PRP (37-01-01) Evaluation of early language identification measure & intervention (ELIM-I) Research Specification

Timetable and Budget

Description	Deadline/Limit
Deadline for Stage 1 Applications	24 October 2023, 1PM
Notification of outcome of Stage 1 Application	09 January 2024
Deadline for Stage 2 application	20 February 2024, 1PM
Notification of outcome of Stage 2 Application	June-July 2024
Expected Potential Project Start	September 2024
Project Duration	30 months (estimated September 2024- March 2027)
Budget	£600,000 to £800,000

Introduction

The National Institute for Health and Care Research (NIHR) Policy Research Programme (PRP) invites applications for a single research project to conduct an independent process and impact evaluation of the early language identification measure and intervention (ELIM-I)[1].

The ELIM-I is a tool that can be used at the 2-2½ year Healthy Child Programme review to enhance the early identification of speech, language and communication needs, so that children can receive appropriate support to develop to their full potential. The tool was developed in partnership with Newcastle University and was published by Public Health England in 2020.

There are three overarching research questions which should be explored as part of this independent evaluation:

1. Delivery of ELIM-I: Is the ELIM-I being delivered as it was originally intended?
2. Impact on service delivery and experience: Is the ELIM-I impacting the delivery of services, and the experiences of the workforce/ families?
3. Impact on outcomes: Is the ELIM-I impacting children’s outcomes and disparities in these outcomes?

This project is an opportunity to inform DHSC policy decisions on the implementation of the ELIM-I, including what improvements can be made to the tool and the way in which it is delivered. It will also provide evidence to inform local decision making by commissioners and providers on whether to implement this tool. Furthermore, it is an opportunity to contribute to the evidence base on how early identification and intervention can impact children’s developmental outcomes, which can go on to impact their outcomes across the life course.

A multi-stage approach is suggested so the commissioning process will need to be flexible and provide applicants with the opportunity to refine plans and costs.

Background

Without appropriate intervention, children with speech, language and communication needs (SLCN) are at risk of poorer outcomes across the life course, including poorer educational attainment, employment prospects, and mental health [2, 3].

In 2018, as part of the government’s Social Mobility Action Plan, the development of the early language identification measure and intervention (ELIM-I) was commissioned by Public Health England (PHE) and the Department for Education (DfE). The tool was developed in partnership with Newcastle University, and was then published by PHE in 2020. In 2020/21, over 1200 practitioners including health visitors, early years practitioners and speech and language therapists (SaLTs) were trained in the use of the ELIM-I, and areas have since cascaded the training locally.

The ELIM-I is designed to be delivered by health visitors at the 2-2½ year Healthy Child Programme (HCP) review. It is intended to enhance the early identification of SLCN, so that children with needs can receive appropriate support to develop to their full potential. It should be used universally with all children at the 2-2½ year review.

The ELIM-I is not mandated and is one of a number of tools that can be used by providers to improve identification of SLCN in the early years. A DHSC survey in January 2023 (with a response rate of 53% of Unitary Authorities) found that 28/81 (35%) of respondents were implementing the ELIM-I universally, 6/81 (7%) were piloting it, and 5/81 (6%) were using it in a targeted way. 14/81 (17%) were planning to implement it. 28/81 (35%) of respondents were not planning to implement the ELIM-I. Some of these areas were using other identification tools such as the WellComm or a locally developed tool, and some were using only the ASQ (which is a population-level measure rather than an identification tool). These findings represent the picture at one point in time. However, this survey supports our understanding that ELIM-I is still in the process of being embedded into service delivery in many areas.

The methodology for the development of the ELIM-I is summarised in the Identifying and Supporting Children’s Early Language Needs report [4]. An extended version was piloted in five sites. The combination of the observation and the word list were found to have a high sensitivity (0.94) and a relatively high specificity (0.65) hence these two elements of the ELIM-I were retained in the final version.

There has not been any formal evaluation of the ELIM-I commissioned by DHSC since it was published.

Research priorities

There are three overarching research questions which should be explored:

1. Delivery of ELIM-I: Is the ELIM-I being delivered as it was originally intended?
2. Impact on service delivery and experience: Is the ELIM-I impacting the delivery of services, and the experiences of the workforce/ families?
3. Impact on outcomes: Is the ELIM-I impacting children’s outcomes and disparities in these outcomes?

These research questions could be explored using a sample of ‘early adopters’ of the ELIM-I, i.e. areas where the tool has been fully embedded into service delivery.

Please note that the proposed methodologies outlined below are suggestions; we are open to other proposals for how these three research questions could be addressed.

