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The interface between Sure Start programmes and their local speech and language therapy services is an important one. Each programme will develop their own links and procedures for liaising with the NHS services. To date different models of practice have arisen in response to local needs and priorities. (Law, 2001, p.5) Working in collaboration with local speech and language therapy services, Sure Start therapists Samanatha David and Marie Hackshall researched the potential of telephone contact with the offer of a home visit to reduce nonattendance at initial appointments.

The call for home de

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IF YOU WANT TO RESEARCH THE IMPACT OF DIFFERENT MODELS OF SERVICE DELIVERY OFFER A MORE CLIENT-CENTRED SERVICE IMPROVE YOUR ATTENDANCE RATES
Marie Hackshall and Samanatha David

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elivery

wo areas within Margate, Kent have Sure Start programmes established. Sure Start Millmead (SS1) is a trailblazer programme which was set up in 2000 and Sure Start Margate (SS2) is a 5th wave programme, established in 2002. Both areas have an identified high level of need and this is supported by a Thanet Jarman score (scale of deprivation) of 21.32, which is over twenty times the national average (DH, 2000). Collaboration between the local speech and language therapy service and Sure Start from the outset of the programmes identified the need for an alternative approach to ensure families have access to local speech and language therapy services. The traditional model of service delivery within the Margate area of East Kent Coastal Teaching Primary Care Trust was clinic and playgroup based initial assessment and therapy. Families were offered an initial appointment within three months of referral. Initial contact was made with the childs family via an appointment letter, which was sent 2-4 weeks prior to the first appointment. An audit exploring the rate of non-attendance at initial clinic speech and language therapy appointments was carried out in July 2003 by Maggie Johnson (speech and language therapist). Non-attendance was found to be at 33 per cent (0-16 years) across the whole of the Margate area. However when this was analysed further in specific geographical areas, it was found that within the Sure Starts Millmead and Margate, non-attendance for children aged 0-4 years was 53 per cent and 40 per cent respectively. Following this study, a proposal for a research post to investigate different models of service delivery, service uptake and customer satisfaction within speech and language therapy was developed. As Sure Start is not intended to replace existing service, rather. add value to what is already available (Law, 2001, p.5), it was agreed by Sure Start and local speech and language therapy managers that a number of new approaches would be trialled alongside the traditional clinic service currently in place. Sure Start Millmead and Sure Start Margate agreed to fund a research project for a 12 month period (July 2003 Aug 2004) which aimed to improve take up of initial appointments. Within the Millmead Sure Start area existing speech and language therapy time and resources funded by Sure Start were used (0.2 whole time equivalent), whilst Margate Sure Start funded 0.2 whole time equivalent specifically to investigate and improve attendance. The new pathway of care for initial assessments was carried out by two senior speech and language therapists. During the study we found it beneficial to have two therapists involved as it provided an opportunity for support and supervision.

way for initial assessment project. The changes to service delivery with this client group included: 1. Where possible we contacted all families by telephone within one week of a referral being processed. For those families whose phone number was unavailable (SS1: 9 and SS2: 5), we sent a letter requesting the family to contact the speech and language therapist to arrange an appointment. If no response was received within two weeks, we sent a standard appointment letter offering an initial appointment at a local clinic. In some cases at Sure Start Millmead a home visit was offered because the therapist felt that this would be a more appropriate venue for an initial appointment. 2. Those parents contacted by telephone were offered the choice of having the initial assessment appointment at the local clinic, at home or in the childs preschool setting. 3. Appointment times and dates were arranged by telephone and confirmed in writing. All appointments were carried out within one month of receipt of referral. 4. Feedback about the assessment process was obtained from parents / carers via an anonymous questionnaire, sent out with a stamped addressed envelope, following the appointment. We evaluated the effectiveness of this approach in reducing the number of people who did not attend initial speech and language therapy appointments over a 12 month period in September 2004: 1. Telephone contact We contacted 38 families in SS1 and 35 in SS2 by telephone to arrange an initial appointment. The average time from referral process to contact was 26.1 days (SS1) and 8 days (SS2). Of those families who returned the questionnaire (SS1 = 23.3 per cent and SS2 = 42.5 per cent return rate), 90 per cent (SS1) and 83.3 per cent (SS2) felt it was useful to receive a telephone call to arrange the appointment but also to discuss what the assessment would involve. 2. Number of did not attends Figure 1 depicts a difference recorded in the did not attend percentage between 2002/3 and 2003/4. When home visits were offered alongside clinic assessments 10.6 per cent (SS1) and 7.5 per cent (SS2) of children did not attend, in comparison to 53 per cent (SS1) and 40 per cent (SS2) for the year 2002/03. As a comparison, within the local clinic where the traditional pathway was used, the did not attend rate remained relatively consistent for the two years (2002/3 = 25.7 per cent and 2003/4 = 24.6 per cent).
Figure 1 Number of did not attends

Sure Start pathway

All children who were referred for a speech and language therapy assessment aged between 0 and 4 years living in the Sure Start Millmead (SS1; n=47) and Sure Start Margate (SS2; n=40) catchment areas were included in the Sure Start pathSPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2006

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3. Uptake of home appointments The choice of assessment venue is shown in figures 2a (SS1) and 2b (SS2). Families were offered a choice of clinic, home or playgroup. There was a clear difference between the take up of home and clinic visits, with the majority of parents preferring a home visit.
Figure 2 (a) Sure Start 1 Chosen assessment venue

use of the telephone when booking appointments can be a contributory factor when attempting to increase attendance. Our findings indicated that of those who did not attend, 80 per cent in SS1 and 100 per cent in SS2 could not be contacted by telephone, either because the family did not have a telephone number or because it had changed since the referral and other professionals did not have the new number. The most popular location for assessment was the clients home. Parents gave a number of reasons for this choice, which included convenience and the performance of the child. From this we conclude that previous non-attendance was generally not due to a parental reluctance for their child to be assessed but rather inconvenient appointments or venues.

