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Speech and language therapy: Is it effective?
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Lettersto the Editor
458
can be of support and encouragement but may not benefit patients any more than the general support of an informed trained volunteer. 1 The conclusions drawn by Dr Pearson are really out of date given the changes in the understanding of the nature of aphasia, the developments of treatments and the more recent evaluative studies. Therapists have particular challenges with regard to research. More needs to be known about the underlying disorders, a greater range of appropriate methodologies need to be accepted and respected, and better outcome measures need to be used. Measuring the accuracy of sound production or the size of word vocabulary may be only one small aim of a speech and language therapist with a patient. In order to truly evaluate treatment, it is important that all the different health gains are tested. The call for more research in this area is welcomed--it is a challenging area and we cannot be complacent. I am pleased that this small, under-resourced and young profession has borne a respectable body of research literature. We must ensure that professions are not driven into a defensive stance as reviews, such as the one published here, do not do justice to the complexity of the area. One way of overcoming this in the future is for more collaborative pieces of work to be developed. Surely the author would have benefited by working more closely with members of this profession so that relevant literature was accessed, and particular nuances of meaning, groupings of studies and interpretations could be addressed. PAM ENDERBY
Chair Royal College of Speech and Language Therapists References 1 Enderby P, Emerson J. Does speech and language therapy work? A review of the literature commissioned by DOH. Accepted for publication (Whurr Publishers, London). Dr V A H Pearson responds as follows:
Speech and !anguage therapy: is it effective? t am delighted that Pain Enderby has commented on the above review as one of the purposes of publishing papers is to stimulate debate. The reason for undertaking the literature review was that, in working with local speech and language therapists in carrying out a needs assessment in Exeter, there was no independent, structured evaluation of the evidence of the effectiveness of speech and language therapy to guide the district's purchasing policy. In a review, it is important for the author to state how information was retrieved, so that readers can assess to what extent the findings can be generalised. The British Medical Journal has published a series of excellent articles on systematic reviews which can be commended to anyone interested in the brave new world of evidencebased practice. 1 Med-Line, while being a reasonably comprehensive database, does have a biomedical slant which may omit some professional publications, and this is acknowledged in the review. The process of publication of original research, peer review and acceptance for publication means that as soon as any review of original research is published, it is 'out of date': any review represents a particular assessment of the evidence at a particular time. However, this is not a reason to refrain from considering the extent and quality of the evidence, and this is one of the roles of
Lettersto the Editor ~ 459
epidemiology and public health medicine. The review has highlighted the lack of highquality research evidence in some important areas of speech therapy (which are often the areas of greatest demand for services), and raises awareness of the need for more research, otherwise purchasing strategies continue to reflect demand rather than need. It is essential that purchasers and speech and language therapists recognise the difference between assessing the efficacy of a treatment and evaluating its effectiveness. In health care there are many examples of current practices which may be effective but which may not have been fully evaluated, and the use of reviews in commissioning future services must necessarily involve local debate and discussion and take account of likely developments. Nevertheless, speech and language therapists are a highly trained expensive resource, and, as with any other professional group, their skills should be used primarily in areas where there is evidence of effectiveness. Having agreed on this point, the issue is whether extending the literature search to involve other databases less likely to contain class I or class II evidence of effectiveness2,3 substantially alters the conclusion of this review: I am sure that, like me, the readers of Public Health await the publication of the Department of Health commissioned review with great interest. V A H Pearson Consultant in Public Health Medicine Exeter and North Devon Health Authority References 1 Mulrow CD. Rationale for systematic reviews. BMJ 1994; 309: 597-599. 2 Woolf SH. Assessing the clinical evidence of preventive manoeuvres, analytic principles and systematic methods in reviewing evidence. J Clin Epidemiol 1990; 43: 891-905. 3 Ellis J, Mulligan I, Rowe J, Sackett DL. Inpatient general medicine is evidence based. Lancet 1995; 346; 407-410.
