1. Introduction
Good communication skills at 5 years of age are strongly linked with a range of positive outcomes in later life, including literacy skills, employment, mental and physical health and wellbeing [
1,
2], particularly for those from disadvantaged backgrounds [
2]. Recently, the detrimental effects of COVID-19 exacerbated concerns about the consequences of poor speech, language and communication (SLC) on young children’s school readiness [
3,
4].
With this in mind, it is increasingly important for early years practitioners to be able to identify children who may require support with their speech, language and communication development. As part of everyday practice, EYPs are advised to observe children and to identify if they are developing typically for their age. However, studies have raised concerns about whether it is always reliable to depend on EYPs to identify speech, language and communication difficulties or delays. EYPs report receiving minimal training, both pre- and post-qualification, in speech and language difficulties [
5]. EYPs have also consistently reported that they feel that they lack necessary knowledge to identify and support children with speech and language difficulties, which has also been reflected in practice [
6,
7].
Screening tools, which can be used in the setting and in the context of usual practice, can be useful in overcoming this knowledge gap. Since they provide an objective measure of children’s communication skills, they may be particularly useful in settings where practitioners are inexperienced at identifying child needs, or in cases where children’s needs are not easily observed. Screening tools may, therefore, help practitioners identify children in need of support and to pinpoint the areas in which support is required, so that targeted interventions may be selected.
One such screening tool is the WellComm toolkit, developed by the Sandwell Primary Care Trust [
8]. The toolkit includes both a screening tool and corresponding handbook of interventions, called the Big Book of Ideas (BBOI). The GL Assessment website describes the toolkit as “Requiring no specialist expertise, [the screen and BBOI] quickly identify areas of concern in language, communication, and interaction development in order to ensure early targeted intervention” [
8].
The screening tool allows practitioners to assess children’s speech, language and communication skills, pinpointing child profiles and identifying strengths and areas of concern and comparing them to age-related UK norms. It can be used with children between 6 months and 6 years of age. The screening process is a one-to-one interaction between practitioner and child. The screening toolkit is broken up into sections that allow for the assessment of different age groups, each of which contain between 10–12 items. Practitioners assess children by starting with the assessment for the relevant age group, and then moving up or down in age (and, therefore, difficulty) depending on the child’s performance. Practitioners score the assessment simply by noting “yes” or “no”, reflecting whether the child was able to correctly respond to a prompt. A traffic light system is used to identify the child’s profile; if the child scores “green”, this indicates that they meet the criteria for the age at which they have been assessed. An “amber” score indicates that additional support is required, and a “red” score prompts practitioners to consider a referral to a Speech and Language Therapist (SaLT).
Once children have been assessed, practitioners can use the accompanying BBOI, which provides intervention ideas targeting areas of speech, language and communication. The screening tool and the BBOI are structured in such a way that practitioners are able to match a child’s specific needs, as highlighted by the screen, to appropriate interventions that can be implemented one-to-one or in groups.
The WellComm toolkit is used across the UK in various early years setting types; this includes pre-schools, nurseries, primary school early years settings, and childminder settings. There is evidence for its success in enabling practitioners to identify children who have delays in receptive and expressive language [
7,
9], which is independent of the qualification level of the EYP administering it [
10].
In York, a city in the North of England, use of the WellComm toolkit is supported by Early Talk for York (ETFY), a place-based whole systems approach. This programme, developed by the City of York Council (CYC), aims to improve the speech, language and communication of children in York settings aged 0 to 5 years. ETFY centres around provision and practice in early years settings, including childminders, pre-schools, nurseries, and schools. In the first step of the three-step ETFY programme, practitioners are required to “Screen all children annually using the WellComm toolkit, sharing this data with the local authority” [
11].
The ETFY programme, however, extends beyond screening. The first step also encourages practitioners to engage with the community by joining regular network meetings “with a focus on improving children’s speech, language and communication skills” and also working “in partnership with parents and carers to support the wider development of children’s speech, language and communication skills” [
12]. Further steps of the programme include practitioners being given the opportunity to complete further training in speech, communication and language, and being able to draw on support from specialist speech and language professionals. Throughout the ETFY programme, practitioners can access support from the ETFY team at CYC.
As of December 2023, 93% of all early years group-based providers (60% of Private, Voluntary and Independent (PVI) settings, 90% of schools) in York have taken up the offer of one of these toolkits and, in doing so, have committed to step one. A roll out of the scheme across the city has been conducted: the toolkit was offered at a subsidised rate to settings until September 2023, and many childminders are also benefiting from the offer and accessing toolkits via a library lending scheme.
The ETFY programme has been demonstrated to positively impact children’s outcomes. Of particular note is that children’s outcomes at age 5 continued to improve in the ETFY area during the pandemic window, particularly for those children who are disadvantaged [
12], whilst those in other areas of England have declined [
13].
The impact of this toolkit and the ETFY approach on children’s communication and language has been well documented, and wider evidence shows that practitioners who report feeling ill-equipped to identify children with SLC difficulties can be supported by using the WellComm toolkit [
10]. However, no research has yet investigated the implications of implementation for practitioners and settings. In particular, it is possible that the use of the toolkit has implications for practitioners’ knowledge and confidence in recognising SLC delays. Additionally, implementing any intervention in settings has implications for practitioners in terms of their workload, time, and staffing requirements. It is important to investigate the implications of the toolkit for practitioners and settings to determine whether it is beneficial to practitioners as well as children, and whether the costs of implementation are balanced or outweighed by these potential benefits. As well as being helpful for the further development of ETFY, the findings discussed here could have significance more widely. A growing number of local authorities in England are pursuing the use of WellComm as a tool across their local areas, so the outcome from this research could well be of interest to a national audience working on this agenda.
