INT J LANG COMMUN DISORD, SEPTEMBER–OCTOBER 2012,VOL. 47, NO. 5, 477–486

Review

Costing children’s speech, language and communication interventions

Jennifer Beecham†,‡, James Law§, Biao Zeng¶ and Geoff Lindsay∗

†Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science, Houghton Street,London WCA 2AE, UK‡Personal Social Services Research Unit (PSSRU), University of Kent, Canterbury, UK§Institute of Health and Society, School of Education, Communication and Language Sciences, University of Newcastle,Newcastle, UK¶School of Education, Communication and Language Sciences, University of Newcastle, Newcastle, UK∗Centre for Educational Development Appraisal and Research (CEDAR), University of Warwick, Coventry CV4 7AL, UK

(Received September 2011; accepted March 2012)

Abstract

Background: There are few economic evaluations of speech and language interventions. Such work requiresunderpinning by an accurate estimate of the costs of the intervention. This study seeks to address some of thecomplexities of this task by applying existing approaches of cost estimation to interventions described in publishedeffectiveness studies.Aims: The study has two aims: to identify a method of estimating unit costs based on the principle of long-runmarginal opportunity costs; and to illustrate the challenges in estimating unit costs for speech and languageinterventions.Method & Procedures: Descriptions of interventions were extracted from eight papers and combined with informa-tion on the unit cost of speech and language therapists to identify information requirements for a full-costestimation of an intervention.Outcomes & Results: Four challenges were found relating to the level of detail about the therapists, the participants,the scope of activities and parents. Different assumptions made about any of these elements will have a markedeffect on the cost of the intervention.Conclusions & Implications: Nationally applicable unit cost data for speech and language therapists can be used asa reference point, but sufficient descriptive data about delivery and receipt of the intervention are key to accuracy.

Keywords: speech and language interventions, children, cost, economics, National Health Service (NHS)

What this paper addsWhat is already known on the subject?There is increasing cost pressure on all public sector agencies. Cost information about interventions for children withspeech, language and communication is rare in the research literature, yet is important to both cost-effectivenessstudies and the decisions that commissioners and providers must take.

What this paper adds:Existing methods and approaches for unit cost estimation can be applied to speech and language interventions buta much more detailed description is required of the resources used. Accounts of staff time should range more widelythan just delivering the intervention. If only salary costs are counted, this will underestimate the full interventioncost by about a half. More information is also required on how children use the interventions and the implicationsfor parents.

Address correspondence to: Jennifer Beecham, Personal Social Services Research Unit (PSSRU), London School of Economics and PoliticalScience, Houghton Street, London WCA 2AE, UK; e-mail: J.Beecham@lse.ac.uk

International Journal of Language & Communication DisordersISSN 1368-2822 print/ISSN 1460-6984 online c© 2012 Royal College of Speech and Language Therapists

DOI: 10.1111/j.1460-6984.2012.00157.x

478 Jennifer Beecham et al.

Background

‘Speech, language and communication needs’ (SLCN) isa recently coined super-ordinate term used to designateneed for services within health or education systems.It covers a range of different difficulties experiencedby children and young people whose needs are specificto speech and language or associated with underlyingconditions such as intellectual or physical disabilities.Prevalence is, therefore, difficult to establish with anyaccuracy; however, there is some consensus that atschool entry, 7.4% of children may have a specificidentifiable SLCN, rising to 10% if children with moregeneral learning and other difficulties are included(Tomblin et al. 1997). Reported use of the term in theeducation data suggests lower figures overall; around 2%for pre-school children and falling to well below 1% insecondary school (Lindsay et al. 2011). Prevalence is alsolikely to be higher in areas of marked social disadvan-tage; one study shows that nearly 50% of children insuch areas fall behind by more than 1 SD (standarddeviation) of the mean (Locke et al. 2002) and socialrisk continues to play a part across the lifespan (Lawet al. 2009).

