Measuring the outcome of any speech and language therapy activity is a vital aspect of the work of every speech and language therapist (SLT). This guidance applies to evaluating the outcomes of speech and language therapy activity outside the level of individualised care and is designed to complement existing RCSLT guidance and resources pertaining to clinical outcomes measures.
Guidance published: June 2021
This guidance outlines:
- Why measuring outcomes outside individualised care is important
- What outcome measures look like at this level of activity
- A framework for the decision-making process from planning to evaluation of outcomes
- Case studies demonstrating best practice
- Quick access to relevant literature
This guidance is intended for a wide audience, and aims to support members irrespective of their clinical areas, stage in their career journey and/or region within the UK where they practice.
The information and resources can be used by all SLTs who may engage in any activity which cannot be described as being at an ‘individualised’ (or ‘specialist’) level – they are not solely for use by SLTs working in specific public health roles.
The guidance is applicable to activities that are designed to ultimately support population groups with, or at risk of, speech, language, communication and/or swallowing needs.
We welcome your feedback on this content.
Call for case studies
We’re developing a collection of case studies to share best practice and illustrate the principles outlined in the guidance using real-life examples.
Have an example you’d like to share? Find out how to submit a case study.
This guidance has been developed on behalf of the RCSLT by Melanie Packer, Cleo Barron, Claire Butler, Deb Gibbard, Jennifer Lloyd and James Reid.
Definitions of key terms
During the development of this guidance, there has been a significant amount of discussion about the terminology used. Some terms may be interpreted differently depending on the client group or environment in which an SLT works, and therefore, using terminology that aligns perfectly with all environments is challenging.
This glossary defines the key terms used in the guidance. It is acknowledged that some may need to be revised and updated over time.
Activities and interventions
Activities and interventions are terms that are used interchangeably to describe work completed by a speech and language therapist.
- Eg an SLT develops a communication friendly environment screening tool that can be used in care homes.
Health inequalities are unfair and avoidable health differences between different groups that are perpetuated by social determinants of health such as living conditions and employment.
- Eg almost twice as many individuals die from illness considered as preventable in the lowest healthy life expectancy (HLE) group when compared to individuals living areas where HLE is at its highest (ONS, 2017).
Individualised care refers to speech and language therapy that is person-centred and designed to meet the individual needs of a child or adult who is known to speech and language therapy. This level of care is often described as ‘specialist’.
- Eg as part of a management plan, a child and her family receive Lidcombe therapy, or an adult and his carers are supported by an SLT to use a specific augmentative and alternative communication (AAC) device to facilitate conversation.
Interim outcomes are shorter-term outcomes that contribute to the longer-term outcomes (ultimate outcomes).
- Eg on school entry children have reached the expected level of speech language communication skills.
Key performance indicators (KPIs)
Key performance indicators (KPIs) are performance measures that have been identified by an organisation, such as the NHS, to ensure the organisation is meeting its key objectives.
- Eg to increase the percentage of children aged between 2-3 years in need of support who are referred accurately and early by practitioners.
Logic models provide a visual representation of how activities/interventions contribute to outcomes (see theory of change).
Outputs are the immediate results of an activity and are usually easy to quantify.
- Eg the speech and language therapy team provides training and at the end of the training the team can confirm that ‘x’ early years workers attended the training. Outputs should not be confused with outcomes.
Outside individualised care
Outside individualised care is an umbrella term that can be used to encompass a range of activities which aim to benefit groups of people (eg residents in a care home, children in an early years setting, the general public). The groups of individuals are not necessarily known to speech and language therapy services.
This term is also used to describe activity that may be referred to as part of universal, targeted and/or public health work. Activities that can be described as ‘outside of individualised care’ seek to improve the health and wellbeing of children, adults and families who directly or indirectly receive the benefits of the activity which may be considered as preventative and/or reducing barriers to health and wellbeing.
- Eg the training provided was arranged with the view of supporting a number of early years settings where many children are at risk of having speech language and communication disadvantage. The activity has not been designed to support any individual child. The children are not currently referred to speech and language therapy and the intervention aims to prevent or minimise the level of specialist support that is required.
