Chickens are coming home

Norbert Lieckfeldt | 15.03.2015

There's been a lot of concern in SLT circles about the proposal by the Australian SLT's Association Speech Pathology Australia to their Treasury that their Healthcare system Medicare should fund interventions for dysfluency in young children - but only if the intervention is based on the Lidcombe approach. This was justified with the assertion that only Lidcombe has a sufficient evidence base in terms of recovering fluent speech.

For a long time, Lidcombe has had a virtual monopoly for the treatment of pre-schoolers in Australia who stammer. To be honest, I am not sure how many Australian SLTs would use anything else. Australian practitioners not wedded to Lidcombe seem to exist (I met one once, in Oxford) but are so rare that I am not certain how much practical difference this proposal, if accepted, would make. But of course it's making a statement.

BSA's view is that this kind of monopoly is neither desirable nor helpful unless you can demonstrate something works for all children, all of the time. There is a monopoly in the treatment of appendicitis, and for good reason. But we feel that monolithic approach doesn't really work for stammering.

BSA believes it is unlikely that all stammering in all young children can be addressed with a single approach. We do get regular calls from parents who've used  Lidcombe therapy for six months, a year, and it hasn't helped, just as we get calls from parents using Parent/Child Interaction Therapy (PCI, developed at the Michael Palin Centre) where they have not seen any progress. It is useful then to be able to say "have you tried Lidcombe/PCI instead?".  If nothing else but Lidcombe were used because nothing else had an evidence base, then there will never be an opportunity to develop an evidence base for any alternative.

Speaking up against a monopoly is a fairly simple choice to make for BSA. But, looking at the Australian scenario, what if the Department of Health were to say "We will centrally fund a system where every child is screened and every child who stammers is guaranteed to be assessed within a fortnight, and guaranteed to get therapy by a Lidcombe specialist starting a fortnight after that should they need it, because the evidence tells us it's effective". This would be a service far superior to that which many children who stammer receive today. Would BSA welcome that? And just like that, the choice becomes rather less clearcut.  I think we can all rest assured that the chance of the DoH coming up with extra cash for speech therapy are such that we will never have to face that choice.

Why are chickens coming home to roost? For the longest time, Australians have invested heavily in research, especially in terms of effectiveness of therapy. Large-scale studies, lots of money involved. Nothing like this ever happened in the UK. Where the Australians (and North Americans) have many studies often with large numbers, we have few, mostly small-scale studies. This isn't a judgment on the quality of the researchers but largely a question of funding (and of the restrictions on therapists working in the NHS).

As I said in an earlier post, we need research to tell us

  1. is this approach more effective than just "wait and see", ie do children going through the treatment programme show a significantly higher rate of recovery than one would normally expect?
  2. does this approach work for most pre-school children, most of the time, with most SLTs, to recover fluent speech?
  3. if recovering fluent speech is not an option, is the approach demonstrably showing a reduction in stammered speech, and
  4. does this approach demonstrate that children can be prevented from developing the psychosocial maladaptations that stammering often brings with it?

In one of the responses to the Australian proposal I have read the view that evidence isn't just published, peer-reviewed research, it's also the feedback from the parents and the observed outcome for the child. Maybe. But the final two in my view are only evidence for clinical decision making. "The parents like it" is not necessarily evidence for allocating resources in a cash-poor healthcare system.

At the moment we will have to wait until September when the NIHR research assessment on effectiveness of stammering therapy is being published - it will tell us what the evidence base is. In a healthcare system like the UK, where Commissioners are asked to decide to spend £50,000 on speech therapy for children, we have a problem. Mainly because that decision in turn means the £50k is not spent on, for example, caring for the feet of people with diabetes where there's evidence this works and prevents severe (and costly) problems later on. I already know of NHS Trusts who have removed their school-age stammering service because 'there is no evidence it is effective'. We know it is effective. We know the positive impact therapy has on children who stammer. But without solid evidence demonstrating that, the chickens have started roosting a long time ago. They're hatching.