A multi-agency approach to tackling language deficit in Stoke on Trent

Themes this local practice example relates to:

  • Early Years
  • General resources
  • Local area early intervention strategies

Basic details

Organisation submitting example

Stoke Speaks Out

Local authority/local area:

Stoke on Trent City Council

 
The context and rationale

In 2002, data was collected in Stoke on Trent by the speech and language therapy team for local Sure Start programmes to gauge children’s speech and language ability on entry to nursery. This found that around 64 per cent of children entering nursery at the age of three years already presented with significantly delayed speech and language skills (at least one year developmentally delayed). This compared to the national incidence of speech and language difficulties, thought to be around 10-15 per cent children (ICAN study/Law study 2002). Speech and language skills underpin all areas of learning and national research shows that difficulty with these can impact on all life chances. It was clear that support was needed for families from before birth to ensure parents accessed consistent and accurate key messages regarding attachment and communication development. It was also clear that this support needed to be available no matter what touch points the family accessed, therefore there was a need for a whole systems coordinated approach. 

Stoke Speaks Out (SSO) was initiated as a strategy for the City in 2004; ensuring all key agencies were involved and that they all had consistent, high quality shared messages. It was multi-layered to ensure that everyone shared the same vision regarding early attachment and communication development and that everyone shared responsibility for this. It consisted of a multi-agency steering group to direct the strategy and to create strategic links, a multiagency team to develop a training and support programme and a commitment from service providers to embed good practice into their work. 

The aims of the programme were threefold: 
• to upskill and empower the workforce to be able to deliver consistent, high-quality messages and support to children and their families to assist early communication development 
• to ensure parents received consistent, high-quality messages about early attachment and communication development to help them to provide the best start in life for their children
• to ensure children started school with well-developed emotional and communication skills to enable them to make the most of life chances offered to them.

The Practice

The programme has evolved since 2004 and evidence at every stage has informed subsequent practice. 
A brief overview is as follows:
1. A multi-agency forum devised a long term City plan.
2. A multi-agency team was set up which included speech and language therapists, clinical psychologists, a midwife, teachers, a bilingual co-worker, play workers and administrative support.
3. A multi-agency steering group was developed to oversee the work of Stoke Speaks Out and ensure strategic leads received accurate up-to-date information.
4. Evidence of need was gathered from practitioners, parents and children.
5. The current provision of services and training across the City were mapped out.
6. The multi-agency team wrote a training framework to address all the gaps or lack of confidence in the knowledge and practice of the children’s workforce. 
7. Training was delivered. Some of this was targeted to areas of the highest deprivation or settings who were identified as needing more support. 
8. Change, impact and effectiveness were continually monitored.
9. A staged pathway was developed to bridge the gap between early intervention and specialist support and altered the referral procedure to speech and language therapy as part of the process.
10. Continually offered a network and hub for all early communication-related activity including a website, conferences, forums, and large-scale events. 
11. Provided support to other local authorities wishing to set up similar strategies.
12. A ‘sustainability’ plan was created to ensure the programme could continue with little ongoing funding. 

The programme is currently in an 'empowering' stage, building on the previous work on people’s core roles and responsibilities to ensure its continuation. You can view the model of support offered through Stoke Speaks Out here.

Stoke Speaks Out is for everyone who works and lives within Stoke on Trent. The key stakeholders are varied:
Funders: Stoke on Trent City Council and NHS Stoke on Trent. Previously funded by Neighbourhood Renewal funds, then Local Strategic Partnership money.
Team Employers: NHS North Staffordshire, combined Healthcare, University Hospital of North Staffordshire, Stoke on Trent LA, Pre-school Learning Alliance.
The team: speech/ language therapists, early years advisors, teachers, bilingual workers, play workers, clinical psychologists, educational psychologists, administrative staff, special educational needs service, health visitors, midwives.
Trainees: anyone within the children’s workforce e.g., nurseries, schools, children’s centres, community teams, such as the fire service, museums and library services, toddler groups, hospital ward staff, specialist services etc. 
Parents
Children
Steering group: Midwifery, Health Visiting, Speech and Language Therapy (SLT), Clinical psychology, strategic leads from City Council training manager, Children’s Centre manager, Special Educational Needs and Disability Service training manager. 

Training for practitioners is offered over four levels which includes accreditation, courses and modules, full details can be viewed here.
The training programme explored why children were presenting with delay, what support they needed and how this was best delivered.

