{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,6]],"date-time":"2026-06-06T04:00:41Z","timestamp":1780718441943,"version":"3.54.1"},"reference-count":42,"publisher":"National Institute for Health and Care Research","license":[{"start":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T00:00:00Z","timestamp":1770768000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000272","name":"NIHR","doi-asserted-by":"crossref","award":["NIHR129577"],"award-info":[{"award-number":["NIHR129577"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["openresearch.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":["NIHR Open Res"],"abstract":"<ns3:p>Background Children with intellectual disabilities and behaviours that challenge (BtC) and their families require complex, multi-agency support. Despite policy commitments to strengthen community-based provision, including those arising from Transforming Care and the forthcoming Mental Health Bill (2025), there remains limited evidence on how these services are configured or what they cost to deliver. The National Institute for Health and Care Excellence (NICE, 2018) identified major evidence gaps in optimal service design, integration, and cost-effectiveness. Objective This research explores the structure and associated costs of community-based services in England that support children with intellectual disabilities and BtC. It aims to describe the configuration of local \u201cservice models\u201d, identify cost drivers, and clarify data requirements for commissioning and evaluation. Methods Within the NIHR-funded MELD (Mapping and Evaluating Services for Children with Learning Disabilities and Behaviours that Challenge) programme, 278 services were identified across England. Using survey data (n=161), Latent Class Analysis and descriptive synthesis produced a typology of five community service models. Nineteen representative sites participated in a detailed costing study using a bespoke data collection instrument aligned with national unit-cost frameworks. Quantitative and narrative data on staffing, pathways, and overheads were analysed descriptively and thematically, with input from a Parent Advisory Group. Results Five distinct service models were identified: generic CAMHS, ID-CAMHS, Children and Young People\u2019s Disability, Specialist BtC Support, and All-Age services. Costs were primarily driven by staffing mix, intensity of BtC support, and organisational structure. Considerable heterogeneity was observed in funding flows, eligibility, and waiting times. Conclusions This study provides the first national overview of community service configurations for children with intellectual disabilities and BtC. The findings highlight significant variation in organisation and cost, informing future economic evaluation and service-model optimisation in line with ongoing policy reform.<\/ns3:p>","DOI":"10.3310\/nihropenres.14153.1","type":"journal-article","created":{"date-parts":[[2026,2,12]],"date-time":"2026-02-12T07:54:08Z","timestamp":1770882848000},"page":"13","update-policy":"https:\/\/doi.org\/10.3310\/nihropenres.crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["The configuration, funding and costs of providing services for children with behaviours that challenge."],"prefix":"10.3310","volume":"6","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0236-2833","authenticated-orcid":false,"given":"Elizabeth-Ann","family":"Schroeder","sequence":"first","affiliation":[{"name":"Nuffield Department of Primary Care Health Sciences Oxford England OX26GG University of Oxford"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0495-8270","authenticated-orcid":false,"given":"Richard","family":"Hastings","sequence":"additional","affiliation":[{"name":"School of Social Policy and Society Birmingham England B15 2TT University of Birmingham"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicholas","family":"Manktelow","sequence":"additional","affiliation":[{"name":"School of Social Policy and Society Birmingham England B15 2TT University of Birmingham"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ashley","family":"Liew","sequence":"additional","affiliation":[{"name":"Paediatric Liaison Psychiatry Service | National & Specialist CAMHS London SE5 8AZ South London and Maudsley NHS Foundation Trust"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8188-2831","authenticated-orcid":false,"given":"Mark","family":"Lovel","sequence":"additional","affiliation":[{"name":"Child & Adolescent Mental Health Service Stockton on Tees TS18 3TX Tees, Esk and Wear Valleys NHS Foundation Trust"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5444-4147","authenticated-orcid":false,"given":"Caroline","family":"Richards","sequence":"additional","affiliation":[{"name":"School of Psychology Birmingham England B15 2TT University of Birmingham"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0379-8877","authenticated-orcid":false,"given":"Jill","family":"Bradshaw","sequence":"additional","affiliation":[{"name":"School of Social Policy and Society Birmingham England B15 2TT University of Birmingham"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nick","family":"Gore","sequence":"additional","affiliation":[{"name":"Tizard Centre Canterbury England CT2 7LR University of Kent School of Social Policy Sociology and Social Research"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9940-6913","authenticated-orcid":false,"given":"Paul","family":"Thompson","sequence":"additional","affiliation":[{"name":"School of Social Policy and Society Birmingham England