A number of studies have been published suggestingconsistently positive results for interventions for youngchildren’s expressive language and speech, althoughthere is less evidence for children with receptivelanguage difficulties or for older children (Law et al.2003/2009). Key themes in that Cochrane Review werethe efficacy of interventions designed to amelioratethe phonological and expressive language disordersrelative to receptive language disorders and the roleplayed by specialist providers such as speech andlanguage therapists (SLTs) compared with trainedteaching assistants or parents. Provision of early effectiveintervention for children’s difficulties is currently highon the policy agenda and such studies provide animportant evidence base to identify which interventionswill generate the best outcomes for children and families(Allen and Duncan Smith 2008, Bercow 2008, Field2010).

Another long-standing policy driver has been theneed to spend public sector resources wisely. More thanten years ago, for example, the UK central government’sobjectives for children’s services included a specificrequirement to ‘maximise the benefit to service usersfrom the resources available’ (Department of Health1999). The subsequent Every Child Matters agendarequired local authorities to look carefully at how theirresources were deployed with a view to improvinguniversal services and providing more specialized helpto prevent problems (H. M. Government 2004).Commissioners and providers have limited resources—resources are scarce when set against the needs of a

population—and the current economic climate makesthese pressures even more evident. Thus, alongsideinformation about what interventions work for whom,commissioners need to know how much these interven-tions might cost and which represent the optimum useof the resources at their disposal.

Economic evaluations, such as cost-effectivenessstudies, can help identify which interventions mightgenerate better outcomes and at what cost (Knappand Beecham 2010, Knapp 1997, van der Gaag andBrooks 2008, Law et al. 2011 for SLCN interventions).Central to any economic evaluations are good-qualitycost estimates of the intervention and it is this topicthat is the focus here. We first illustrate an approachto estimating costs and unit costs with referenceto speech and language therapists, the professionalgroup most likely to provide interventions for childrenwith SLCN. We employ an existing approach thatreflects the theoretical principle of long-run marginalopportunity costs (see below). We then take data frompublicly available UK studies that report effectivenessfindings and use this unit cost for speech and languagetherapists as a building block to identify some of thechallenges in estimating the costs of the interventionsstudied.

The English language journals were searched toidentify effectiveness studies of SLCN interventionsfor children undertaken within the UK that eitherreported costs or which had sufficient information aboutthe interventions being evaluated to allow costs to beestimated. The UK criterion was important as the desirewas to illustrate the challenges using existing unit costsdata for NHS speech and language therapists. While theapproach described is transferable to other countries,the SLT unit costs are unlikely to be. Higher or lowersalaries will be paid in other countries, and the healthcaresystem, the way healthcare providers are organized andthe way SLTs work are also different. Each of thesefactors will have an impact on unit costs.

It is important to stress that we are not commentingon the quality of these papers per se. Only informa-tion that had relevance to the cost estimation wasconsidered.

Estimating unit costs for speech and languagetherapists

Speech and language therapists play a central role inthe treatment and support of children with speechlanguage and communication needs (SLCN). In theUK they are commonly employed by the NHS to workin schools, primary healthcare services and hospitals toprovide a range of interventions for children. There are7486 speech and language therapists (SLTs) working

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in 5968 full-time-equivalent posts for the NHS (NHSInformation Centre 2009). In that year, the numbersworking within the ten Strategic Health Authority(SHA) areas varied from 337 full-time-equivalentstaff in the North East to 1260 in the London SHA.There was also a considerable variation around thecountry in the numbers employed by Primary CareTrusts (which sit within the SHAs), from one to 112full-time-equivalent staff.

The aim was to estimate the marginal opportunity costof an intervention, where the ‘marginal cost’ representsthe cost of treating one extra child (Beecham 1995).The short-run marginal cost of a day nursery wouldshow the additional costs of including one more child;perhaps an extra bean bag, a coat hook, proportion-ately more juice, etc. If a policy to expand nurseryservices were built on this cost, the assumption wouldbe that however many more children needed nurseryplacements, there would be sufficient capacity in thecurrent set of nurseries to support them all. But if thecurrent set of nurseries were already nearly full, onlya few ‘extra’ children could be placed; place too manychildren and the care quality and child outcomes mightbe compromised. Thus, estimates are needed for long-run marginal costs which recognize that to support morechildren one would need to provide more nurseries;more staff time, more building space, more pieces ofequipment, etc. would be required. Unit costs, therefore,should cover not only therapist salaries, but also a costfor all other elements required to provide the servicetoday. This should include all recurrent costs, such as forheating, travel, supervision, food, office expenses, etc.;an amount that recognizes the cost of providing morebuilding space or a treatment room, and equipment(capital costs); and also the cost to the providing agencythat accrue for management, administration and the like(commonly referred to as ‘overheads’). The unit cost ofthe speech and language therapist shown below includesall of these elements.

