Speech, Language and Communication As a Public Health Issue

Speech, language and communication as a Public Health issue

Context

1.1 In my role as government’s Communication Champion for children, I have now visited over half of the 152 local authority/Primary Care Trust partnerships in England. I have been struck by the high-impact work of speech and language therapy teams in many of these areas to tackle language delay at a population level.

1.2For reasons given below, it is clear to me that this work has an important public health function.

2Rationale for a public health role for speech and language therapists

2.1 The link to adult outcomes

2.11Children’s early language skills are powerful predictors of later life chances. After controlling for a range of other factors that might have played a part (mother’s educational level, overcrowding, low birth weight, parent a poor reader, etc), children who had normal non-verbal skills but a poor vocabulary at age 5 are at age 34 one and a half times more likely to have mental health problems and more than twice as likely to be unemployed than children who had normally developing language at age 5 (Law et al., 2010)

2.12 As well as being an independent predictor of adult outcomes, language skills are a critical factor in social disadvantage and in the intergenerational cycles that perpetuate poverty. Poor language skills are the key reason why, by the age of 22 months, a more able child from a low income home will begin to be overtaken in their developmental levels by an initially less able child from a high-income home – and why by the age of five, the gap has widened still more.

2.13 Research in the USA found that on average a toddler from a family on welfare will hear around 600 words per hour, with a ratio of two prohibitions (‘stop that’, ‘get down off there’) to one encouraging comment. A child from a professional family will hear over 2000 words per hour, with a ratio of six encouraging comments to one negative (Hart and Risley, 2003).

2.14 Low income children lag their high income counterparts at school entry by sixteen months in vocabulary. The gap in language is very much larger than gaps inother cognitive skills (Waldfogel and Washbrook, 2010).

2.15 Vocabulary at age 5 has been found to be the best predictor (from a range of measures at age 5 and 10) of whether children who experienced social deprivation in childhood were able to ‘buck the trend’ and escape poverty in later adult life (Blanden, 2006).

2.16 As the Marmot Review has shown, poor health in adulthood is strongly related to poverty and to factors in early childhood that affect development. Marmot found that “giving every child the best start in life is crucial to reducing health inequalities across the life course. What happens during the early years has lifelong effects on many aspects of health and well-being – from obesity, heart disease and mental health, to educational achievement and economic status. To have an impact on health inequalities we need to address the social gradient in children’s access to positive early experiences.” Marmot identified as a priority objective reducing inequalities in the early development of physical and emotional health, and cognitive, linguistic and social skills – and put giving every child the best start in life as the review’s highest priority recommendation.

2.2 Examples of existing Public Health action and its impact

2.21 A number of Primary Care Trusts and local authorities have recognised the predictive power of early language and communication development and have taken action to tackle the issue, aligning the work of speech and language therapists with the Healthy Child Programme and Sure Start Children’s Centres.

2.22 Stoke Speaks Out, for example, is a primary prevention initiative set up in 2004 to tackle the high incidence of speech and language difficulties in the city. It aims to support attachment, parenting and speech and language issues through training, support and advice. The initiative is led by a speech and language therapist.

2.23 The programme has developed a multi-agency training framework for all practitioners working in the city with children from birth to seven years, or their families. The training has five levels, ranging from awareness-raising to detailed theoretical levels, and was jointly written by the project team of speech and language therapists, a psychologist, a midwife, play workers, teachers and a bilingual worker. All levels have an expectation that the practitioner will create change in their working environment. In addition the initiative has developed resources for parents, including a model for toddler groups to follow which enhances language development, and a website offering practical information for parents to help with children's language development. ‘Talking walk-ins’ provide drop in sessions at Children’s Centres where parents can get advice from speech and language therapists.

2.24 Outcomes have been impressive. In 2004 64% of three year olds in the city had significantly delayed language skills. Now, as a result of the initiative, that figure is down to 39%.

2.25Nottinghamshire has developed a Language for Life strategy, stemming from a decade of speech and language therapy work in Sure Start Local programmes. In the most disadvantaged areas the therapy service provides training for all Early Years practitioners, support for practitioners to run listening and narrative groups for children with language delay, and leaflets, posters and charts for parents, such as a Talking Tree height wall chart which includes speech and language milestones. The speech and language therapy Children’s Centre core offer includes support for harder to reach families with 0-3 year olds through a ‘Home Talk’ home visiting programme. The Healthy Child Programme 2-year development check includes an SLT-developed parent-interview language screen, with a ‘traffic light’ alert system which triggers use of relevant advice leafletsor access to the Home Talk programme, which has lifted 60% of 2 year olds supported out of language delay, with the remaining 40% referred early for speech and language therapy.

2.26In Derby there is a team of speech and language therapists, therapy assistants and Family Visitors, who work from Children’s Centres in one of Derby’s localities. All two year olds are assessed on their language and development by Health Visiting team nursery nurses, or Family Visitors. Where the screening shows language delay, children are signposted to parent/child interaction groups, or home visits by the speech and language therapist or Family Visitor, to carry out a 4-6 week programme with the family.