B15 2TT University of Birmingham"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7745-1825","authenticated-orcid":false,"given":"Peter","family":"Langdon","sequence":"additional","affiliation":[{"name":"School of Social Policy and Society Birmingham England B15 2TT University of Birmingham"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stavros","family":"Petrou","sequence":"additional","affiliation":[{"name":"Nuffield Department of Primary Care Health Sciences Oxford England OX26GG University of Oxford"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"name":"MELD Research Study Team","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"6221","published-online":{"date-parts":[[2026,2,11]]},"reference":[{"key":"ref-1","doi-asserted-by":"publisher","first-page":"217-28","DOI":"10.1007\/BF02287708","article-title":"Administrative, clinical, and ethical issues surrounding the use of waiting lists in the delivery of mental health services.","volume":"29","author":"S Brown","year":"2002","journal-title":"J Behav Health Serv Res."},{"key":"ref-2","article-title":"Risk of 'failing the future' if children and young people don't get the care they 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The case of the SF-6D.","volume":"1","author":"S Walters","year":"2003","journal-title":"Health Qual Life Outcomes."},{"key":"ref-41","first-page":"1108-1113","article-title":"Development of the EQ-5D-Y: a new version of the EQ-5D questionnaire for children and adolescents.","volume":"14","author":"N Wille","year":"2011","journal-title":"Value Health."},{"key":"ref-3","doi-asserted-by":"publisher","first-page":"1027-37","DOI":"10.1542\/peds.2012-0668","article-title":"Predictors of delayed or forgone needed health care for families with children.","volume":"130","author":"L Wisk","year":"2012","journal-title":"Pediatrics."}],"container-title":["NIHR Open Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-13\/v1\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-13\/v1\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-13\/v1\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,6,6]],"date-time":"2026-06-06T03:14:14Z","timestamp":1780715654000},"score":1,"resource":{"primary":{"URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-13\/v1"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,11]]},"references-count":42,"URL":"https:\/\/doi.org\/10.3310\/nihropenres.14153.1","relation":{"has-review":[{"id-type":"doi","id":"10.3310\/nihropenres.15400.r39849","asserted-by":"subject"},{"id-type":"doi","id":"10.3310\/nihropenres.15400.r39852","asserted-by":"subject"},{"id-type":"doi","id":"10.3310\/nihropenres.15400.r39855","asserted-by":"subject"},{"id-type":"doi","id":"10.3310\/nihropenres.15400.r39849","asserted-by":"object"},{"id-type":"doi","id":"10.3310\/nihropenres.15400.r39855","asserted-by":"object"},{"id-type":"doi","id":"10.3310\/nihropenres.15400.r39852","asserted-by":"object"}]},"ISSN":["2633-4402"],"issn-type":[{"value":"2633-4402","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,11]]},"assertion":[{"value":"Indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-13\/v1#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.3310\/nihropenres.15400.r39852, Sunil Karande, Pediatrics, Seth GS Medical College and KEM Hospital, Mumbai, India, Mumbai, Maharashtra, 20 Mar 2026, version 1, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-13\/v1#referee-response-39852","order":0,"name":"referee-response-39852","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.15400.r39849, Laurence Taggart, Queens University Belfast, Belfast, 24 Mar 2026, version 1, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-13\/v1#referee-response-39849","order":1,"name":"referee-response-39849","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Elizabeth-ann Schroeder<\/b>; \n<i>Posted: 25 May 2026<\/i>; Taggart L. Peer Review Report For: The configuration, funding and costs of providing services for children with behaviours that challenge. [version 1; peer review: 1 approved, 2 approved with reservations].&nbsp;\n<i>NIHR Open Res<\/i>&nbsp;2026,&nbsp;\n<b>6<\/b>:13 (https:\/\/doi.org\/10.3310\/nihropenres.15400.r39849)   Dear L Taggart, thank you for the time you have invested in reviewing the manuscript and in providing your expertise as feedback.   We thank the reviewer for their positive and supportive assessment of the manuscript and for recognising the importance and timeliness of this work. We are pleased that the study is seen as addressing a clear gap in understanding service configurations and associated costs for children and young people with learning disabilities and behaviours that challenge in England. We also appreciate the constructive suggestions provided to strengthen clarity and consistency, which we have addressed as outlined below.    \n<b>Title and Abstract<\/b>  The title should explicitly state that the study focuses on children with intellectual disability and was conducted in England Please ensure consistent use of the term intellectual disability throughout, rather than learning disability Avoid abbreviations where possible; terms such as behaviours that challenge and intellectual disability should be written in full  &nbsp;  \n<b>Title<\/b>: The title has been revised to explicitly reflect the focus on children with learning disabilities and the England context.   \n<b>Terminology<\/b>: We have adopted a consistent approach by using \u201clearning disability\u201d throughout, reflecting standard terminology used within UK services and policy contexts. To ensure clarity for an international readership, we have included an early statement noting that \u201clearning disability\u201d (UK terminology) corresponds to \u201cintellectual disability\u201d as used internationally. \n<b>Use of abbreviations<\/b>: In line with the reviewer\u2019s suggestion, we have reduced the use of abbreviations throughout the manuscript and now use full terms such as \u201clearning disabilities\u201d and \u201cbehaviours that challenge\u201d where possible to improve clarity and readability.  We believe these revisions improve both clarity and accessibility for a broad readership.    \n<b>Background<\/b>  This section is well written and provides a strong overview of the current legislative and policy context in England.  &nbsp;  In describing the five service models, it would strengthen the paper to 1) Specify the professional groups involved in each model (noting that this is only partially described, e.g., nursing in Model 2) Outline the types of interventions\/therapies delivered within each model (e.g., behavioural and psychological support is only explicitly referenced in Model 4).    We agree that further clarity regarding the professional composition and types of support delivered within each service model would be valuable. In response, we have made targeted revisions to improve clarity where possible. Given the scope of the current paper and the variability and incompleteness of the data, we have not sought to provide a comprehensive description of interventions across all service models. Instead, we have ensured appropriate signposting to the staffing case-mix tables and relevant sections of the Results, where this information is presented in more detail. Ethical approval has been clearly stated in the Methods section.  Section 1 \u2013 Background (service model descriptions); Section 3 \u2013 Results (staffing descriptions and case-mix tables); Section 2 \u2013 Ethics approval  \n<b>Data Collection<\/b>  Clarify that Stage 1 survey findings have been reported elsewhere. This paper reports Stage 2 (follow-up survey and interviews), which aimed to collect more detailed data on staffing, overheads, and cost structures.  Nineteen sites participated in this phase but only ten responded.  The purpose-designed data collection instrument (seven sections) completed by clinical leads\/team managers and finance staff is appropriate The involvement of a PPI group (including parents, children and young people, the Challenging Behaviour Foundation, and a Parent Advisory Group) are a strength.   \n<b>Stage 1 and Stage 2 clarification<\/b>: We have revised the Data Collection and Methods sections to more clearly and consistently state that findings from the Stage 1 mapping survey \n<i>have been reported in detail elsewhere<\/i> (Taylor et al., 2023). We now emphasise that the current paper focuses on Stage 2 of the study, which involved a follow-up data collection to obtain more detailed information on staffing, overheads, and cost structures. \n<b>Site participation<\/b>: We have clarified that nineteen sites were invited to participate in the Stage 2 costing study, of which ten returned data, and have ensured this is clearly reported and consistently presented across the manuscript. \n<b>Data collection instrument and PPI involvement<\/b>: We thank the reviewer for noting these strengths. The description of the purpose-designed data collection instrument and the involvement of the Parent and Public Involvement (PPI) group have been retained and clarified where appropriate. The revisions have been made in: Section 2 \u2013 Data Collection methodology (Stage 1 and Stage 2 clarification; site participation); Section 3 \u2013 Results (opening paragraph \u2013 denominators); Section 2 \u2013 Patient and Public Involvement  \n<b>Results<\/b> &nbsp;  Data completeness is a key limitation: only 10\/19 sites returned data, and only two sites per model provided complete datasets. This is appropriately acknowledged Funding structures and flows are clearly described and well supported with tables Operational and overhead costs are less complete; Models 2 and 5 provided no data, and other models provided limited information Staffing data are clearly presented, demonstrating substantial variation in professional composition across sites and models Reported staff costs vary and appear sensitive to contractual arrangements, agency use, and on-call requirements The inclusion of staffing organograms and associated cost tables is useful; however, interpretation should be cautious given the extent of missing and inconsistently reported data The description of service configuration and community reach across models is informative   We thank the reviewer for their positive assessment of the Results section and for recognising the clarity of the funding, staffing, and service configuration descriptions.  We agree with the reviewer\u2019s point that interpretation of the staffing organograms and associated cost tables should be approached with caution, given the extent of missing and inconsistently reported data.  In response, we have strengthened the accompanying narrative to emphasise the limitations of the dataset and the need for cautious interpretation.  