The concept of opportunity costs is also important. Ithighlights the fact that resources are scarce and choosingto spend resources one way means that benefits havebeen forgone (the opportunity lost) of spending thoseresources on another service or support. Should morenursery care be funded that will benefit pre-schoolchildren? Or should more speech and language therapistsbe provided to help children with SLCN? These choicesand decisions are faced by commissioners and providersevery day. The full resource implications of the options,alongside the outcomes and a range of other local data,are an important component of the information theymust consider.

To estimate the cost of providing a speech andlanguage therapist four basic stages are followed(Beecham 1995, 2000):

• Stage 1: Describe the elements of the service.• Stage 2: Identify the activities of the service and

a relevant unit of measurement, perhaps 1 h ofworking time or the number of patient contactsper week.

• Stage 3: Estimate the cost implications of all serviceelements identified at Stage 1.

• Stage 4: Calculate the unit cost by totalling thecosts of each service element and dividing this bythe number of ‘units’ of interest.

Thus, the first task in estimating a cost for an SLTis to describe the elements of this service. Obviouslya qualified member of staff is central, but while theirsalary is likely to be the largest element, a widerview is needed to estimate the long-run marginal costsof providing an SLT. A UK employer, for example,will have to fund some National Insurance contribu-tions, and employer contributions to pensions arecommon; these salary on-costs are part of the directcost of employing a professional. Once on site, SLTswill require some support, perhaps a line manager,clinical supervision and administrative assistance. Theywill also be able to claim some travel allowance, willusually have an office base, use a computer, a telephoneand other office and clinical supplies, and will havethe use of therapy rooms. These are all ‘overhead’costs that the employing agency (healthcare provider,education authority, etc.) must bear so that the SLTcan treat patients. Moreover, without some input fromthe human resources department, the SLT would nothave been employed, without some input from thefinance department, the SLT would not receive theirmonthly payslip, etc. Therefore, costs also accrue to theemploying agency for items that the SLT shares withother employees; other examples would be domestic ormaintenance services, or heating and lighting, and allthe wider management functions that ensure the wholeagency continues to operate (for a diagram identify-ing these different ‘levels’ of inputs for children’s socialservices in England, see Beecham 2000: 45–48).

With this description in hand, the next two stagesof the four-stage model are illustrated using data from acompendium of unit costs (Curtis 2010). This annualvolume brings together a range of data to calculatenationally applicable costs for more than 100 health-and social-care professionals and services. The volumeuses a standardized template so that the elements of theservice are clearly listed and the data sources identified.This disaggregated presentation gives the volume’s usersthe flexibility to replace elements—perhaps the salary orthe unit of measurement—with a figure that is specificto their local area.

Tables 1 and 2 reproduce much of the informationin Schema 9.3 from The Unit Costs of Health and Social

480 Jennifer Beecham et al.

Table 1. Speech and language therapist working time and activities

Unit of measurement 2009–2010 value Notes

Working time 41.3 weeks worked per year; 37.5h per week; 1547 h per year

Includes 29 days’ annual leave, 5 study/training days and 12 days sicknessleavea

Ratio of direct to indirecttime for patient contact

1:0.67 50% of the time is spent in patients’ homes, 10% in clinics, 20% onnon-clinical activity and 20% on travel (derived in consultation withNHS Trusts)

Duration of contactsClinic contact 30 min Information derived from consultation with NHS TrustsHome visit 60 min

Sources: aNHS Information Centre (2005) and NHS Employers (2009).