Delivery of ELIM-I

The ELIM-I was designed to be delivered in specific way, to ensure a high level of sensitivity (i.e. most children with risk of SLCNs are accurately identified as needing support) and a relatively high level of specificity (i.e. few children without risk of SLCNs are wrongly identified as needing support). The tool is also intended to be part of a speech, language and communication pathway, to ensure parents/carers are signposted to appropriate support when a SLCN is identified.

We envisage the methodology for this research question could be qualitative research with health visitors to explore whether the tool is being delivered in line with the guidance handbook. Example questions could include:

• Is the word list completed at the 2-2½ review, rather than being sent out for parents/carers to complete?
• Is the ELIM-I used only at the 2-2½ review or also at other ages?
• Is the ELIM-I being appropriately tailored to multilingual children/ children whose first language is not English
• Which staff are carrying out the ELIM-I assessment?

Impact on service delivery and experience

It is important that families have a positive experience of the 2-2½ HCP review, to ensure continued engagement with the health visiting service. It is important that the ELIM-I helps them to feel engaged and empowered to support their child’s early language development, as parents/carers have a key role in shaping the home learning environment.

Meanwhile, we know that the health visitor workforce is facing vacancies, resulting in high caseloads. It is important that the ELIM-I does not place a significant additional burden on health visitors and their teams, and that it contributes to a positive experience of delivering the service.

One of the DHSC Secretary of State’s priorities is to address backlogs following the COVID-19 pandemic. Published data shows that, in May 2023, there were 72,168 children and young people on the waiting list for SaLT. It is possible that the ELIM-I has increased demand on SaLT by identifying more children with needs; it is also possible that the ELIM-I has reduced pressure on SaLT by identifying needs early, before they escalate, and by improving the appropriateness/quality of referrals.

We envisage the methodology for this research question could be qualitative research with health visitors and their teams, parents/carers, and wider system partners including SaLTs and early years practitioners. Questions could focus on a) how the ELIM-I impacts the experiences of health visitors and their teams, and families, b) how the ELIM-I impacts the delivery of the 2-2½ year HCP review, and c) how the ELIM-I impacts wider service delivery, such as further contacts with the health visiting service, and referrals to SaLT. Example questions could include:

• How long does the ELIM-I take to deliver a) when it is first rolled out, and b) when it is embedded?
• Does the ELIM-I help parents/carers to feel more informed, more supported, and more confident in supporting their child’s early language development?
• What is the experience of the ELIM-I for families with multilingual children/ children whose first language is not English?
• Has the ELIM-I resulted in more or fewer / more appropriate/ more detailed referrals to SaLT?

Impact on outcomes

SLCNs may result in poorer educational outcomes; evidence shows that 1 in 4 children who struggle with language at age 5 do not reach the expected standard in English at the end of primary school, compared with 1 in 25 who had good language skills at age 5 [2].

Meanwhile, SLC skills in the early years are socially distributed; children from disadvantaged families are more than twice as likely to be identified with a SLCN [5], and in some areas of deprivation, more than 50% of children start school with SLCN [6]. There are also ethnic disparities; in 2021/22, significantly lower proportions of children who are Asian (inc. Chinese) or Black achieved the expected levels in communication and language skills at the end of reception year [7].

ELIM-I has the potential to identify needs early so that more children receive the support they need and are ‘school ready’ by 5. It also has the potential to increase equitable access to identification and support, therefore reducing disparities in the language and communication skills of children from different backgrounds at school entry.

We envisage the methodology for this research question could be:

1. Qualitative research with health visitors and their teams, parents/carers and early years practitioners to gather case studies on whether delivery of the ELIM-I has impacted a child’s speech, language and communication, and has impacted other outcomes such as their wider social and emotional development.
2. Data analysis to investigate whether delivery of the ELIM-I impacts children’s outcomes and reduces disparities (inc. socioeconomic and ethnic disparities). Example questions could include:

• Have areas who have implemented ELIM-I seen a change in % of children achieving expected levels of development in communication and language skills at the end of reception, compared to areas who have not implemented ELIM-I?
• Have areas who have implemented ELIM-I seen a change in disparities in % of children achieving expected levels of development in communication at the end of reception, compared to areas who have not implemented ELIM-I
• Does the use of ELIM-I impact a) the persistence of SLCNs from 2 years to 4/5 years, and b) disparities in the persistence of SLCNs from 2 years to 4/5 years?

