Updated March 2011

New model of commissioning for children and young people’s speech, language and communication needs

The NHS White Paper Liberating the NHS and the Schools White Paper The importance of Teaching signal the introduction of new commissioning arrangements, including of speech, language and communication services, with GP consortia and school families or clusters taking the lead role. This paper outlines good practice being taken by current commissioners, in local authorities and primary care trusts, relevant to the new arrangements.

This is one of a number of papers, prompted by discussions with commissioners in children’s and health services, which the Communication Champion hopes that commissioners may find helpful. The papers, and case studies from local areas, are available on the Champion’s website, at

The Communication Champion, for children and young people aged 0-19 in England, was appointed by Government in response to the 2008 Bercow Report on services for children and young people with speech, language and communication needs (SLCN). A key role for the Champion, who is independent of Government, is to assist commissioners and providers to develop services that improve outcomes for children with SLCN, including through spreading good practice.

Joint commissioning

My observationsfrom visits to commissioners in local areas across the country suggest that the most effective practice is rooted in joint commissioning across local authorities and the NHS.

The advantages of joint commissioning are quality and productivity. Two contrasting scenarios illustrate this:

Scenario A- multiple commissioners

Stretched health visitors work from GP surgeries, attempting to provide the checks on children’s speech and language development at the age of two and a half that the Healthy Child Programme requires – but not succeeding. They have only intermittent contact with children’s centres in the area. Speech and language therapists (SLTs) operate a clinic-based service with long waiting lists and a high number of missed appointments. They try hard to liaise with schools but this usually takes the form of sending wads of notes and activities for school staff to undertake. Schools are dissatisfied with the help children receive and often push the local authority to issue costly statements of special educational need.

Scenario B – joint commissioning

Health visitors work in integrated teams within children’s centres. There is joint planning for delivery of the Healthy Child Programme, with children’s centre staff completing a 15-minute standardised language screening tool with all two and a half year olds, and health visitor time prioritised for targeted work with families most in need of support. An authority-wide prevention team made up of SLTs, SLT assistants, early years consultants and health visitors runs a multi-agency campaign to inform parents on how to support their children’s language development from birth to three. Pre-school referrals for speech and language therapy have dropped significantly and therapists are able to work intensively with appropriate referrals. They provide a school-based service for school-aged children, and do not waste costly time on missed appointments. Referral rates have reduced for this age group too, because of the work therapists have done to train teachers and teaching assistants in classroom strategies, to help them plan lessons with language in mind, and to set up and supervise small-group interventions for children with language delay run by teaching assistants. Schools are confident that they can make a contribution, and do not need to pursue costly statements. Because they are pleased with the services they receive, some have come together in clusters to purchase further SLT time to enhance the core entitlement.

Challenges

The government’s plans for future commissioning of children’s services present both challenges and opportunities. There is a need to plan for:

  • The involvement of GP consortia as budget holders for the commissioning of a range of services including speech and language therapists, and, potentially, staff involved in the Healthy Child programme.
  • The increased role of schools as commissioners, either individually or as ‘families’/clusters, with a reduced role for the local authority as the budget holder for a range of special education needs services.
  • Best use of resources that are increasingly stretched.

Good practice

The good practice in meeting these challenges that I have seen has the following characteristics:

Whole-system mapping

The local authority (LA) and primary care trust(PCT) have mapped the continuum of provision for children and young people with SLCN, at universal/targeted/specialist level and for 0-5/primary/secondary age groups. This has enabled them to identify duplication and identify gaps in provision. The map enables future commissioners such as GPs and schools to see the ‘whole picture’ – to be aware for example, that spend on targeted and specialist service will increase if universal/preventative services are not commissioned in sufficient quantity.

New tools to support whole-system mapping are available from the Commissioning Support Programme

Involving parents and young people

The LA and PCT involve service users – young people and their parents/carers – at every stage of the commissioning process. Users help to shape the pattern of local provision , and this helps avoid disputes over what should/should not be available and to what degree.

Recognition of commissioners’ needs and motivations

The PCT and LA understand that, whilst nervous of commissioning for children’s community health services, GPs may also have of late felt marginalised in their role as key point of contact for each local family over time, as midwives, health visitors and children’s centres have increasingly taken a lead for children pre-birth to five and moved out of GP practices. The LA and PCT respect and emphasise the vital role of the GP over the life course, including the early years.

The LA and PCT also understand schools’ need for a strong say in the services provided for their children, and their sense of localism – what our children in our context need.

The LA and PCT recognise that this sense of a local, unique community is shared by the school, the GP practice and the children’s centre, and that by facilitating joint planning by these three key partners they will be unlocking energy and commitment and sustainability of services.

Reaching out to GPs

The Children’s Trust Board have reached out to GPs, visiting them on their own territory and listening to what they say about their future role in commissioning.

Taking an enabling role

Many LAs are arranging training sessions and information for headteachers and governing bodies on how to commission effectively. In some cases they are providing schools with information on the benefits of different types of investment, and on the evidence base for different types of services. A paper on schools as commissioners of speech and language therapy services is available at . Where they are establishing trading arms to sell services to schools they are planning joint services – for example for SLCN a specialist educational psychologist, advisory teacher, SLT and SLT assistant(s) team.

Building credibility and putting commissioning structures in place

Many LAs and PCTs are maintaining existing joint-funded children’s commissioner posts and continuing to move ahead with joint commissioning of SLCN services (and child and adolescent mental health services (CAMHS)). They take the view that if services are working effectively, GP consortia may well want these commissioners to remain in place.

One LA/PCT will, under Section 75 arrangements[1], establish a joint commissioning unit, incorporating the PCT’s (small) children’s commissioning unit with the LA’s (larger) team. GPs have already voted to have the unit continue to undertake commissioning for some children’s services on their behalf, in the future. The LA/PCT were able to demonstrate to GPs that:

  • This arrangement would enable them to access a larger commissioning team and a range of LA services (data, communications and so on) that would be very costly for them to provide on an NHS-only basis.
  • The arrangement would maximise limited resources by pooling LA and NHS budgets to provide integrated SLCN (and CAMHS) services – avoiding duplication and overlap.

The LA/PCT have also developed and shared with GPs a model to show a continuum of commissioning, as a basis for discussion on where lead commissioning might sit and how that might by agreement change over time. Acute services sit at the left hand end of the continuum (lead with GP consortia); children’s therapy services and child and adolescent mental health services (lead with LA joint commissioning unit) sit at the right hand end.

Office of the Communication Champion

Updated March 2011

[1] Section 75 of the National Health Service Act 2006 allows health and local authority partners to pool funds, to place the lead for commissioning with one partner, or to integrate their provision.