Care 2010, plus an updated figure for overheads from the2011 volume. Table 1 identifies the relevant activities. Itshows the total number of hours an SLT works undercommon NHS working conditions (1547 h/year). Oneunit of measurement for which a cost can be estimated is,therefore, the cost per working-hour (total cost dividedby number of contracted hours). Another unit costmight be for ‘a contact with patient’ so table 1 also showsthe proportion of time spent on different activities suchas contact with patients, travelling etc., and the contactduration in locations where patients are most commonlyseen. Table 2 estimates costs for each element of theservice (salary, on-costs, overheads, etc.) using bothroutinely available information and previous research.The total cost of employing a community-based SLTwithin the NHS is £43 166, just under twice the salaryfigure.

This schema also shows the cost of travel at £2.80per home visit, based on discussions with NHS Trusts.For 2009, the AA (Automobile Association) estimatesa cost of £0.41/mile for a car valued between £22 000

and £30 000, which is driven 30 000 miles/year.1 Thecost of £2.80, therefore, suggests an average journey fora home visit of about 7 miles. NHS reimbursement ratestend to be lower at around £0.35/mile.

Bringing together the information on the annualcost of the service (the final line in table 2) and theinformation on working time and the ratios of differentactivities (table 1) allows the calculation of two ‘unitcosts’ (Stage 4). The cost per contracted working-hour(£43 166 per year/1547 h) is £27.90. By contrast, thecost per hour of client contact is £45.60. To calculatethis, the cost per working-hour was adjusted to takeaccount of the time spent on non-clinical activities andtravel using the ratio of 1:0.67 (the ratio of direct patientcontact time to indirect time; table 1).

The costs of SLCN interventions

The previous section looked at the cost of providing aspeech and language therapist, the professional groupmost likely to provide SLCN interventions. This

Table 2. Costs of providing a speech and language therapist

Service elements 2009–2010 value Notes

Wages/salary £22 200 per year Median full-time-equivalent basic salary for Agenda for Change Band 5,January–March 2010. Total full-time-equivalent earnings were £23 300a, whichincludes basic salary, hours-related pay, overtime, occupation and locationpayments, and other payments including redundancy or notice period pay

Salary on-costs £5218 per year Employers’ national insurance contribution plus 14% for employers’ contribution tosuperannuation

Management and supervision £4218 19% of direct-care salary costs and includes administration and estates staff b

Direct and indirect overheads £8888 40% of direct-care salary costs including items such as office expenditure,travel/transport, supplies and services (general and clinical), and premises costs suchas water, heating and lightingb

Capital costs for buildings,fixtures and fittings

£2642 per year Based on new-build and land requirements of NHS facilities, adjusted to reflect shareduse of treatment and non-treatment space.c,d Capital costs are annuitized over 60years at 3.5% as recommended by H. M. Treasury

Total cost per annum £43 166

Sources: aNHS Information Centre (2011).bNHS (England) Summarised Accounts, 2009–2010.cThe Royal Institution of Chartered Surveyors (RICS), Building Cost Information Service (2010).dDepartment for Communities and Local Government (DCLG) (2010).

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estimated cost does not say anything about how SLTsprovide treatment (perhaps a specific type of therapy),just that there is a cost attached to employing theSLT and making this professional service available. Thissection uses this cost per working-hour for an SLT as abuilding block to derive a cost for SLCN interventionsand it illustrates the main challenges to accuracy in thatcalculation.

Staff time plays a major part in delivering suchinterventions, so it is particularly important to describethis component. For SLCN interventions this shouldinclude the number of staff involved and theirprofession, the band or grade at which they are paid,the support those staff receive, any supervision relatedto that child or the intervention, the number of sessionsfor the intervention, and the length of each session.Information on additional time spent is important suchas assessing the child, preparing the intervention orcontacting parents, and time spent before and aftereach session reviewing notes, readying the room, etc.If a group intervention is provided, then the number ofattendees at each group is also needed to arrive at anaverage cost per child per session. Without a quantifieddescription of staff inputs, the accuracy of the costestimation may be severely compromised.

In addition, good information is needed about wherethe intervention is provided (perhaps a communityvenue or the family home), travel implications for staffand/or reimbursements to patients, and any materialsor equipment used. Together, these items will show thecost of the intervention to the provider—commonlythe health services. The more detailed and inclusivethe description, the more accurate is the cost. Fourchallenges are identified to estimate the cost of a SLCNintervention and these are illustrated using data frompublished studies.