Lettersto the Editor
458
can be of support and encouragement but may not benefit patients any more than the general support of an informed trained volunteer. 1 The conclusions drawn by Dr Pearson are really out of date given the changes in the understanding of the nature of aphasia, the developments of treatments and the more recent evaluative studies. Therapists have particular challenges with regard to research. More needs to be known about the underlying disorders, a greater range of appropriate methodologies need to be accepted and respected, and better outcome measures need to be used. Measuring the accuracy of sound production or the size of word vocabulary may be only one small aim of a speech and language therapist with a patient. In order to truly evaluate treatment, it is important that all the different health gains are tested. The call for more research in this area is welcomed--it is a challenging area and we cannot be complacent. I am pleased that this small, under-resourced and young profession has borne a respectable body of research literature. We must ensure that professions are not driven into a defensive stance as reviews, such as the one published here, do not do justice to the complexity of the area. One way of overcoming this in the future is for more collaborative pieces of work to be developed. Surely the author would have benefited by working more closely with members of this profession so that relevant literature was accessed, and particular nuances of meaning, groupings of studies and interpretations could be addressed. PAM ENDERBY
Chair Royal College of Speech and Language Therapists References 1 Enderby P, Emerson J. Does speech and language therapy work? A review of the literature commissioned by DOH. Accepted for publication (Whurr Publishers, London). Dr V A H Pearson responds as follows:
Speech and !anguage therapy: is it effective? t am delighted that Pain Enderby has commented on the above review as one of the purposes of publishing papers is to stimulate debate. The reason for undertaking the literature review was that, in working with local speech and language therapists in carrying out a needs assessment in Exeter, there was no independent, structured evaluation of the evidence of the effectiveness of speech and language therapy to guide the district's purchasing policy. In a review, it is important for the author to state how information was retrieved, so that readers can assess to what extent the findings can be generalised. The British Medical Journal has published a series of excellent articles on systematic reviews which can be commended to anyone interested in the brave new world of evidencebased practice. 1 Med-Line, while being a reasonably comprehensive database, does have a biomedical slant which may omit some professional publications, and this is acknowledged in the review. The process of publication of original research, peer review and acceptance for publication means that as soon as any review of original research is published, it is 'out of date': any review represents a particular assessment of the evidence at a particular time. However, this is not a reason to refrain from considering the extent and quality of the evidence, and this is one of the roles of
Lettersto the Editor ~ 459
epidemiology and public health medicine. The review has highlighted the lack of highquality research evidence in some important areas of speech therapy (which are often the areas of greatest demand for services), and raises awareness of the need for more research, otherwise purchasing strategies continue to reflect demand rather than need. It is essential that purchasers and speech and language therapists recognise the difference between assessing the efficacy of a treatment and evaluating its effectiveness. In health care there are many examples of current practices which may be effective but which may not have been fully evaluated, and the use of reviews in commissioning future services must necessarily involve local debate and discussion and take account of likely developments. Nevertheless, speech and language therapists are a highly trained expensive resource, and, as with any other professional group, their skills should be used primarily in areas where there is evidence of effectiveness. Having agreed on this point, the issue is whether extending the literature search to involve other databases less likely to contain class I or class II evidence of effectiveness2,3 substantially alters the conclusion of this review: I am sure that, like me, the readers of Public Health await the publication of the Department of Health commissioned review with great interest. V A H Pearson Consultant in Public Health Medicine Exeter and North Devon Health Authority References 1 Mulrow CD. Rationale for systematic reviews. BMJ 1994; 309: 597-599. 2 Woolf SH. Assessing the clinical evidence of preventive manoeuvres, analytic principles and systematic methods in reviewing evidence. J Clin Epidemiol 1990; 43: 891-905. 3 Ellis J, Mulligan I, Rowe J, Sackett DL. Inpatient general medicine is evidence based. Lancet 1995; 346; 407-410.