A feasibility study including a review of available data may need to precede analysis on the impact of ELIM-I on outcomes. The analysis could potentially link data on ELIM-I outcomes to data from the Early Years Foundation Stage Profile (EYFSP), to see how early identification and support resulting from the ELIM-I impacts children’s communication and language skills at age 5. Researchers could explore the use of national datasets including ELIM-I data in the Community Services Data Set, and the national EYFSP data. Alternatively, if data quality in national datasets is not sufficient, they could explore using local data records.

We expect the robustness of the evaluation design for this part of the research may depend on data availability and the extent of ELIM-I roll-out. However, as the impact of the ELIM-I on outcomes is a key research focus, we would like to understand your plans for establishing an evaluation design that is as robust as possible, such as identifying a counterfactual/comparator group.

If feasible, we would also welcome an economic evaluation, looking at the cost-effectiveness of the ELIM-I. However, we recognise that this may depend on data availability and the extent to which it has been possible to measure and quantify the impact on outcomes.

Phased approach

This independent evaluation is anticipated to be a long-term project which could take place in a phased approach:

• Phase 1a: Qualitative research on the delivery of ELIM-I (estimated September 2024- April 2025).

• Phase 1b: Qualitative research on the impact of ELIM-I on service delivery and experience, and the impact on children’s outcomes. Feasibility study on analysis of impact of ELIM-I on outcomes (estimated May 2025- February 26).

• Phase 2: Data analysis of impact on children’s outcomes (estimated March 2026- March 2027).

This phased approach would ensure that researchers could investigate whether the ELIM-I is being delivered as intended within a local area, before evaluating its impact. It would also enable the feasibility study to be conducted to determine how, or even whether, phase 2 can be delivered.

This phased approach would also allow for the fact that, depending on the approach taken, the evaluation of the impact of ELIM-I on outcomes may not be immediately possible. Data analysis linking ELIM-I outcomes to the EYFSP data will not be possible until a sufficient number of children who received the ELIM-I at 2-2½ years have reached the end of reception year. The ELIM-I was published in December 2020, and it is estimated that early adopters may have taken up to a year to embed the ELIM-I. Therefore, it is estimated that by July 2025, a sufficient number of children who received the ELIM-I will be finishing reception year. The EYFSP data for these children is likely to be published in Autumn 2025, and would therefore be available for the start of phase 2 in March 2026.

Alternatively, a decision may be taken to restrict the analysis to children who were not affected by the COVID-19 lockdowns. Children born from summer 2021 (when restrictions were lifted) will be finishing reception from July 2026. The EYFSP data for these children is likely to be published in Autumn 2026, therefore the start of phase 2 may be delayed until Autumn 2026.

The lengths of these phases are estimates. Applicants are welcome to present alternative proposals for how the different elements of the research could be phased over time, which may depend on their proposed methodologies.

Areas out of scope for this programme of work

Other early identification tools for SLCN are not in scope for this independent evaluation.

The evaluation should look at the implementation of the ELIM-I in England; the devolved administrations are out of scope. This is because we are interested in its use as part of the Healthy Child Programme.

Eligibility

Eligibility for the NIHR PRP is laid out in our Standard Information for Applicants and applies to all calls unless otherwise stated in the individual research specification.

Expertise required

Qualitative research skills (essential): This evaluation will involve qualitative research (e.g. interviews, focus groups, case studies) with healthcare professionals and with parents/carers from different socioeconomic and cultural backgrounds.

Quantitative research/ data analysis skills (essential): Researchers will need to develop a quantitative methodology for evaluating the impact of ELIM-I on children’s outcomes. They will need to identify and analyse appropriate datasets, therefore skills such as data cleaning, data linkage, and data visualisation will be important.

Knowledge on child health data (valuable): Familiarity with the child health data landscape (e.g. provider records systems such as System 1, EMIS and RIO; the Child Health Information System; national datasets such as the Community Services Data Sets and the EYFSP; Fingertips) will be valuable although not essential.

Expertise on SLC and service pathways (valuable): Expertise on SLC in the early years will be valuable although not essential. It will support an understanding of how the ELIM-I works, which will support evaluation of its delivery. An understanding of speech and language development, and of the trajectories of children with SLCN, will support the development of an appropriate methodology to evaluate the impact of the ELIM-I on children’s outcomes. An understanding of the service landscape will be valuable for evaluating the impact of the ELIM-I on service delivery, such as how ELIM-I impacts the delivery of the HCP and referrals to SaLT. An understanding of the role of health visitors and the HCP will also facilitate research with health visitors.

Economic expertise (valuable): Expertise in economic evaluation would also be valuable to explore whether an economic evaluation of ELIM-I may be feasible.