2.27In Herefordshire, local teams have maintained a Healthy Child developmental check at 9 months, 2 years and 3 years. All members of the Health Visiting team (Health Visitors and community nurses) receive at minimum a two day course on children’s speech, language and communication development delivered by speech and language therapists. The community nurses follow an in-depth ten-week course, so that they are able to contribute to the developmental checks and provide follow up support to families where the check indicates a need. All early years consultants receive the in-depth training so that they can provide advice and support to early years practitioners and signpost them to appropriate training. This means that where children are identified as having difficulties, the first line of support can be delivered in the early years setting the child attends. Highly trained speech and language therapy assistants model for early years practitioners how to run group interventions for children.

2.3Beyond the early years

2.31Whilst the majority of public health input needs to focus on under-fives, effective work is also needed in the 5-19 Healthy Child Programme. A number of local areas currently commission speech and language therapists to undertake programmes of training for school staff to help them provide school and classroom environments that protect and promote language development.

2.32 InWalthamForest, for example, a commissioned programme provides a universal, dedicated speech and language therapy service to all 54 mainstream primary schools. The service includes

Setting up and training support staff to run language stimulation and language for thinking groups from Reception up to Year 6 – initially involving joint delivery with the support staff, but later just the provision of ideas, plans and resources for support staff to continue running the groups independently

Working with class teachers to develop the listening and attention skills of the whole class

Running workshops for education staff on specific areas of speech and language difficulties
Organising accredited training for support staff to develop their knowledge and skills to support children with speech, language and communication needs in the classroom

Working with parents to raise their awareness of speech and language difficulties, and how they can support their children’s speech and language development, by running coffee mornings, drop in sessions and training workshops

2.33 External evaluation undertaken by a nearby university has shown significant improvements on standardised tests of language skills for children taking part in language stimulation groups. The evaluation also used before and after questionnaires from class teachers to assess attention and listening skills, understanding spoken instructions, use of sentences and vocabulary, and children’s social interaction skills with peers. Significant positive changes were found on all measures.

3The issues

3.1 Under current proposals for commissioning of children’s community health services, GP consortia will hold the budget for speech and language therapy services. It is unlikely that they will commission therapy services to provide the kind of universal prevention work described above. They would rightly see this as falling within the public health remit.

3.2 Current DH public health proposals and consultation documents do not mention the importance of primary prevention work to tackle children’s poor communication skills, particularly in areas of high social deprivation. Nor do they mention the public health role of speech and language therapists.

3.3 For these reasons there is a high risk that no-one will commission therapy services to undertake this work , unless there is a strong steer from DH that it should be part of the local authority’s public health spend.

3.4 Similar issues are likely to affect the promotion of resilience and good mental health in childhood, where again there is a risk that specialist CAMHs staff who play a key role at the universal level may no longer be commissioned to work in this area.

4Recommendations

4.1 This paper recommends thatDH /Public Health England include the vital public health role of speech and language therapists in guidance on the use of public health funding under the proposed transfer of commissioning from Primary Care Trusts to local authorities.

4.2 Such an arrangement should not be funded by any attempt to disaggregate current NHS spend on speech and language therapy and allocate a proportion to the public health ‘pot’. Where speech and language therapists are currently involved in universal preventive activity this work has in many cases been funded by local authorities (until recent budget reductions, which are in some cases leading to de-commissioning of the preventive role). Any transfer of current NHS spend on speech and language therapy to the public health budget would, moreover, put at risk the specialist therapy provision which is currently overstretched in many local areas, with average waiting times to treatment of 22 weeks, and often no provision at all for some age groups

4.3The public health work of SLTs should be funded, therefore, by a reallocation of priorities within existing public health spend, towards the early intervention/life course approach now recommended by DH, which willyield greater health benefits than much current provision

4.4 A further recommendation would be that public health guidance emphasises the need for local authorities to work with GP consortia (via the local Health and Wellbeing Board), so that potential speech and language therapy service providers are asked to demonstrate how they will ensure a smooth transition to targeted and specialist level interventions for those children identified as in need through universal provision.

4.5 One way of achieving this smooth transition would be joint local authority/GP consortia commissioning of the universal , targeted and specialist elements of provision from a single service provider for a given locality, so that there is a coherent and seamless care pathway for children. This would ensure that costs are kept low. A speech and language therapist working in an early years setting or school with a child in need of specialist helpwould, for example, be able to use this opportunity to engage all the staff in the setting in training on promoting language development. Less professional time would be spent on bureaucracy and handovers from one therapy team to another. Commissioning both the public health elements and the targeted and specialist elements from a single locality provider would also ensure good outcomes for children, enabling those whose needs have been identified by the universal service to access therapy in a timely way, and meeting the needs of harder-to-reach families, where it takes time to build trust and relationships.