Evidencing your practice has made a difference to children, young people and families

Evidence of the impact of the service has been collated through 


• Standardised assessments on children entering nursery (every three years across the city and annually in one specific area, with one control area).
• Data from the Every Child a Talker National Strategy.
• For parents, we conducted parent stories with two cohorts of parents and a wide-scale parental questionnaire asking where parents seek support, what they know and how confident they feel.
• For the practitioners, we collected a pre- and post-training questionnaire on every training course to see how much their knowledge had improved and we also collected feedback from every course or training event.
Case studies have been collected.
• In addition, we commissioned external evaluation in 2005, 2006 and 2009 to validate our evidence and to talk to stakeholders and service users. 

We measured the children’s language development with standardised assessments, conducting this three-yearly across the whole City and annually in one area of Stoke on Trent. The standardised assessments used were Reynell Developmental language scales 3, and the Renfrew Word Finding picture test. 

Additional data was collected from 12 schools through the ‘One Step at a Time’ programme, which was introduced as one of the strategies for schools as part of early intervention. 
The result of this work identified an improvement from a 64 per cent to a 48 per cent delay. This relates to the number of children presenting with a significant delay in language ability as assessed through standardised assessments by speech and language therapists. The samples of children were taken from all nurseries across the City of Stoke on Trent who met the age criteria for the assessments (3:06-3:11 years), had a Stoke on Trent postcode and where parents/carers signed consent for assessment. All children fitting the criteria were then allocated a number and were randomly selected for assessment to represent a third of the nursery intake. The 2010 study had a sample size of 239 children with even numbers of boys and girls assessed which represented a third of the City nursery intake of this age. 
Outcomes for children:

Children’s language delay in nurseries in Stoke on Trent

All parents with children born in North Staffordshire receive information leaflets from Stoke Speaks Out as part of a pregnancy pack. The majority of nurseries and schools have engaged with the programme and are able to offer high-quality generic support for early communication development. The Stoke Speaks Out level 4 Communication Friendly Award has been achieved by 31 settings. This required the setting to gather evidence of their practice, gather references and have a moderation visit to verify the evidence. 

Parent impact

Parent stories revealed that parents are now given key messages at important touch points, such as the midwife or health visitor. All of the student midwives and paediatric staff nurses have accessed the SSO level 1 training. All of the health visitors and school nurses have also accessed this training.

As part of the Every Child A Talker evaluation linked to Stoke Speaks Out, parents were invited to complete a questionnaire to help identify their confidence in supporting their child’s development. A summary of the findings from the 2010 survey of 448 parents and carers indicated that the majority of parents (97 per cent) felt very confident or a bit confident in helping their child’s speech and language to develop. The majority of respondents (73 per cent) felt that they had had either a lot or a bit of support from professionals. Linking with this, many also felt they had received a lot or a bit of support from friends and family. Eighty five per cent of parents felt that they knew where to get help and support and the pattern of where this support is from is changing over time, moving from almost exclusively friends and family to a range of professionals and other sources. 

Parents were asked a series of questions to test out what they knew about child development, specifically speech and language development. The majority of parents knew the answers. Some of these have been focus messages for Stoke Speaks Out e.g., dummy and bottle use, but there are two key messages which are still not widely shared: 38 per cent of parents still believe that you can spoil a baby by picking it up too much and 68 per cent of parents still do not realise that if you tend to a baby’s needs quickly the baby will cry less in the long term. Half of all respondents still did not know that having a television on constantly in the background can delay children’s language development. The information collected from this data has been used to help individual settings identify key messages for their parents and to offer appropriate support . Where issues are identified, a menu of support is encouraged within the setting which can be mentored by the Stoke Speaks Out team. This may be in the form of parent awareness workshops, induction sessions, leaflets, parent information boards or other activities. As part of the level 4 accreditation, settings must demonstrate how they involve parents as partners. 

As part of the sustainability plan, the parent questionnaire analyses have been shared with the multi-agency steering group and the ‘Better information better health’ group to look at the long term messages we need to develop as a City. 

Very positive feedback has been received from service users.

Service delivery:

Between 2005 and 2010, training was delivered to over 4,000 people.

Speech and language therapy: 
The service has created one point of referral via a form which captures the staged pathway information to demonstrate that practitioners have provided early generic advice before referral. This has ensured referrals are appropriate and of a high quality. Therapists are able to provide settings with programmes for children which are written at a more technical level, as setting staff have undergone the SSO training and now have a shared language. 

Early Years:
The Early Years Quality team have built the level 4 competencies into their practice so that settings they are supporting are all developing the competencies as part of the expectations of core visits. The Early Years teams are also being trained to be moderators for level 4. 

Midwifery/ paediatric nurse training:
Level 1 SSO is now an integral part of the training all students at Keele University school of nursing receive. This year the nursing and midwifery tutors are being trained to deliver these themselves to improve sustainability. 