This includes clearer statements within the Results and Discussion sections that cost estimates are indicative and not directly comparable across sites, and that findings should be interpreted in light of data completeness and variability. These revisions align with the broader changes made throughout the manuscript to reduce the appearance of precision and avoid over-interpretation. Section 3 \u2013 Results (Section 3.3.2, staffing and costing sections,); Section 4 \u2013 Discussion (cost estimation subsection)  \n<b>Discussion<\/b>  This is a novel and valuable contribution, providing insight into the configuration and costs of service models for this population in England Limitations are clearly acknowledged, particularly the extent of missing cost data and the inability to undertake robust or complete economic analyses Full costings were not possible for most sites, and overhead\/operational cost data were largely unavailable for some Site engagement was limited (10\/19), which may affect representativeness The recommendations for commissioners and future research are appropriate and helpful   Overall, this paper makes a strong and valuable contribution to an under-researched but policy-relevant area. Its key strength lies in attempting to systematically characterise and compare service models and associated costs for children and young people with intellectual disability and behaviours that challenge, an area where empirical evidence is notably limited. The inclusion of multiple sites, engagement with stakeholders including PPI contributors, and the transparent reporting of challenges in data completeness all enhance the credibility and usefulness of the work. Despite limitations in the dataset, the study provides important preliminary insights that can inform commissioners, support service planning, and lay the groundwork for more robust future economic and implementation research in this field.   We thank the reviewer for their positive and thoughtful assessment of the Discussion and overall contribution of the manuscript. We are pleased that the study is seen as providing a valuable and policy-relevant contribution to an under-researched area.  We particularly appreciate the recognition of the study\u2019s strengths, including its national scope, engagement with stakeholders and PPI contributors, and the transparent reporting of data limitations.  We have ensured that the Discussion and Conclusions remain appropriately balanced with strengthened emphasis on the exploratory nature of the study, clearer articulation of limitations (including data completeness and representativeness), and cautious interpretation of findings.  We have also ensured that the implications for commissioners and future research are clearly aligned with the scope and limitations of the data.","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-13\/v1#referee-comment-3584","order":2,"name":"referee-comment-3584","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.3310\/nihropenres.15400.r39855, Kerim Munir, Boston Children's Hospital ,Harvard Medical School, Boston, Massachusetts, USA, Boston, Massachusetts, 01 Apr 2026, version 1, indexed","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-13\/v1#referee-response-39855","order":3,"name":"referee-response-39855","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"<b>Elizabeth-ann Schroeder<\/b>; \n<i>Posted: 25 May 2026<\/i>; Munir K. Peer Review Report For: The configuration, funding and costs of providing services for children with behaviours that challenge. [version 1; peer review: 1 approved, 2 approved with reservations]. NIHR Open Res 2026, 6:13 (https:\/\/doi.org\/10.3310\/nihropenres.15400.r39855)   Dear Professor K Munir, thank you for the time you have invested in reviewing the manuscript and in providing your expertise as feedback.  Overview: This is an important policy-relevant paper addressing a major service gap for children with intellectual disabilities and behaviours that challenge (BtC) in England.  The paper attempts to move beyond broad policy discussion and describe how community services are configured, funded, and costed across five service models: (1) Child and Adolescent Mental Health Services (CAMHS) (43%); ID CAMHS (17%); Children\/Young People Disability (16%); Specialist BtC Support (17%); and All age (7%). It makes a useful contribution, particularly because the authors situate the work within the context of Transforming Care, NICE guidance, and current efforts to reduce inappropriate institutional care and strengthen community provision.  The principal strengths are the project\u2019s national scope, its attempt to link typology and costing, its inclusion of Parent Advisory Group input, and its honest acknowledgment that routine service-level costing data are very difficult to obtain in real-world systems. The paper is especially valuable as a description of the present state of data availability and fragmentation in this field.  A major recommendation is for authors to more clearly frame the paper as an exploratory, service-mapping study rather than a robust comparative costing analysis. The central concern is not the importance of the question, but the degree of missingness and heterogeneity in the cost data, which substantially limit the strength of the inferences. For example, the manuscript itself states that 278 services were identified; 161 informed the typology; 19 sites were selected for detailed costing; and only 10 sites returned some data. In its current form, the manuscript risks overstating what can legitimately be concluded from the available data. Because the detailed costing phase yielded responses from only 10 of 19 sites, with substantial missingness within and across sections, very limited overhead data, and inconsistent full-time equivalent (FTE) posts devoted to the service being costed reporting. Given the lack of meaningful case-mix adjustment by severity, the paper should be framed more explicitly as an exploratory scoping or feasibility study of service models and data readiness, rather than as a robust comparative costing analysis.  