What is The Balanced System®?
The Balance System is a whole system strategic approach to supporting children and people with a whole range of needs, that has primarily come out of work in the area of speech, language and communication.
Marie Gascoigne has been developing the Balance System framework for over 15 years. It is used by a whole range of stakeholders, including commissioners from all disciplines and providers, particularly of therapy services.
As the diagram shows, it is a see-saw model with a set of blocks that provide the base above which balanced support is delivered.
The bottom block of the framework is getting the right outcomes commissioned for children and families. In the current legislative context that increasingly means jointly commissioned where possible, so asking various constituencies who have money, who have responsibility for making sure that services are available, to do that together and setting clear outcomes that they share for children, young people and their families.
The next block shows that whatever these outcomes are, to achieve them, we need an integrated workforce. There has been emerging recognition over the last decade that you can't, as a professional, achieve something on your own from just your professional perspective. It invariably involves working with colleagues and indeed with families themselves. In the next block we recognise parents and carers as a core set of partners in these building blocks that underpin any whole systems approach.
Leadership and management forms a fulcrum right at the centre of the model. Over numerous reviews looking at collaboration around speech and language services, although leadership and management was hard to quantify and evidence in a formal way, it was clear that where there were local champions and good strong supported leaders, services flourished and where that wasn't the case, the opposite, sadly, was also true. The Balanced System framework therefore recognises and emphasises its importance.
Sitting on top of everything is the service delivery framework itself. Training and development is a core plank that underpins all that goes above, then we have the universal, targeted and specialist levels of support which are delivered together by a wider workforce and a specialist workforce. They're both needed at all levels, albeit their roles might be different and the specifics of what they do might be very different at each level.
The Five Strands
Alongside this model, there are five areas that the outcomes that we include in any framework have to cover. These areas form the five strands of the Balanced System.
First we have family support: supporting families, children, and young people themselves as they get older, with information, with skills and with advice to actually make decisions and build, resilience and be in charge of the situation in which they find themselves.
Next are the environments in which they exist, whether that be the home, a community environment, school learning environments etc. In an ideal world these need to be audited, adapted and enhanced to allow children and people with speech, language and communication needs (or other needs if you are looking at it through a different lens) to access and participate as much as possible.
Moving on, the workforce needs to be appropriately skilled. For that we need to acknowledge the fact that there are specialists in the workforce. We have to make sure that there are enough specialist competencies in a skill mix, but also that knowledge transfer and capacity building is happening so the wider workforce is continually being refreshed and renewed with skills that they need in order to support packages around children and young people.
Then we come on to identification and intervention. They are two, but only two, of the five strands. Intuitively and historically the focus has been on intervention in particular, and to a slightly lesser degree, identification. The core principle of the five strands model is that identification and intervention are only as effective as they can be within that whole system, and acknowledging that there has to be a context of family, environment and workforce in which they happen.
Our identification needs to be as efficient and as accessible as possible. That involves making sure that people in the wider workforce have support to know what to look for, to bring the right children through, but also that we don't put unnecessary barriers in the way of access to services. If we can quickly see something that will help, we should be able to move through to that even if we think there are elements that need more delving into.
We do identification in order to respond to needs that are identified with intervention and we need our interventions to be appropriate and timely. It doesn't matter whether they're direct, indirect, individual or group, there needs to be a core functional purpose. We know from research like the Better Communication Research Programme that families value things that they can see are making a difference in their child's life in terms of their wellbeing, their confidence and their participation whilst accepting the importance of working on other areas. Those outcomes are what matters to families.
Is it making a difference?
To think about how we might measure what we do, we've used the well documented model from American economist Friedman. We’ve taken the quantity, quality, effort and effect grid and given a layer of language that is more appropriate to our needs into describing what the different quadrants are about.
The first quadrant is called level one and is an input measure; it's about measuring how much we did through traditional measures of input such as face to face contacts, etc. These measures have a value. They tell commissioners and contract managers that something happened, but they don't tell us whether it made any difference. That’s a key leap to think about and something we work on with commissioners using this framework.
Staying on the quantity side of the grid, the quadrant below is level two: reach. This stays with the notion of accounting but means: did we set goals as to how many of these things we wanted to do, for how many people and who these people are? How well are we doing in getting to that reach: was it 100% of what we set out to do or was it 80% or 70% or whatever. This gives us a bit more meaningful information, but it's still very much about the doing rather than the impact.
We then move over to the quality side, and we have level three: implementation, which is around the quality of what we've done. So: was it good training? Was it a good, well-planned intervention?
Sadly, it can be excellent but still not making a difference to the child or young person, for a whole host of reasons. This is not about being critical, it's saying that we need to recognise that's a possibility and try and move to include some measures that are about impact. So did we make a difference? Can we show that we made a difference? Whether that difference is for an individual, for a group such as a specific intervention group or a class or a school, or even going up to a population at a much broader level.