Cost estimation challenge I: insufficient informationabout the therapists

Denne et al. (2005) studied an intervention for childrenwith expressive phonological disorders intended toreflect usual practice reasonably well. Children weretreated in groups of three and received 12 h oftherapy over eight weekly sessions which took place incommunity clinics and by two therapists who providedthe treatment. However, it is not clear whether boththerapists were present at all the sessions or whetherthe sessions were shared between them. If one looks atjust the staff costs for leading the treatment sessions,this uncertainty would lead to two very different costestimates. Using the SLT cost per working-hour shownabove, the average staffing cost to deliver the interven-tion could be either £335 (£27.90∗12 h) or £670

if two members of staff are present at the sessions((2∗£27.90)∗12 h).

Another study of group therapy notes that partici-pants were offered six weekly sessions, each lasting 1 h(Munroe 1998). However, there is no information onthe grade of staff, which may considerably change theunit cost. For 2009–2010, Band 5 of the Agenda forChange salary scales (commonly used in UK healthcareproviders) ranges from £20 710 to £26 839. By insertingthese figures into the unit cost calculations given in tables1 and 2, one arrives at a range of unit costs of between£26.90 and £30.90 per working-hour. Twenty-one SLTsparticipated in another trial (Glogowska et al. 2000) (seebelow). From the published paper their salary levels arenot known, nor the overheads accruing in each of thethree NHS Trusts, nor the treatment venue in each of the16 ‘community clinics’. It may well be that there are 21different unit costs for the intervention, each pertainingto the local conditions. Greater precision in describingstaff and other components of the intervention makesinformation on the cost of the intervention far morerelevant for local commissioners and providers.

Cost estimation challenge 2: insufficientinformation about the participants

Munroe (1998) highlighted another challenge, notingthat each session included up to six children—but thecost per child will change considerably if there are sixchildren compared with, say, only four. Again, this canbe illustrated with the cost per working-hour for SLTscited above. If it is assumed two SLTs were present foreach 1-h session, the cost would be £55.80 (£27.90∗2).If there were six children attending, the average costof the session per child would be £9.30 (£55.80/6),but if only four children attend, this cost increasesto £13.95 (£55.80/4). Does this matter? Arguably thenumber of attendees will make very little difference tothe cost to the NHS Trust or provider agency; two staffmembers’ time (cost) is still being used to provide thesession, so it cannot be used for anything else. (Thatis, the opportunity of gaining benefits from using thisstaff time in another way has been lost.) However, itmay make a difference when considering the totality ofresources used to treat a particular child. There shouldbe an association between the amount of therapy a childreceives (in pharmaceutical studies this would be thedose) and their outcomes—the extent to which theirspeech and language improves following the interven-tion. In this example, the four children would be gettingmore intensive support than had six children attendedthat session. This treatment intensity can be reflectedin the cost per session (and indeed, the number ofsessions each child actually attends) so one should

482 Jennifer Beecham et al.

expect an association between costs and outcomes,other things being equal. In a cost-effectiveness analysis,use of the ‘average amount’ or ‘average cost’ oftherapy for all participants will mask any dose–responserelationship.

In the much larger study of preschool children withdelayed speech or language, Glogowska et al. (2000)compared routine practice with a ‘watchful waiting’control. Children randomized to the therapy groupreceived one-to-one speech and language therapy asroutinely offered by the therapists. On average childrenreceived 6.2 h of therapy (range = 0–15 h). Even thoughthere is little detail on staff grades or time taken onactivities related to the intervention, these data canusefully illustrate the wide variation in total interventioncosts per child. Using the ‘average SLT cost per working-hour’ and assuming one SLT led each session, at themean the therapy cost for the participants would be £173(£27.90∗6.2 h), but those receiving the most therapytime would cost around £419 (£27.90∗15 h). The articlepresents other aspects of ‘dose’ variation that will changethe child’s intervention cost. On average, the childrenhad 8.1 contacts, but the range was between none and17 contacts; and sessions lasted between 20 and 75 minaround an average of 47 min. Of course, such variationshould be expected. Children vary so much in theircharacteristics and communication abilities (and in theway that they react to treatment) that perhaps it isperfectly reasonable to expect staff to respond to eachchild differently. This is what therapists are trained todo and this is why costs are likely to vary. It is, however,very rare for a study to present such detailed informationabout the way children use an intervention.