For further information and examples, please refer to the next section.
Population refers to a group of individuals that are directly or indirectly in receipt of the speech and language therapy activity. This group could exist at local or national level depending upon the nature of the project.
- Eg children aged between 2-4 years of age in ‘y’ county.
Public health activity
Public health activity is any organised activity that aims to promote and protect the health and wellbeing of the population, either preventing ill health or factors associated with reduced wellbeing and/or quality of life.
- Eg an awareness campaign that increases parental awareness and use of strategies that support early language development.
Research is an investigation of a service delivery model or method of intervention. The research is likely to be relevant and applicable to a number of similar services and unlike a service audit or evaluation it is not limited to the locality in which the investigation has been completed.
Service audit aims to support service change or development at a local level. Service audit is a continuous process of observation of practice against a set of standards that leads to the implementation of change as a result.
Service evaluation involves a detailed assessment of service model or intervention with the aim of identifying whether the needs of service users in a given locality are being met and/or whether resources are being used clinically and cost effectively.
Social determinants of health
Social determinants of health are the social and economic factors that influence the health and wellbeing of individual through the course their life (Public Health England, 2017), such as education, employment, diet and social connection, or networks. There is a positive correlation between poverty and the experience of poor health and poorer health outcomes (Public Health England, 2017).
- Eg where a child lives increases the probability that a child will experience greater social disadvantage in their early life that can impact on the development of their language skills, education attainment and job opportunities later in life that has an impact on physical and mental wellbeing.
Theory of change
Theory of change is a framework or map that helps us to think about the desired outcomes and the steps that are necessary in order to achieve the desired outcomes. The steps or processes within the framework should be based on the current evidence base and demonstrate the complex relationship between activities or interventions, outputs, interim outcomes and ultimate outcomes.
Ultimate outcomes are longer-term health and/or wellbeing outcomes. Ultimate outcomes explain the end goal. Often, speech and language therapy work contributes to these.
- Eg people are supported effectively to live well in later life.
Speech and language therapy outside individualised care
Speech and language therapists working in all clinical areas may already engage in activities that could be categorised as being outside individualised care, or potentially could have a role to play in such activities. Some examples include:
- Health promotion and awareness raising campaigns.
- Training the wider health, education and social care, and voluntary sector workforce to support prevention, early identification and early intervention.
- Working collaboratively with adults, young people, children, as well as families and carers, to co-produce initiatives to improve outcomes and reduce inequalities.
- Adapting the environment to reduce the barriers that perpetuate and limit activity and participation for groups or sections of the population.
For the purposes of this guidance, the work is referred to as being outside individualised care. In the literature or locally it may be referred to as ‘public health’, ‘universal’, ‘targeted’ or ‘population-level’ work (Gascoigne, 2006; Enderby and Law, 2019).
In practice, outside individualised care describes any organised activities seeking to improve outcomes primarily for those outside the speech and language therapy referral system, specifically supporting those who are at greater risk of poorer health and greater health inequalities as a consequence of wider social determinants of health. The scope of this work is outlined in greater detail in the next section.
Services and individuals in the profession already contribute to this area of work. Sometimes the activity is above the initial work remit of the service. Examples of good practice are being collected and will form part of this guidance.
SLTs may report challenges in finding time or resources to plan for and collect data in this area. Measuring the impact of this aspect of professional activity requires commitment from the planning stage through to the analysis and dissemination of findings. In the project planning stage, account for time for data collection, analysis and write ups.
Measuring outcomes outside individualised care
When measuring the impact of speech and language therapy activity outside the level of individualised care, SLTs are interested in finding out whether input and activity has had an impact upon the population or specific groups within society.
It is important to note that, in this context:
1. Focus on impact supporting wider population
The outcome measurement should focus upon the impact of intervention supporting targeted groups or the wider population rather than the level of the individual. Often, activities at this level are part of a strategic approach to protect health and wellbeing, improve quality of life and prevent avoidable negative social and health outcomes. The interventions may:
- be designed to have an impact outside of the speech and language therapy referral process, and to benefit children or adults who may never be referred to speech and language therapy; or,
- be undertaken primarily to support or make improvements for the benefit of individuals on a caseload, but the work also has a positive impact on a wider group of individuals.