Ante-natal and post-natal information:
The maternity hospital distributes information to parents of every newborn in North Staffordshire (approx 6000 per year), on bonding and attachment, early language and dummy use. 

Other services:
12 Schools have embedded ‘One Step at a Time’ groups as part of their ongoing differentiated curriculum.

31 settings have achieved level 4 Communication Friendly status. 

24 toddler groups have been supported to develop a structured session which has session plans and planned outcomes. 
More than 1000 practitioners have completed level 2 projects which demonstrate a change in practice. 

The website is a first port of call for many parents and practitioners when they are seeking further information about communication development. 

The referral process to speech and language is now uniform and the health audit revealed that referrals are of better quality and more appropriate, with more practitioners trying out strategies before referral. 

Feedback includes:

Stoke Speaks Out has developed into a highly valued and respected service…Stoke is ahead of the field addressing the issues identified in the Bercow review 2008 (External evaluation- D Wigley 2008)
Stoke Speaks Out has improved the competencies of settings (Head of speech and language therapy) 

The external evaluation in 2009 concluded that:
This report strongly endorses that view. As already observed, the Stoke Speaks Out project has gone beyond a "project" and has developed into a highly valued and respected service in many settings across the City and its messages, services, resources and materials have been embedded into mainstream delivery in many health and educational settings.
It has also been observed that Stoke Speaks Out is experiencing recruitment difficulties in key posts due to uncertainty of funding. This is also a common feature of voluntary organisations with short term funding agreements and threatens continuity of service as well as making longitudinal evaluations difficult, if not impossible.

Helping others to replicate your practice

The project, which previously stood alone, is now part of the learning services within the City Council structure. 

Cost

This programme was initially funded through Neighbourhood Renewal funds for 3 years (2004-2007) jointly from the Health and Wellbeing pillar and the Education pillar. This was followed by funding from the Local Strategic Partnership, again with joint funds from Health and Education allocations (April 2007-2011). It is currently funded by Stoke on Trent City Council. 
Funding was as follows:
April 2004 - March 2006 - £700,000
April 2006 - March 2007 - £300,000
April 2007 - March 2010 - £750,000
April 2010 - March 2012 - £110,000

The funding has mainly been for salaries of team members and to pay for trainers to be released. In addition, it has enabled quality resources to be produced and a website to be constructed. 

The correlation between children with a communication difficulty and low attainment, behavioural and emotional difficulties, mental health issues, poor employment or training prospects or youth crime is strong. A study by the Audit Commission developed a case study to illustrate the financial cost of not intervening to support the speech, language and other educational and social needs at an early age. Actual interventions and costs gave a figure of £153,687. This included two custodial terms in secure units before the age of 16. The cost of providing speech, language and educational psychology support up to age 15 was £42,243. Assuming that the crime route was avoided, the saving of £111, 44 was made through early diagnosis and intervention.
With a staffing budget this year of £110,000, training provided to approximately 4000 practitioners, and support and advice provided to approximately 6500 parents, the service offers good value for money. 

The core staffing of Stoke Speaks Out totals 6.41 wte and consists of the following:
Project Lead 0.20 wte
Business Manager 1.00 wte
Admin. Asst. 1.00 wte
Cleaner/Caretaker 0.27 wte
Midwife 0.40 wte
Midwife 0.60 wte (vacant) 
Playworker 0.80 wte (vacant)
Community Playworker 0.54 wte
Assistant Psychologist 0.60 wte
Inclusion (SEN) Manager 0.40 wte
Total 5.81 wte

In addition, there are a number of staff working in settings:
Early Years 0.20 wte
Literacy 0.20 wte
Bilingual Nursery Asst 0.20 wte
Total 0.60 wte

Hot tips and barriers:

This is a whole systems approach. You need a clear leader for the programme who has a strong network of colleagues to liaise with and bring on board. You need a high-quality steering group which can make strategic decisions. You need the flexibility to react to evidence gathered and imagination to devise ways of reaching families. 

In the early days, the multi-agency team all had their own agenda and there were many barriers, such as the lack of a shared vocabulary and different systems which did not join up. These were overcome by talking, engaging a wide audience in all new developments to give them ownership and ensuring that the vision is clear and shared. Any major changes introduced, were discussed at large-scale multi-agency events so that all opinions could be considered. This has meant that some large-scale debates and issues have been tackled relatively quickly e.g., responsibility for selective mutism was discussed at a whole day training event and the staged pathway was introduced at a half-day multi-agency event with 100 practitioners attending.

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