Cost estimation challenge 3: the scope of SLTactivities

While finding sufficient information on staff inputs orthe amount of the intervention participants receive isuncommon in the literature, even rarer is informationon other activities required to deliver the interven-tion. For example, neither of the first two paperscited above included information on the time spenton related activities pre- and post-session, travelling,in supervision, writing notes, etc. For busy front-linestaff, recording this information is difficult (but notimpossible) and would again have led to more accuratecosts. Two UK studies illustrate the scope of someof these additional resource use requirements: a studyof different therapy delivery modes for children withprimary language impairment compared with standardtreatment (Dickson et al. 2009); and a study of currentpractice versus a parent intervention (Gibbard et al.2004).

These two papers were included in our review ofcost-effectiveness evaluation in speech and languagetherapies (Law et al. 2011). In Dickson et al. (2009)the therapists and assistants were asked to record timespent delivering the interventions (groups and individ-ual therapy) as well as preparation time associated witheach child. The average SLT non-contact time persession was recorded as 9 min and 14 min for SLTassistants (Dickson et al. 2009: 375). Therapists’ traveltime was also recorded; as were the costs associatedwith children’s travel to therapy. The authors notethat group therapy can pose particular organizationalchallenges and additional costs where children have tobe transported from one school to another to attend agroup, often accompanied by an escort (also imposingadditional costs). Travel costs amounted to an additional77% of the therapy cost in the control group (standardcare) and between 66% and 98% for the four interven-tions under study (Dickson et al. 2009: table 1). On theone hand, this study has taken into account a broaderrange of activities related to the delivery of the interven-tion. On the other hand, and as the authors note,Dickson et al. took a narrow perspective for the unitcosts. Only salary costs to the NHS Trust (SLT andSLT assistants’ scale midpoint, and employer NationalInsurance and pension contributions) were used toestimate a cost per hour; the provider’s overhead costswere excluded.

The study of current practice versus a parentintervention also takes into account a wider scope ofactivities and time spent (Gibbard et al. 2004). Studytherapists were asked to record:

time spent in consultations with the parent, writingup case notes, and liaising with other professionals.Use of telephone, stationary and other miscellaneousitems associated with a meeting but related to a specificpatient were also recorded. (Gibbard et al. 2004: 235)

Thus, collecting detailed resource use about an interven-tion is possible, and although leading to a higher overallunit cost, it will better reflect the true cost to theprovider. In this study, cost data for each setting wereobtained from the provider’s Financial Directorate andincluded labour (salaries for the three different gradesof staff ), administration and overheads (Gibbard et al.2004: 235) and capital costs (for offices, treatmentrooms, equipment, etc.). The authors note that ‘costsidentical for the two groups (such as pre- and post-assessment meetings) were ignored’ (p. 234). Thiscomment provides a useful reminder that stating thequestion and perspective is important, and that beingclear about what has been included, or excluded, incalculating the cost is key to understanding the findingsor making comparisons across studies.

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Cost estimation challenge 4: costs to parents

One of the recent developments in SLCN interventionshas been the increasing prominence of the role of parentsin delivering treatment.

Parent-based language intervention models are basedon the premise of providing a frequent, familiar,repetitive and salient input for the language-impairedchild. These features, as a basis for language interven-tion, are well established (Gibbard et al. 2004: p. 230).

Surely if parents are to be considered as providing(part of ) the therapy and the aim is to estimate the cost ofthe intervention, then any costs to parents should alsobe included? Gibbard et al. (2004) designed a recordsheet for parents on which to identify out-of-pocketexpenses for travel to therapy and miles travelled, timetaken to get to the session, employment status and anytime taken off work to attend therapy. The researchersidentified these as items that might differ between thetypes of therapy received.