Furthermore, the activities/interventions may benefit more than one cohort of individuals.
SLTs may design and/or deliver training that benefits individuals living in a care home. The training leads to improvements in care for all, including individuals who might not have been referred and/ or reduces the numbers of referrals required.
2. Activity may contribute to wider outcome measures
The speech and language therapy activity may contribute to overall wider health and wellbeing outcome measures achieved as result of activities and outputs from a number of services in health, education or social care. The activities may therefore be part of a larger initiative or programme.
3. Activity may be implemented by non-SLTs
The activity may be designed by an SLT, but implemented by others who have received training, supervision, and/or coaching to support speech, language and communication needs and/or eating and drinking. Evidence may be collected by and submitted by partners and stakeholders (eg other health, care and education professionals/practitioners, caregivers, volunteers) who are involved in the implementation of interventions (eg Healthy Beginnings).
4. National initiatives and local funding may influence activity
National initiatives and local funding/commissioning may influence both the nature of the speech and language therapy activity completed and the indicators that must be captured as evidence.
Best practice involves working in collaboration with clients, families, carers and other professionals from the point of inception, co-development, co-implementation and evaluation and therefore outcome measurement is likely to be influenced by local variation (NICE, 2017).
Despite this, there is mutual benefit in considering the methods that are currently being utilised across the profession to measure the impact of activity outside the level of individualised care.
5. Economic evaluation is integral
Economic evaluation is an integral part of the overall evaluation of work completed. The speech and language therapy profession works within a social, economic and political context where resources are often finite. Therefore, consideration for both clinical effectiveness and cost effectiveness will have a role to play in future decision-making.
An economic evaluation therefore may be of interest to key partners, both within and outside of the profession, providing added value and support for the sustainability of successful innovation. Cost benefit analysis helps to answer the complex question of whether preventative approaches are value for money (HM Treasury, 2014). Suggesting that there is an economic argument for introducing a preventative approach because of its potential to support reduce in budgets in the long term (HM Treasury, 2014).
Measuring the outcomes of speech and language therapy is essential, both at the individualised level and outside of individualised care (ie supporting groups or the wider population).
The Health and Care Professional Council (HCPC) standards of proficiency for speech and language therapists (standard 12), state that measuring outcomes is a compulsory component of any speech and language therapy activity (HCPC, 2021). SLTs and speech and language therapy services should engage in practices that enable them to be clear about the level of effectiveness of any speech and language therapy activity. The evaluation of practice is an essential part of quality assurance, service improvement and the sustainability of best practice (HCPC, 2021).
The RCSLT provides guidance and resources to support members to meet these standards in practice.
Why is outcome measurement outside individualised care important?
The combination of national drivers and findings from a growing evidence base suggests that there is a shift in thinking towards services giving greater attention to prevention, public health initiatives and a move towards a ‘whole system’ or population approach to managing health and wellbeing (Enderby and Law, 2019; NHS, 2019; Allied Health Professions Federation, 2019). Activities that do not fit into what might be described as ‘individualised care’ must still be evaluated.
SLTs and services must be able to assure the quality of their practice (HCPC 2021). Activity that sits outside the referral process may still be a significant part of the work SLTs do. A pilot project completed in 2017 indicated that 12% of the work completed by SLTs working with Adults with Learning Disabilities, is activity that is outside of the referral process (Money, 2018).
The UK Allied Health Professions Public Health Strategic Framework has set out a vision that states:
“…AHPs will improve population health, public health will have a core element of all AHP roles and the impact of AHPs on the population’s health and reducing health inequalities will be increasingly recognised.” (Allied Health Professions Federation 2019-2024)
Nevertheless, the profession needs high quality evidence to support any change in approach (Smith et al, 2017). Commissioning bodies and practice partners are not necessarily aware of what the profession can offer. The profession needs to gather data and evaluate practice that supports improvements at a population level.