Outputs

We expect an unpublished evaluation report at the end of each phase of the research. Based on the anticipated phases of research (set out under ‘research priorities’) we would expect:

• A report of phase 1a (qualitative research on the delivery of ELIM-I) by April 2025
• A report of phase 1b (qualitative research on the impact of ELIM-I on service delivery and experience, and the impact on children’s outcomes) by February 2026
• A feasibility report on analysis of impact of ELIM-I on outcomes by February 2026
• A report of phase 2 (data analysis of impact on children’s outcomes) by March 2027. This may be delayed to Autumn 2027 if 2026 EYFSP data is used.

Receiving reports on phase 1a and phase 1b at these earlier points in time will mean that we can commence any work required to improve compliance and make improvements to the tool, rather than having to wait until the full project has concluded.

However, as set out above, applicants are welcome to present alternative proposals for how the different elements of the research could be phased over time. Therefore, a final decision on what reports are expected and by what date can be agreed with the successful applicant.

We expect a published end of project report, synthesising findings across all phases of research. Alongside this, we would invite a presentation for DHSC colleagues to hear the researchers’ recommendations. We would also invite the researchers to deliver a webinar to local commissioners and providers to disseminate the findings.

Applicants are asked to consider the timing and nature of deliverables in their proposals. Policymakers will need research evidence to meet key policy decisions and timescales, so resource needs to be flexible to meet these needs. A meeting to discuss policy needs with DHSC officials will be convened as a matter of priority following contracting.

Budget and duration

We have not specified a budget for this project, as we invite bidders to cost what they think delivering research to address the above specification to a high quality will require. However, there is an upper call limit of £600-800K, which should not be exceeded and applications at the top end of this range should be clearly justified. Costs for the proposed research should be justified and represent value for money.

Costings can include up to 100% full economic costing (FEC) but should exclude output VAT. Applicants are advised that value for money is one of the key criteria that peer reviewers and commissioning committee members will assess applications against.

Based on the anticipated phases of research (set out under ‘research priorities’) we would expect the project to take place over 2 ½ years, from around September 2024- March 2027. However, applicants are invited to confirm the project duration required for delivery of their proposed research within their application.

Management arrangements

A research advisory group including, but not limited to, representatives of DHSC, DfE and other stakeholders, and the successful applicants for the research should be established. The advisory group will provide guidance, meeting regularly over the lifetime of the research. The successful applicants should be prepared to review research objectives with the advisory group, and to share emerging findings on an ongoing basis. They will be expected to:

• Provide regular feedback on progress
• Produce timely reports to the advisory group
• Produce a final report for sign off

Research contractors will be expected to work with nominated officials in DHSC, its partners and the NIHR. Key documents including, for example, research protocols, research instruments, reports and publications must be provided to DHSC in draft form allowing sufficient time for review.

Guidance on Health and Care Inequalities and associate data collection within NIHR PRP Research:

Health and care Inequalities is a high priority area within the Department of Health and Social Care and the NIHR and is often present in a majority of funded projects.We are now assessing all NIHR research proposals in relation to health inequalities. We ask that you please clearly identify in the research plan section of the application whether your application has an inequalities component or theme as well as how this research hopes to impact inequalities or not. Please also detail the core set of inequality breakdown data that will be collected, if applicable. More information on this request can be found in the Standard Information for Applicants.

References and key documents

1. Public Health England. Early language identification measure and intervention: Guidance handbook. 2020. Available from: Early language identification measure and intervention: guidance handbook

2. Save the Children. Early language development and children’s primary school attainment in English and maths: new research findings. 2016. Available from: early-language-development-and-childrens-primary-school-attainment.pdf

3. Law J, Rush, R, Parsons, S, Schoon, I. Modelling developmental language difficulties from school entry into adulthood: Literacy, mental health and employment outcomes. Journal of Speech, Language and Hearing Research. 2009;52:1401-16.
4. Public Health England. Identifying and supporting children’s early language needs: Summary report. 2020. Available from: Identifying and Supporting Children’s Early Language Needs: summary report
5. Early Intervention Foundation. Language as a child wellbeing indicator. 2017. Available at: Language as a child wellbeing indicator | Early Intervention Foundation (eif.org.uk)
6. Locke A, Ginsborg, J, Peers, I. Development and disadvantage: implications for the early years and beyond. International Journal of Language & Communication Disorders. 2002;37(1):3-15.
7. Office for Health Improvement and Disparities. Fingertips: Child and Maternal Health Profile. Available at: Child and Maternal Health - Data - OHID (phe.org.uk).