It is perhaps useful to consider the subject ofopportunity costs again. In a parent-based intervention,the provider might reimburse some parental out-of-pocket expenses for attending the training sessions, butthese will not compensate the parents for the time theymay spend providing the intervention. For example,one US study describes a parent-led intervention wherein addition to attending nine training sessions, parentswere given assignments to implement with their childrentwice each day for 15 min and were asked to keepa log of their interaction activities (Barnett et al.1988). In the Hanen Parent programme, parents areassigned ‘carry over activities relating to the contentof the training sessions’ (Baxendale and Hesketh 2003:405). The Heidelberg Parent-based Language Interven-tion provides eight parent-training sessions and, forexample, encourages sharing picture books with thechild (Buschmann et al. 2009).

There are clearly two ways of viewing parents’ input.On the one hand, the recommended activities maybe seen as part of the usual parenting task and theintervention helps parents adapt their own linguisticbehaviour to improve the child’s SLC. In turn, thisgenerates a change in the way parents go about theirusual tasks and activities with the child. On the otherhand, it may be that additional parent time is requiredto administer the intervention. Parents are busy peopleand they may have given up other activities to providethe intervention; domestic tasks, spending time withother children, a leisure opportunity, or in some cases,hours of paid work. Valuing informal care time in aneconomic evaluation is a contentious and complex issue(for example, Francis and McDaid 2009) and particu-larly so for children where, as for spouse-carers for peoplewith dementia, it is difficult to distinguish time spent

in usual care tasks and time spent specifically due tothe person’s condition or needs (for example, Netten2003). Researchers and practitioners should, however,look closely at the intervention and where necessary beaware of the time or activities parents may have to ‘giveup’ to attend sessions and provide the intervention athome.

Discussion

The aim of this paper was to present an approach forestimating the costs of an SLCN intervention and, byusing published evaluations, identify and address someof the challenges in undertaking such a task. The articleswere selected because they provided some detail on stafftime and other resources needed to deliver interventions.Four challenges were identified. At their heart, each isconcerned with identifying the information required toestimate intervention costs accurately.

Table 3 summarizes these information requirementsproviding a broad ‘checklist’ for estimating the costs ofan intervention. An accurate account of staff inputs isvery important as these costs comprise a high proportionof the total intervention cost. Which professionals, andat which grades, are involved? Moreover, the time takento deliver the intervention is usually only part of the totaltime required. One study reported that travel-relatedcosts were nearly as high as the session costs and prepara-tion added a further one-third to a half of the sessiontime (Dickson et al. 2009). In an intervention for olderpeople with dementia, 4 h were allowed for the prepara-tion, travel and delivery of a 45-min therapy session(Knapp et al. 2006). Such information also allows teammanagers to plan workloads appropriately.

Cost estimations also need good information onthe ‘unit’ of interest—here the number and durationof sessions for the intervention (Stage 2). Recordinghow children or parents use the intervention is alsoimportant. How often did children attend and forhow long? How many intervention-hours did the childactually receive? Not only will this differ betweeninterventions, but it is likely that it will differ withininterventions reflecting the amount—the dose—of theintervention each child actually receives (Beecham 2006,Boyle et al. 2007).

Two studies that took a broad approach to recordingthe intervention activities highlight a different challenge(Dickson et al. 2009, Gibbard et al. 2004). Costs shouldnot be compared across studies unless the scope of theunit cost calculation is the same (Stage 3). The formerstudy based their costs on salaries plus on-costs and thelatter study includes a far wider range of costs to theprovider. The national estimates presented in table 2show that the full cost of making an SLT service available

484 Jennifer Beecham et al.

Table 3. Checklist for estimating intervention costs

InputsNumber of staff Profession and grade for each member of staffStaff time Hours spent on the intervention by each member of staff on preparation, travel, delivering intervention, reviewing

notes, etc.Other resources used Special equipment, clinical supplies, other materialsVenue For example, clinic or family homeParents’ time Travelling and attending the intervention. Also consider any additional time spent delivering the intervention at homeOutputsDuration of session Hour(s) received by participantsNumber of sessions Preferably the number each child attended, although for some purposes the typical (or mean) number might be

sufficientNumber of attendees Either one-to-one, or number of children in each groupCostsStaff Salaries and on-costs (such as employer pension contributions), travel allowances, subsistence paymentsDirect overheads For items that can be linked to the level of service activity: (clinical) supervision, administrative support, office costs,

etc.Indirect overheads Often a proportion allocated to each service to cover overarching support and functions that allow the organization to

operate: finance or human resources departments, senior management, maintenance, communications, etc. Thesemay be identified locally as overhead charges, recharges, service level agreements, etc.