The challenges that services face in seeking to meet the needs of the populations that they serve cannot be ignored. Inadequate funding and resources have impacted negatively on the services that are provided and the outcomes for populations (Institute of Health Equity, 2020; ICAN and RCSLT, 2018) and health inequalities are increasing (Institute of Health Equity, 2020). Correlation between poverty and health inequalities is undeniable (NHS Scotland, 2017; Health Foundation, 2020; Institute of Health Inequality, 2020; WHO, 2020). It is also widely recognised that generational poverty and the persistent health inequalities will not be reduced without appropriate interventions (Health Foundation, 2019; Institute of Health Inequality, 2020; WHO 2020). This is reflected in studies that have focused on speech and language and communication needs (SLCN) (Law et al, 2017; Law et al. 2017a; Wylie et al, 2015; Gascoigne and Gross, 2015; Atkinson et al, 2013).
SLTs are well placed to engage in activities that seek to reduce the inequalities that specific groups may experience in society, for example, co-producing community projects that can support early identification, early intervention and timely referrals. Whether it is training, a health promotion campaign or an informal drop-in session, it is essential SLTs record the impact of these activities. The profession’s contribution is important, yet sustainability and further development continues to be vulnerable without robust and systematic evaluation. Further research is required to evaluate both the process of completing activity, as well as evaluation of the outcome of activity, that focuses on raising awareness and behaviour change at a population level (Simmons-Mackie et al, 2020).
A national example – COVID-19
A national level example of service challenge was the 2020 COVID-19 pandemic. The crisis posed an additional risk to existing preventative speech and language therapy programmes at a time when our contribution could have played a valuable and innovative solution to some of the challenges that our clients, the profession, and wider health and social care systems faced. The pandemic not only brought existing inequalities to the forefront of public thinking, but the predicted long-term impact of the pandemic may mean significant increase in health inequalities (Health Foundation, 2020). The Marmot report used the pandemic as an opportunity to ‘Build Back Fairer’ and focus on reducing health inequalities. It provides a call to action to all health professionals, including SLTs, to address these inequalities (Marmot et al, 2020).
Benefits of outcome measurement
Outcome measures are required so that the profession can show that activity outside the level of individualised care provides added value. Outcome measurement helps to:
- Illustrate the extent to which activities have an impact on populations and communities.
- Evaluate the cost effectiveness of a specific activity or collection of activities
- Inform service delivery and/or service redesign.
- Influence funding and commissioning decisions, potentially leading to new opportunities and growth in workforce capacity.
- Demonstrate how this work complements other approaches and activities.
- Illustrate how activity may contribute to wider health aims and a whole system approach.
Key national drivers
- Department of Health, Social Services and Public Safety – Making Life Better: A Whole System Strategic Framework for Public Health (Northern Ireland) (2014)
- NHS England – The NHS Long Term Plan (2019)
- NHS Health Scotland – A Fairer Healthier Scotland: A strategic framework for action 2017-2022 (PDF)
- Public Health England – Protecting and improving the nation’s health: PHE strategy 2020-2025
- Public Health Wales – Long Term Strategy: Working to achieve a healthier future for Wales (2018)
- Royal Society for Public Health – Impact pathways for everyday interactions (2020)
- Scottish Government – Public health priorities for Scotland (2018)
- UK Allied Health Professions – Public health strategic framework 2019-2024 (PDF)
- Welsh Government – A Healthier Wales: our plan for health and social care 2019 (PDF)
- Welsh Government – Allied health professions framework for Wales 2020 (PDF)
Framework to support outcome measurement of speech and language therapy activity outside individualised care
This framework has been designed to take SLTs and/or teams through the necessary steps to generate outcome measures to support the evaluation of activity that is completed at a local and/or national level.
The six main questions within the framework are supported by complementary prompt questions and links to useful resources. It is recommended that you follow the steps in order. However, depending where you are in the project process, you may find some steps and resources more relevant than others.
The six main questions
- What are the intended outcomes?
- What will you measure to find out whether you have made an impact?
- How will the data be collected?
- What does the data show?
- How will you present the data?
- How will you use your findings to sustain and influence change?