The sampling flow and analytic denominators need a clearer presentation. The manuscript reports on several denominators: 278 potentially eligible services, 161 respondents to the typology survey, 19 sites selected for detailed costing, and 10 sites that returned some follow-up data. This is important but currently difficult to follow. A flow diagram is needed. The authors should also explain more clearly how the 19 sites were selected as \u201crepresentative,\u201d how representativeness was judged, whether there were systematic differences between responders and non-responders in the costing phase, and what implications this has for inference. Without this, the reader cannot judge how far these site-level costing observations can be generalized.   Recommendations:  The paper should be reframed more explicitly as exploratory and oriented toward feasibility. The strongest contribution is not that it provides definitive comparative costs of five service models, but that it shows how difficult such costing currently is in this service landscape. The manuscript itself acknowledges that full costing was not possible for most sites, that operational and overhead costs were almost entirely missing, and that case-mix by severity was unavailable. Under those circumstances, conclusions about service-model optimisation and cost structure should be substantially softened. I would encourage the authors to state earlier and more consistently that this is a top-down, exploratory mapping and costing exercise whose main output is the identification of evidence and data gaps.   We thank the reviewer for this important observation and agree that the manuscript would benefit from a clearer and more consistent framing as an exploratory study. We have revised the manuscript throughout to emphasise that this work represents a national, top-down mapping and exploratory costing exercise, with a primary aim of identifying service configurations and highlighting current data limitations. In particular, we have:  Revised the Abstract and Introduction to foreground the exploratory and feasibility-oriented nature of the study Softened language relating to comparative costing and service optimisation Emphasised the identification of evidence and data gaps as a central contribution of the work  We believe these revisions better align the claims made with the scope and limitations of the available data.  These changes are reflected in the Abstract, Introduction, Methods, Results, and Discussion sections, where the study is now consistently framed as exploratory and descriptive, and where conclusions have been moderated accordingly. The revisions can be viewed in:&nbsp; Abstract (Objective and Conclusions); Section 1 \u2013 Background (final paragraph); Section 2 \u2013 Data Collection methodology (final paragraph); Section 3 \u2013 Results (opening paragraph and model subsections); Section 4 \u2013 Discussion (opening paragraph and cost estimation subsection)  2.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The transition from Latent Class Analysis (LCA) to five final service models requires more methodological transparency. The paper states that LCA identified two service models, and that descriptive analysis, broader survey, and interview data were used to inform the final classification into five models. That may be entirely reasonable, but the process is not adequately explained. The authors should spell out which variables entered the LCA, how the number of classes was chosen, why the LCA yielded only two classes, and by what explicit decision rules the final five-model typology was produced. At present, the process appears to be partly statistical and partly interpretive, but the balance between them is unclear.  We agree that the transition from Latent Class Analysis (LCA) to the final five service models required clearer explanation. In response, we have revised the manuscript to provide a more concise clarification of this process. Specifically, we now state that five service models were identified through analysis of survey data using a combination of Latent Class Analysis and subsequent consensus-based refinement. To maintain focus on the aims of the current paper, we have avoided extensive repetition of methods reported in detail elsewhere and instead strengthened signposting to the original MELD typology paper (Taylor et al., 2023), where the full methodological approach is described. We believe this revision improves transparency while preserving the primary focus of this manuscript on service costing and data availability. The revisions can be viewed in:&nbsp; Section 1 \u2013 Background (Typology development subsection); Section 2 \u2013 Data Collection methodology (Stage 1 description and reference to Taylor et al., 2023)  3.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The manuscript needs a clearer separation between Stage 1 and Stage 2 findings throughout the Results section. The paper repeatedly combines detailed follow-up costing observations from a very small number of sites with broader descriptive observations from Stage 1. This is sensible in context, but it is not always clear which claims derive from the larger mapping dataset and which from the sparse costing dataset. The phrase that the Survey 2 data were \u201ctriaged with\u201d the Stage 1 data is also not sufficiently clear methodologically. The Results would be stronger if each section were explicitly distinguished: (a) findings from Stage 1 mapping data; (b) findings from Stage 2 costing returns; and (c) interpretive synthesis across both.  