The length of time that we will need to have those measures in place will vary depending on what it is we're trying to measure and at what level. Population measures, notoriously, will require trend data that might take a number of years to actually be available. Building a measuring framework is not about the tools; you could use a whole range of tools to get those measures. The key is to have a system that allows us to consider all aspects: have we got a measure for that or are we even setting out to measure that?
All of this comes together in Integrated Solution Tool.
The Integrated Solution Tool
The Integrated Solution Tool considers a whole system, for example from the point of view of supporting speech, language and communication needs. We need to identify shared joint outcomes across partners, health, education etc. and families themselves at each of the three levels (Universal, Target and Specialist) and for each of the five strands.
For each of those outcomes we then need to work through:
- what the overall outcome looks like
- what the outputs might look like that one would need to produce in order to achieve those outcomes, the likely tangible things that would need to be there
- what the processes might be to make it happen. This is personalised to the particular context in a particular area or service, or whoever is using this from whatever angle, to get it right for the circumstances that it's being focused on.
- we also have to identify potentially four types of measures for each outcome: an input measure, a reach measure, an implementation quality measure and an impact measure.
We then need to try and specify who has to do what in order to achieve this outcome. A core principle which is fundamental to the Balanced System framework is that no outcome can be achieved just by one element of the specification. There isn't an outcome that just speech and language therapists can solve, or just specialist teachers or EPs or health visitors or SENCOs. There isn't an outcome that can just be solved by good teaching or by parents doing their best and working as hard as they possibly can. It needs a collaboration, and that collaboration will have a different mix and a different balance for each outcome at different levels but there is always going to be a mix required.
In the Integrated Solution Tool, for every one of those outcomes are worked through examples of what you might see, how you might do it, how you might measure it, what you'll need from your speech and language therapist, your SENCO or your health visitor, your class teacher or your nursery nurse and what parents will need to do. The context section is about other things like space and capacity and perhaps support from senior leadership etc.
Population, intervention and workforce
How does this fit together in terms of who does what and for whom?
The first pyramid diagram shows a population of children and young people. Based on our research data and other figures that are available, we can say what we expect to find in any population of children and young people in terms of different kinds of speech and language needs.
We can expect 1% will have quite severe, complex, long-lasting and specific speech and language needs that are going to need some sort of support over a period of time.
We can expect to find a larger group with more varied needs that are still significant, perhaps 7 to 10% of a population. Inside that larger group would be children and young people who have other primary needs that speech and language and communication is part of.
There will be a much larger group which is more varied in terms of needs. Some will go on to be identified as having more significant needs but we know that there are children who, through disadvantage or lack of early experience or various factors that are perhaps not as well understood as they will be in the future, will be more likely to have speech and language needs, particularly in the early years. So the bottom of the pyramid is a larger group of children and young people, which will vary from situation to situation, many of whom can be expected to respond well to support and then move down the pyramid to not having any needs, as opposed to moving up if those needs are not addressed early.
The middle diagram is the pyramid of universal offer and targeted and specialist interventions. In the whole systems approach, some of the things that we do for children and young people will be to enhance and manipulate the universal and the general environment that all young people exist in, some will be about targeted interventions and some will be specialist. There is debate around exactly where the lines are drawn between targeted and specialist but it is recognised that there is a continuum of intervention support.
The third pyramid shows the workforce ranging from the wider workforce, which is absolutely everybody, through to those that have developed enhanced skills in a particular area. In the case of speech and language needs that might be a teaching assistant that has completed a Level Three qualification in speech and language and developed lots of enhanced skills through to the specialist workforce of speech and language therapists, specialist teachers, EPs etc.
We have a range of ways of travelling across these three pyramids. There might be, for example, a child with quite complex needs who sits in that 1%, but whose needs are appropriately met by targeted interventions at the moment, delivered by either somebody within enhanced skills or potentially even just through the wider workforce. At the same time, we might have a young person who has a less complex profile and sits further down the population pyramid, but for whom a specialist intervention delivered right now might be really effective and make all the difference, and might even be all that they're ever going to need.
Equally, when we're looking at the universal offer and enhancing the universal provision that's out there for all children and young people, we might need specialists to be the people doing that, because they may have better training and knowledge to impart their specialist knowledge in that wider context. We want to avoid the assumption that we travel horizontally across these three pyramids. We do sometimes, but it shouldn't be the default and that's not something that everybody is totally comfortable with.
What does a child or young person’s journey look like?
If we think about what a journey might look like and what the provision itself might feel, if we consider all the processes and outputs that sit in the Integrated Solution Tool we're talking about many, many units of activity that you could define as separate units. For any child at any one time accessing any element of the service, they're likely to be accessing perhaps six or seven of those simultaneously and they might be coming from all different levels.