Further reading, resources and references
Please note this list is not exhaustive. Please contact us to suggest any additions.
National guidance, strategies, and policy documents
- Allied Health Professions Federation – UK Allied Health Professions Public Health Strategic Framework 2019-2024
- Department for Education – Improving the home learning environment (2018)
- Department of Health – Making Life Better: A Whole System Strategic Framework for Public Health (2014)
- Public Health England – Best start in speech, language and communication (2020)
- Public Health Scotland – A Fairer Healthier Scotland (2017)
- Public Health Scotland – Scotland’s Public Health Priorities (2021)
- Welsh Government – Dementia action plan 2018–2022
- Welsh Government – Talk With Me: Speech, language and communication (SLC) Delivery Plan (2020)
- Welsh Government – AHP Framework for Wales Looking Forward Together (2020)
- Welsh Government – A Healthier Wales (2019)
RCSLT guidance and resources
- The 5 Good Communication Standards – easy read version (PDF)
- The 5 Good Communication Standards – Reasonable adjustments to communication that individuals with learning disability and/or autism in specialist hospital and residential settings should expect (PDF)
- Inclusive communication guidance
- Outcome measurement guidance
- Public health guidance
Online resources and tools
- Allied Health Professions (AHP) Outcome Measures UK working group – Key questions to ask when selecting outcome measures: a checklist for AHPs (2019)
- Better Communication CIC – The Balanced System
- Early Intervention Foundation – EIF Maturity matrix: Speech, language and communication in the early years
- GOV.UK – PHE data Analysis tools
- The Care Aims Intended Outcomes Framework Collaborative: Decision-making for wellbeing (PDF) (2015)
- MENCAP – Research and statistics
- NHS England and Improvement – Quality, service improvement and redesign (QSIR) tools
- NHS England – Patient activation measure
- NHS Improvement – ACT Academy online library of quality service improvement and redesign tools: A model for measuring quality care
- Parkinson’s UK – Clinical tools and assessments
- Public Health information for Scotland – The Scottish Public Health Observatory
- Public Health information for Scotland – ScotPHO profiles tool
- Public Health Scotland – Improving our services
- Public Health Scotland – Sharing our data and intelligence
- Public Health Scotland – Tools and resources
- Royal Society for Public Health – Allied Health Professions Hub
- Public Health Wales Observatory
- Public Health Data (Wales)
Campaigns, programmes, and initiatives
- Using the RCSLT 5 Good Communication Standards to audit the communication environment and affect change (PDF)
- Flying Start SLC Guidance
- Dementia Friends – Become a Dementia Friend
- Devon County Council – Let’s Talk More
- Health Education England – Evaluating MECC (Making Every Contact Count)
- MENCAP – Treat Me Well
- NHS Nottinghamshire Healthcare NHS Foundation Trust – Language for Life
- Stamma – BSA Five-Year Plan
- Stoke Speaks Out
- Stoke Speaks Out – Research and data
- Stroke Association – Aphasia awareness
- Warwickshire Time to Talk
Articles and reports
- Education and Training Inspectorate – Second sure start evaluation report
- Education and Training Inspectorate – An evaluation of improving practice in sure start (2020)
- The Center on the Developing child – Key Concepts
- ICAN and RCSLT – Bercow: Ten years on (2018)
- Health Foundation – Creating Healthy Lives (2019)
- Institute of Health Equity – Fair Society Healthy Lives (The Marmot Review) (2010)
- Institute of Health Equity – Marmot Review 10 Years On (2020)
- Institute of Health Equity – Build Back Fairer: The COVID 19 Marmot Review (2020)
- British Medical Journal – Children’s centres are the foundation of social regeneration
- Early Intervention Foundation – Language as a child wellbeing indicator (2017)
- First 1001 Days Movement – Working for babies: Lockdown lessons from local systems (PDF)
- University of Hertfordshire – The Health Equalities Framework (HEF): Prioritising clinical decisions and supporting the measurement of outcomes for people who have intellectual disabilities (2018)
- World Health Organization (WHO) – Health Inequity and the effects of COVID-19 (PDF)