We agree that clearer separation between Stage 1 (mapping) and Stage 2 (costing) findings was needed. In response, we have revised the manuscript to more clearly distinguish the sources of data throughout. Specifically, we have removed the term \u201ctriaged with\u201d and replaced it with clearer descriptions of how Stage 2 findings are interpreted in the context of Stage 1 mapping data. In line with the primary aim of the current paper, we have also reduced the volume of Stage 1 material presented in the Results section, retaining only essential contextual information where needed. The Results now focus primarily on Stage 2 costing data, with Stage 1 findings used selectively to support interpretation rather than direct comparison. We believe this approach improves clarity regarding data sources while maintaining focus on the costing study and its associated data limitations. The revisions can be viewed in:&nbsp; Section 2 \u2013 Data Collection methodology (Stage 1 and Stage 2 clarification); Section 3 \u2013 Results (opening paragraph and model subsections); removal of \u201ctriaged with\u201d terminology  4.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The costing tables will benefit from a revision to improve precision. This is a central issue. The tables present apparently \u2018precise\u2019 cost totals. Still, many of these are based on incomplete salary\/FTE information, national band-based estimates from the PSSRU compendium, and a \u201cpragmatic\u201d apportionment of overheads when real overhead data were unavailable. In several instances, the paper itself notes that direct comparisons are not possible due to missing FTE data. I think the tables should visually distinguish: (a) observed salary\/cost data provided directly by sites; (b) band-derived or benchmark estimates; (c) assumed or imputed components; and (d) totals not suitable for direct comparison. Otherwise, the reader may over-interpret these totals as actual comparable costs rather than partial modelled estimates. The authors should consider presenting these as illustrative resource profiles or indicative cost ranges rather than precise comparative service costs.  We agree that, given the extent of missing data and the use of estimated inputs, there is a risk that the tables may convey a greater degree of precision and comparability than is warranted. In response, we have revised the manuscript to improve transparency in how cost estimates were derived. Specifically, we have:  Clarified within the text and table notes where costs are based on (a) data reported directly by sites, (b) national band-based estimates (e.g. PSSRU), and (c) assumptions or incomplete where data were missing Strengthened accompanying narrative to emphasise that these figures should be interpreted as indicative and not as directly comparable service costs  We have retained the main costing tables in their current format to preserve readability, but believe that the additional clarification and supplementary material address the concern regarding over-interpretation and improve the overall transparency and interpretability of the findings. The revisions can be viewed in:&nbsp; Section 3.3.2 \u2013 Staffing as a cost driver (interpretation of cost estimates); costing tables and accompanying footnotes.  5.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Case-mix and severity are insufficiently developed for the conclusions drawn. The paper correctly notes that service populations are heterogeneous and that the study could not adjust for mild, moderate, or severe intellectual disability, nor for the severity or the behaviours that challenge. This is an important limitation. It means that one cannot make strong claims about whether one service model is more or less costly or efficient than another, because the populations served may differ substantially in complexity. This limitation should be moved earlier in the paper and explicitly incorporated into the abstract and conclusions.  We agree that the inability to adjust for differences in learning disability severity and the nature and intensity of behaviours that challenge limits the extent to which service models can be compared in terms of cost or efficiency. In response, we have:  Incorporated this limitation more explicitly within the Abstract Moved and strengthened discussion of this issue earlier in the manuscript Further emphasised in the Discussion and Conclusions that findings should be interpreted cautiously, particularly in relation to cross-model comparisons  This limitation is now explicitly highlighted in the Abstract, discussed in the Results and early Discussion sections, and reiterated in the Conclusions to ensure it is clearly visible to the reader. The revisions can be viewed in:&nbsp; Abstract (Conclusions); Section 3.3.2 \u2013 Staffing as a cost driver (limitations paragraph); Section 4 \u2013 Cost estimation subsection; Section 4 \u2013 Person-centred approach subsection; Conclusions  5.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; The paper often argues that long waiting lists suggest underfunding, unmet need, service inequity, or structural inadequacy. These are plausible interpretations and may well be correct, but the study design is descriptive and does not directly demonstrate causation. Given the sparse and incomplete cost data, I would encourage the authors to use more cautious language. For example, \u201care consistent with,\u201d \u201csuggest,\u201d or \u201craise concern about,\u201d rather than more definitive causal statements. The same applies to broader claims about optimal service design and the implications for future commissioning.  