are measured at baseline only, teams cannot tell which barrier was consequential when, and so target the wrong strategy. | inferred | Conduct local needs assessment | Use evaluative and iterative strategies | mapped_only |
| Implementation Process | Engaging | INFERRED: equity of reach is not modelled by any implementation plan, so improvement in aggregate uptake can mask worsening inequality of access. | inferred | Capture and share local knowledge | Develop stakeholder interrelationships | mapped_only |
| Innovation | Design Quality and Packaging | INFERRED: the paucity of aphasia-accessible trial materials/consent is itself a barrier to the evidence base that would justify provision. | inferred | Develop educational materials | Train and educate stakeholders | validated_other |
How to read the map in practice. Take the rows whose evidence_standing is validated_other first, but read their evidence in its original setting: a generic implementation trial in stroke rehabilitation is not a UK aphasia effectiveness result. Treat mapped_only and untested as hypotheses to test, not as interventions to buy. The most-attacked barriers in the map, in the lanes' own ordering, were the dose shortfall, the absence of a standardised approach, and the workforce and skill mix constraints, each of which sits in more than one domain.
Sources cited in this section: [62] [63] [64] [65] [66] [67] [68] [69] [70] [71] [72] [73] [74] [75] [76] [77] [78] [79] [80] [81]
The verification wave re-fetched every load-bearing number at source on 16 October 2026 and checked 70 items across the three lanes: 55 confirmed verbatim, 4 corrected (3 distinct corrections), 1 killed, 10 unverifiable. The lanes are substantially right on the numbers that carry the argument. The corrections are narrow and are applied in this base:
No correction changes a conclusion. The three most load-bearing claims were attacked directly and all three survived: the dose gap, the falling six-month review, and the absence of UK effectiveness evidence for the mapped strategies.
This is an internal working artefact, not a published report, and it should be read as one. The composition, counted by distinct work:
These are the items that could not be re-verified at primary source. They are carried with the confidence the verification wave assigned, not dropped:
Sources cited in this section: [7] [9] [10] [12] [13] [16] [19] [24] [25] [26] [27] [30] [31] [33] [36] [41] [42] [45] [46] [49] [50] [53] [54] [56] [59] [60] [80] [81]
Eighty-one registered source URLs, numbered once across the whole base. A handful are mirrors or page-variants of the same document (the NICE NG236 page, the ESO guideline, Monnelly 2023, the SSNAP post-acute audit and the Hilari telehealth survey each appear under two URLs); collapsing those gives about 76 distinct works. The lane each source entered through is shown.