In addition, the potential implications of the WellComm toolkit’s use for research have not yet been investigated. The toolkit is available to settings and organisations across the UK, and is being rolled out by local authorities in Bournemouth; Christchurch and Poole [
14]; Kensington and Chelsea [
15]; Oxfordshire [
16]; Cheshire East [
17]; and more. Simultaneously, school-based research is ongoing across the UK; the Education Endowment Foundation, a charitable organisation involved in funding research and supporting evidence-based practice, lists over 50 currently active research projects taking place in school-based settings [
18]. Large-scale evaluation projects may include settings where the toolkit is being adopted; if the toolkit does indeed impact the skills, knowledge and confidence of EYPs, this may in turn have unintended implications for the observed outcomes. The use of the WellComm toolkit may, therefore, be an extraneous variable in studies where researchers are aiming to measure the impact of other interventions.
Furthermore, researchers may consider using the WellComm toolkit as a tool to research children’s levels of speech, language and communication. It offers seemingly objective identification of age-matched child SLC profiles, allows for the discernment of typically developing children from delayed children with a good level of sensitivity, and has concurrent validity with other commonly used screening tools, all of which may make it attractive to researchers. However, the tool has not been developed for research purposes. Additionally, the use of this toolkit as a standardised research measure has not yet been investigated. In large-scale evaluation research, standardisation of outcome measure application is paramount. It is, therefore, important to establish whether this toolkit can be used to objectively and consistently measure child speech, language and communication profiles in practice.
It was, therefore, the aim of this paper to examine the implications of the use of the WellComm Toolkit, within the context of the Early Talk for York programme, for practitioners and researchers. The data this paper utilises are from a review of the use of the WellComm Tool in ETFY settings, funded by the York Policy Engine [
19].
The research questions were as follows:
RQ1—What are the positive and negative implications of implementing the WellComm toolkit for practitioners?
RQ2—What bearing do these implications have for future evaluation research?
4. Discussion
The use of the WellComm toolkit through the ETFY programme has clear implications for practitioners. Professional development and knowledge appear to be supported by the use of the WellComm toolkit, and also possibly as a result of the training and support that is provided as settings progress through ETFY steps. Although there are obvious costs of implementation in terms of time and workload, these costs may be somewhat balanced by the benefits of not having to spend time searching for appropriate interventions.
The finding that the use of the toolkit helped practitioners to avoid making unnecessary referrals to SaLT, and to improve the quality of referrals when they were required, is an important one. In a report from the Royal College of Speech and Language Therapists [
21,
22], it was reported that 77% of surveyed SaLTs reported that the demand for their services had increased, with 28% reporting that the demand was at least double what it had been before the pandemic. In 2023, the RCSLT reported that requests for Education Health and Care plans (EHCs) in 2021/2022 had increased by 83% on the 2018/2019 number [
22]. This increased demand is associated with longer waiting times for service users, and also negative implications for the mental wellbeing of SaLTs [
22]. The findings of this paper show that the implementation of the WellComm toolkit in settings increases the knowledge and skills of practitioners, and helps them to identify the support that they are able to provide, which could be instrumental in easing the crisis that is currently facing SaLT services nationwide. This implication warrants further investigation, as National Health Service SaLT teams are currently facing increased demand, challenges in recruitment, and low morale [
22].
Furthermore, as large-scale evaluations take place in early years settings across the UK, the WellComm toolkit also has implications for research. The toolkit appears to have implications for the skills and knowledge development of practitioners, and this may impact research examining the effect of interventions on child outcomes. Researchers may observe improved outcomes for practitioners and children at baseline testing in settings where the WellComm toolkit is being used. Additionally, settings which have adopted the WellComm toolkit over the course of an intervention study may also see improved outcomes at endline that are misattributed to the intervention itself. Researchers may, therefore, consider using the WellComm toolkit as an Randomised Control Trials stratification variable.
However, the suitability of the WellComm toolkit as a stratification variable is debatable for several reasons. For one, there is clear variation of implementation even within the ETFY framework; some settings use the tool more frequently than others, and it has been observed that the quality and accuracy of implementation can also vary. Additionally, the ETFY framework provides training for practitioners beyond the use of the toolkit, and also offers support in its implementation from SaLTs. Should the use of the WellComm toolkit be used as a stratification variable in large-scale evaluations, there would likely be large degrees of variation within this group; not only between individual settings, but also between those which are supported through ETFY and those which do not have such a strong support network. We, therefore, recommend that the use of screening tools, and the degree to which they are embedded in settings, is evaluated through an implementation process evaluation.
Alternatively, researchers may wish to use the WellComm toolkit as an outcome measure. It is important to note that this is not the intended use of the toolkit. The toolkit is designed to help practitioners identify child speech, language and communication needs, and to implement relevant interventions to address those needs. The toolkit may be used to assess children’s language abilities for research purposes; however, since this is not its intended purpose, there is no method of scoring these without modification to the screening tool.
Finally, researchers should take note of feedback from the practitioners in this study. It was identified that practitioners do not think the toolkit is as accurate for SEND or EAL children as it is for first-language English speaking, typically developing, children. If further research including SEND or EAL children aims to use the WellComm toolkit as an outcome measure, it would be important to consider that the outcomes may not be representative of the expressive or receptive language abilities of these children.