To illustrate, this diagram shows the three levels on a vertical axis and the notion of time from left to right: things to do with pre-identification which is information and awareness raising generally, things to do with identifying which is specific to particular individuals or groups, things around intervention and things around evaluation.
The two and a half year Health Visitor check is a universal identification activity, as it happens for everybody and it's definitely about identification. However, if we're thinking about that whole systems model from a commissioning perspective, if the outcome is around identification and a core component is that the Health Visitor does their two and a half year check, the Health Visitor has to be supported at some level by training, by confidence in their own competencies to actually do the identification. That will undoubtedly involve professional collaboration with speech and language colleagues, or even training delivered by speech and language therapy colleagues, which will have to be funded and commissioned in order for the whole thing to work. They need to be therefore identified as clear components of what's needed in the bigger whole.
Let’s think about a language rich environment within a school or a nursery setting. A Health Visitor might see a child at two and a half and think “I don't think a speech and language referral is needed here, but they definitely would benefit from a little bit of experience and enrichment. So I'm going to direct the family to a setting that has a particularly good language rich environment.” That language rich environment won't come about by accident; it would have needed staff training, consideration of the environment and whether the environment is suited to enabling and communication friendly and so forth. That might involve training from speech and language therapy service or from other colleagues, bringing in materials that have been sourced or might be available nationally, but all of those things have to be there in order for it to happen.
Thinking more specifically, we might have a targeted intervention like a rolling programme of groups. For example, a speech language service can predict that there are always going to be children that require attention and listening support, vocabulary development and certain speech sound system issues that are common. So rather than organising your service around who comes to the door you might decide to set these group up and have these running. In an ideal situation you would be doing that collaboratively with schools and settings where those young people might be.
Then, of course, there are situations where a specialist intervention is required. Here the example is within a school setting where you might have a specialist intervention going on and indeed, the child that's receiving that specialist intervention might also be accessing a group in the rolling programme. They may also be benefiting from a language rich environment and may have been identified at two and half years old by their health visitor.
All of this is to illustrate the fact that we need to think more flexibly. We don't want the pathways that we have to become silos. For example, if a child in the identification part of this model were felt to need a specialist multidisciplinary assessment that required a longer wait but it was obvious that they would also benefit from accessing something at a targeted level immediately, that should be possible. They shouldn't be sort of hived off into a pathway that becomes confining, as opposed to doing something in the meantime while moving forward towards that more complex identification. It's thinking more fluidly about things.
Who's using the Balanced System framework and how?
The Balanced System for Commissioners
From a commissioning point of view we’re already starting to see how useful the Integrated Solution Tool and online platform can be.
There are tools and templates around needs assessment at a population level. That population could be defined at a local authority, CCG or health commissioning level, whatever that may be, or at a school level. You can define a population however you like but those are typically the two demographic levels that would be relevant. That allows us to look at what we predict the need would be in an area based on an interaction between what we know about the population and what we know about the area itself in terms of the demographics.
Through the model we can support development of specifications. In this instance, we have looked at speech, language and communication needs. The Integrated Solution Tool looks across the whole of the SLCN system, identifying what specialist teachers need to be doing, what class teachers need to be doing, and what speech and language therapists will be doing. One part of the overall specification like speech and language therapy, can be taken out and made into the specification just for that service. This acknowledges the fact that some services have to be commissioned unilaterally and it is not always appropriate or possible to commission around the whole area in one set of contracts.
Increasingly, the principles and methodologies of the Balanced System are being transferred to look at the commissioning of other therapies.
The Balanced System for Providers
From the provider perspective, The Balance System framework offers a way of analysing the service provision. If you feel it shows that there's a need to do something slightly different, it supports service redesign. It supports allocation of resources across schools and settings, and evaluating service provision using outcome focused data. There are a variety of tools for those outcome measures, which is one of the core principles of the whole framework. The Balanced System philosophy is about defining the what and what has to happen and the so what and the why but not to be prescriptive on the how, which can be absolutely flexible within certain parameters.
The framework provides potential support with stakeholder engagement and evidence for commissioners. In some areas we have commissioners commissioning to the model and providers providing to the model, which generate a higher level of sophistication in terms of the two coming together.
The Balanced System for Schools and Settings
We also have the Balanced System Scheme for Schools and Setting which is essentially a version of the whole model which has been adapted to a school level. It's a strategic approach for a school to support speech and language throughout the setting across those five strands. It's not simply a communication friendly environment tool; it would require one to be in place but that would just be about the enabling environment strand. It's about the whole five strands of family support, enabling environment, workforce development, identifying and intervening.
There's a formative process: it's a four term cycle, or an academic year plus cycle if you're into semesters, with mentoring and online tools and support. If desired there's an accreditation which has been developed in conjunction with Naplic and Afasic and it completes step three of the Communication Trust Communication Commitment.