We have revised the manuscript throughout to adopt more cautious and precise language. In particular, statements have been rephrased using more appropriate terms such as \u201csuggest,\u201d \u201care consistent with,\u201d and \u201craise concerns about,\u201d rather than implying direct causation. These revisions have been applied consistently across the Results and Discussion sections, particularly in relation to interpretations of waiting times, service capacity, and system-level implications. We have also reviewed broader interpretive statements to ensure that conclusions remain aligned with the scope and limitations of the data. The revisions can be viewed in:&nbsp; Section 3 \u2013 Results (service model subsections); Section 4 \u2013 Discussion (service model jurisdiction and waiting times subsections); Section 4 \u2013 Implications for commissioners  6.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Discussion includes detailed statements about parent experiences, postcode lottery effects, early discharge after a single assessment, fragmentation across jurisdictions, workforce dormancy due to vacancies, and inequity in rural and remote regions. These are important observations, but the reader needs to know more precisely where they came from. Were these findings from the Parent Advisory Group, free-text survey responses, online meetings, a distinct qualitative component, or a synthesis of stakeholder consultation? The methods section currently does not support that level of specificity in the Discussion.  We have revised the Methods and Discussion sections to clarify that these insights are drawn from a combination of sources, including:  free-text responses within the survey instrument discussions with participating sites during online meetings input from the Parent Advisory Group and stakeholder engagement activities  We have also ensured that the Discussion more clearly reflects the nature of these data as contextual and interpretive, rather than as findings from a formal qualitative analysis. These sources are now explicitly described in the Methods (Patient and Public Involvement section) and clearly signposted in the Discussion where such insights are presented. The revisions can be viewed in:&nbsp; Section 2 \u2013 Patient and Public Involvement; Section 4 \u2013 Discussion (service model jurisdiction and arrangements subsections)  7.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Terminology should be standardized: The manuscript says it will use \u201cintellectual disability\u201d consistently, but \u201clearning disability\u201d still appears, especially in the MELD programme title and in the Discussion of guidelines and services. Some of this is unavoidable in UK service naming, but the manuscript should distinguish between retained formal service titles and the authors\u2019 preferred descriptive terminology.  We have adopted a consistent approach by using the term \u201clearning disability\u201d throughout, reflecting standard terminology used within UK services and policy contexts. To ensure clarity for an international readership, we have added an early statement noting that \u201clearning disability\u201d in the UK context corresponds to \u201cintellectual disability\u201d as used internationally. Where formal service names or policy documents use specific terminology, these have been retained as appropriate. We believe this approach improves consistency while maintaining alignment with both UK practice and international understanding. The revisions can be viewed in:&nbsp; Section 1 \u2013 Background (definition paragraph); throughout manuscript (terminology standardisation)  8.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Some additional minor suggestions to strengthen clarity and consistency include:&nbsp; \n<b>a)<\/b> The title should explicitly mention both intellectual disability and England. As written, it sounds broader than the actual study. \n<b>b)<\/b> Tables need all abbreviations to be defined beneath each table, including FTE, WTE, ICB, CCG, LD, CAMHS, BtC, BCBA, PBS, and CTPLD. It should also be clearly stated whether \u201cSalary\u201d refers to the annual salary and whether the adjusted totals include on-costs, qualifications, management overheads, capital overheads, and travel. The tables currently require too much back-and-forth with the text. \n<b>c)<\/b> There appear to be typographic and internal consistency issues in the tables. Examples include spacing and punctuation inconsistencies in cost figures, unclear labels such as \u201cTotal FTE N\/A,\u201d and what appears to be an implausible \u201cassumed 0.5% FTE\u201d for the external supervisor, which may in fact mean 0.5 FTE. These should be carefully checked. \n<b>d)<\/b> The phrase \u201csection seven provided free text for miscellaneous information\u201d should be clarified. It would be better to say what kinds of information were sought there, for example, unusual service features, contextual information, non-standard staffing arrangements, or uncaptured costs. \n<b>e)<\/b> Service model descriptions could be made much easier to understand. A summary figure or one-page comparison table would help, with columns for each model and rows for eligibility, age range, core disciplines, typical interventions, funding