Figure 2 (b) Sure Start 2 Chosen assessment venue

Opportunity to discuss
Every attempt was made to contact families within four weeks to arrange the initial assessment. We feel this may have decreased the likelihood of carers either forgetting the appointment time or deciding over time that their child no longer required the service. Stathopulu et al. (2003) support this in that, if the child had waited more than four weeks for an assessment they were more likely to fail to attend. However within this it has to be considered that therapist and parental time commitments do not always allow this to happen. What seems to be of importance is giving the parent an opportunity to discuss their childs language development or the assessment process as soon as possible after the referral has been made.

The questionnaire responses gave us some reasons as to why parents preferred the home visiting option. These included: relaxed environment convenience (including transport issues and timing) response of the child. 4. Analysing did not attends Five families in SS1 and three families in SS2 did not attend an initial appointment; either they were not in for the home visit, or they failed to attend a pre-arranged clinic appointment. Of these all but one did not have a contact telephone number, and therefore the appointment had been arranged by letter and not by telephone. None of the families who did not attend had moved out of the area. The therapist contacted the families of all those who did not attend an initial appointment to offer one further appointment. In both SS1 and SS2, 100 per cent attended.

the increase in attendance recorded across the year at initial assessments is due to a combination of a number of changes in service delivery.
Marie with a parent and child at their home It is evident that both within the Sure Start Millmead and Margate areas an alternative model of service delivery has proved to be a positive move in reducing non-attendance. Whilst this was our original aim, we have also concluded that involving parents in arranging the appointments not only reduces the barriers to accessing the service but also empowers them to take an active role in their childs development. By initiating contact

to discuss the appointment time, parents had an opportunity to find out about the assessment and give their views regarding their childs development prior to the assessment taking place. During the assessment there were opportunities to model strategies within the home for promoting language development. It is evident from clinical experience that parents often feel they need specific toys or activities to carry out therapy. This illusion is broken down within the home environment and parents become empowered to develop their childs language through everyday routine and play. We believe that the research has been beneficial for all involved. The East Kent Coastal PCT speech and language therapy department has increased parent / carer satisfaction and efficiency in provision for this client group, whilst Sure Start has a more localised service which addresses the needs of the immediate community. Following the project evaluation, it was decided that the option of a home visit assessment would be offered to all pre-school children across the Canterbury, Coastal and Thanet areas of the East Kent Coastal Teaching PCT. We agreed that this would not be of benefit to school aged children, as on the whole the assessment process requires a quiet environment where standardised and often lengthy assessments can be completed. The team also decided that, where possible, initial assessments would be arranged by telephone. We have seen how we can improve attendance for initial assessment, but what about attendance for therapy? Recently it became possible to site speech and language therapy clinics within the SS1 and SS2 areas and as a result to offer people more localised venues for post-assessment sessions; however the effectiveness of this on increasing attendance for therapy is a study in itself!

References
Department of Health (2000) Compendium of Clinical and Health Indicators. December. (See www.nchod.nhs.uk) Law, J. (2001) Promoting Speech and Language Development - Guidance for Sure Start programmes. Available at: www.surestart.gov.uk/_doc/P0000839.pdf (Accessed: 12 January 2006). Morris, T., & Stein, L. (2005) Stepping Stones, Speech and Language Therapy in Practice Autumn, pp. 4-6. Stathopulu, E., Ajetunmobi, S. & Selling, D. (2003) Non attendance in community paediatric clinics in Dartford, Gravesham and Swanley PCT, Quality in Primary Care 11, pp.163-5. Stewart, F. & Williams, L. (1998) Pre-school Assessment Project Comparing Assessment in the Clinic or Home, International Journal of Language and Communication Disorders 33 (supplement).

Changes in service delivery

We cannot attribute the increase in attendance recorded across the year at initial assessments to one isolating factor; rather, it is due to a combination of a number of changes in service delivery: telephone contact to arrange an appointment (with a letter confirming the appointment) offering a choice of venue arranging a time convenient to the carer arranging the appointment within four weeks of referral. Use of the telephone as a key factor in increasing attendance is highlighted by previous studies. Stewart & Williams (1998, p.520) found that attendance rates for assessment were directly correlated with prior contact by phone to establish the appointment. Morris (2005) also found that

REFLECTIONS

DO I RECOGNISE THAT THE TELEPHONE IS NOT JUST ABOUT CONVENIENCE, BUT ESTABLISHING AN EARLY DIALOGUE? DO I UNDERSTAND THAT PEOPLE CAN BE EMPOWERED BY AN ASSESSMENT ON THEIR OWN TERRITORY? DO I SEEK SUPPORT AND SUPERVISION WHEN IMPLEMENTING NEW INITIATIVES?

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