is almost twice as high as the salary. If SLTs in the localhealthcare provider are employed on a different salary,or the agency overheads (for human resources, estates,utilities, etc.) are lower, or the contracted hours orsickness days are higher, the result will be a different costper working-hour (Stage 4), but one that better reflectslocal conditions. The final section in table 3 attemptsto summarize the finance data required, althoughaccounting procedures will vary between provideragencies.

The place of parent time that may be spent on theintervention was discussed above and this leads to abroader issue in economic evaluation: the cost perspec-tive. This paper focuses on the SLCN intervention,but expected outcomes tend to be broader that justimproving a child’s speech, language or communication;perhaps improved school performance or employmentprospects, perhaps improved behaviour because thechild can communicate more clearly, etc. Moreover, itis likely that parents will have consulted other servicesabout their child. They may have spoken to a teacherwho has been working with the child. They may havevisited their general practitioner or the practice nurse,or been to a hospital outpatient clinic, and perhapsconsulted a voluntary sector organization or other familymembers and friends. SLCN interventions are rarelythe only source of a child’s support. Any servicesused will carry a cost and will have a role to play insupporting the parents and influencing the child’s SLCdevelopment. This broader cost perspective, which mayinclude a whole range of education, health- or social-care services (public sector perspective) or extend morewidely to include impacts on family members’ timeor parents’ and young peoples’ employment (societalperspective) is not discussed here, but is important

consideration when designing any form of economicevaluation (Drummond and McGuire 2001).

While this paper has focused almost exclusively onresource inputs, each article used to illustrate the costestimation challenges also reports effectiveness findings.These are commonly in the form of relative improve-ments in aspects of speech and language (outcomes),and cover different types of therapy (say, phonologicalawareness, articulatory therapy or general care) whichhave been provided in different venues to children witha range of SLCN. The evaluations aim to identify whichof the interventions studied works best. However, ontheir own, neither this information on effectivenessnor costs data should drive commissioners’ decisions.The best intervention for any set of needs should beavailable, but it has to be provided within limitedresources. For example, if Intervention A will generatebetter outcomes for certain children than InterventionB but at the same (or lower) costs, it would be sensibleto provide Intervention A. It is this comparison ofcosts and outcomes that economic evaluation aims toaddress.

Conclusion

There is an increased demand for economic evidenceto help support provider and commissioner decisionsabout which interventions are made available to thelocal population. Unfortunately, the body of economicevidence from children’s SLCN intervention research isvery small. Cost and cost-effectiveness analyses are rare(Law et al. 2011) and, as shown here, effectiveness papersshow which interventions generate better outcomes buttend not to report sufficient details to allow estimationof the full costs of those interventions.

Costing SLC interventions 485

We have outlined a four-stage model for unit costestimation and provided a ‘checklist’ of data itemsthat should be collected about any intervention beingevaluated. We have illustrated some of the challengesusing nationally applicable unit costs for speech andlanguage therapists in England employed by the NHS.Both the model and checklist can be applied toother circumstances in which SLCN interventions areprovided, perhaps other professional groups, locationsor employing agencies, both in the UK and elsewhere. Inall countries, the cost of an intervention is an importantcriterion for selecting one service or intervention overanother, but it is not sufficient on its own. It is justone of many necessary components in making decisionsabout spending resources wisely.

Acknowledgements

The research was undertaken as part of the Better Communica-tions Research programme, funded by the Department for EducationGrant number EOR/SBU/2009./030. Declaration of interest: Theauthors report no conflicts of interest. The authors alone are responsi-ble for the content and writing of the paper.

Note

1. See http://www.theaa.com/.

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