basis, waitlist profile, and data completeness. The current narrative is rich but dense. \n<b>f)<\/b> The exclusion of special school services should be justified more explicitly. Given the role schools often play in supporting children with challenging behaviours, the rationale for exclusion should be clearer. \n<b>g)<\/b> The phrase \u201cfirst of its kind\u201d should be softened: A more defendable phrasing would be \u201cthe first national exploratory overview\u201d or \u201cthe first national top-down service-model and costing exercise of which we are aware\u201d for community-based services in England for children with intellectual disability and behaviours that challenge. \n<b>h)<\/b> \u201cRecommendations for commissioners\u201d may be too strong. Given the exploratory nature of the work and the acknowledged missingness, \u201cImplications for commissioners\u201d or \u201cConsiderations for commissioners\u201d would be more appropriate than formal recommendations.  We have addressed each of these points in the revised version as follows: \n<b>a). Title<\/b>: The title has been revised to explicitly reflect the focus on children with learning disabilities and the England context. \n<b>b)Tables and abbreviations<\/b>: All abbreviations (e.g. FTE, WTE, ICB, CCG, LD, CAMHS, BtC, BCBA, PBS, CTPLD) are now defined beneath each table and across the manuscript. We have also clarified that total salary figures refer to annual values and that adjusted totals include on-costs, qualifications, management overheads, capital overheads, and travel. \n<b>c)Table consistency<\/b>: Tables have been carefully reviewed and revised to address typographical and formatting inconsistencies, including clarification of labels and correction of ambiguous entries (e.g. FTE values). \n<b>d)Section seven clarification<\/b>: The description of \u201cmiscellaneous information\u201d has been revised to more clearly indicate the types of contextual and service-level information captured (e.g. non-standard staffing arrangements, service features, and uncaptured costs). \n<b>e)Service model descriptions<\/b>: We have improved the clarity of service model descriptions. \n<b>f)Exclusion of special school services<\/b>: We have clarified in the Methods section that special school services were excluded as they do not typically constitute community-based health and care service models within the scope of this study. While these settings play an important role in supporting children with behaviours that challenge, they do not usually provide the types of community-based health and care services examined in this study. \n<b>g)\u201cFirst of its kind\u201d phrasing<\/b>: This has been revised to a more cautious formulation, reflecting the exploratory and national overview nature of the study. \n<b>h)Recommendations for commissioners<\/b>: We have revised the wording to \u201cImplications for commissioners\u201d to better reflect the exploratory nature of the findings. The revisions can be viewed in:&nbsp; Title page; Section 2 \u2013 Data Collection methodology (Section seven clarification and exclusion criteria); Section 3 \u2013 Results (tables, abbreviations, and service model summary table); Section 4 \u2013 Discussion; Section 4 \u2013 Implications for commissioners  Implications for future research:  I would recommend adding the following closing comment: This policy-relevant paper addresses an understudied yet highly important area. Its value lies primarily in national service mapping, early refinement of typology, and candid exposure of the current limitations of service-level costing data. With revision, the paper stands to make a strong contribution as an exploratory study of service configuration and data readiness. To achieve that, however, the authors should narrow some of their claims, improve methodological transparency, more clearly separate Stage 1 from Stage 2 findings, and revise the costing tables to reduce false precision and improve interpretability.  We thank the reviewer for this constructive recommendation. We agree that the primary contribution of this paper lies in its national service mapping, the refinement of service model typology, and the identification of important gaps in service-level costing data. In response, we have revised the manuscript to more clearly reflect its role as an exploratory study of service configuration and data readiness. Specifically, we have:  Narrowed and refined the claims made throughout the manuscript Improved methodological transparency, including clearer description of the typology and data sources Strengthened the distinction between Stage 1 mapping and Stage 2 costing findings Revised the presentation and interpretation of costing data to reduce the appearance of false precision  We have also strengthened the Conclusions section to more clearly articulate the exploratory nature of the study, its key contributions, and the implications for future research and routine data development. The revisions can be viewed in:&nbsp; Abstract (Conclusions); Section 4 \u2013 Discussion (opening and costing subsections); Section 5 \u2013 Conclusions","URL":"https:\/\/openresearch.nihr.ac.uk\/articles\/6-13\/v1#referee-comment-3586","order":4,"name":"referee-comment-3586","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"The study is funded by National Institute for Health Research (NIHR) Health and Social Care Delivery Research programme (Ref NIHR 129577). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.","order":5,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}