Services, Final Summary Report prepared on behalf of...

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Developing Community Therapy Services, Final Summary Report prepared on behalf of CMCSU for St Helens CCG.

Table of Contents

1 OVERALL COMMENTARY ............................................................................................. 4

1.1 INTRODUCTION AND SCOPE ................................................................................................................................ 4

1.2 PROJECT BRIEF ......................................................................................................................................................... 4

1.3 APPROACH ................................................................................................................................................................. 4

1.4 ACKNOWLEDGEMENTS .......................................................................................................................................... 5

1.5 CONSTRAINTS ........................................................................................................................................................... 6

1.6 OTHER FACTORS ...................................................................................................................................................... 6

1.7 SUMMARY OF KEY FINDING & CONSIDERATIONS ....................................................................................... 8

2.0 EXISTING COMMUNITY THERAPIES PROVISION - DIRECTORY OF SERVICE (DOS) ...... 11

3.0 REVIEW OF EXISTING SALT, PODIATRY AND DIETETICS SERVICES ............................. 12

3.1 CONTRACT AND ACTIVITY DATA .................................................................................................................... 12

3.2 DIETETIC SERVICES ............................................................................................................................................. 13

3.3 SPEECH AND LANGUAGE THERAPY SERVICES ........................................................................................... 16

3.4 PODIATRY AND ORTHOTICS ............................................................................................................................ 18

4.0 OUTLINE SPECIFICATION FOR COMMUNITY PHYSIOTHERAPY .................................. 22

4.1 CURRENT SERVICE OVERVIEW ........................................................................................................................ 22

4.2 DRAFT OUTLINE SPECIFICATION FOR SERVICE ........................................................................................ 22

5.0 REABLEMENT SERVICES AND RAPID RESPONSE SERVICES ........................................ 23

5.1 BACKGROUND ........................................................................................................................................................ 23

5.2 INFORMATION SOURCES .................................................................................................................................... 23

5.3 REABLEMENT ‘AS IS” POSITION ...................................................................................................................... 24

5.4 RAPID RESPONSE ‘AS IS’ POSITION ................................................................................................................ 29

5.5 FOR FURTHER CONSIDERATION ..................................................................................................................... 31

6.0 OTHER POINTS FOR CONSIDERATION ..................................................................... 33

Developing Therapies Final Report – August 2013 Page 3

APPENDIX I – PROJECT BRIEF FOR DEVELOPING THERAPY SERVICES (TO BE INSERTED WHEN SIGNED OFF) ........................................................................................................ 34

APPENDIX II – SCHEDULE OF MEETINGS / DISCUSSIONS HELD WITH KEY STAKEHOLDERS 38


1 OVERALL COMMENTARY

1.1 INTRODUCTION AND SCOPE

This report has been prepared by the Cheshire and Merseyside Commissioning Support Unit (CMCSU). The report summarises the outputs of the project brief developed and agreed with St Helens Clinical Commissioning Group (St Helens CCG) and represents the final summary report for the project ‘Developing Therapy Services ‘. The overarching aim of the project is: To work with stakeholders across the CCG, to produce a strategic vision and options for delivery, for the provision of community therapies for St Helens – Developing Therapy Services. In terms of defining ‘community therapies’, the scope was agreed to include: Dietetics; Speech and Language Therapy (SALT); Physical Therapies – Physiotherapy and Occupational Therapy; Podiatry and Orthotics and the Therapies provision within Reablement (RAB) and Rapid Response (RR): and to exclude: paediatric therapy services and Musculo Skeletal Therapy (MSK) services.

1.2 PROJECT BRIEF

In discussions with the St Helens CCG lead, Ruth Hunter, it was agreed that the project would consist of a number of phases. A copy of the project brief is appended (Appendix I).

1.3 APPROACH

Key Stakeholders The approach outlined by St Helens CCG was not a forensic examination of the current services but to engage with key stakeholders to clarify the current service provision and identify from these discussions, opportunities for improvement. For the purposes of this project, the key stakeholders were identified by St Helens CCG as:

Five Boroughs Community Health Services (5BPCHS) – the current service provider of community therapy services to St Helens CCG;

The Local Authority - as much of the therapy provision is provided by the

Reablement team (RAB) which is led by the council;

Lead GPs (Steve Cox and Julie Whittaker) within the CCG and the CCG quality lead (Lynda Carey);

Bridgewater Community Hospitals NHS Trust - as they provide the nursing

elements within the St Helens Rapid Response Team and the Reablement Team and are also lead provider for Newton Hospital, with the objective to understand the transfers of care from these services to community therapy services;


St Helens and Knowsley Hospitals NHS Trust - as they commission therapy

services from 5BPCHS for their secondary care and intermediate care hospitals with the objective to understand the relationships and transfers of care from these services to community therapy services;

Users of the services – patient users and non patient users

A table outlining the meetings / discussions which took place with the key stakeholders, is attached at Appendix II. It should be noted that the information from these discussions was accepted in good faith and was not validated. Data As outlined within the brief the modelling utilised is basic and relies primarily on contract data. In addition to the contract data, 5BPCHS outlined where feasible, the notional WTE staffing within each of the services and the historic activity data in relation to community physiotherapy services. Best Practice A library search was carried out in relation to areas of best practice for the therapy services. Engagement with Patients/Public Direct engagement with patients has to date been limited. The rationale for this being that:

i. The need to be respectful of both staff and patient’s time and to only engage when it is absolutely clear what is to be achieved from the engagement;

ii. The need for due consideration of engagement which has occurred / planned as part of other reviews

As such it has been agreed to defer the production of a detailed engagement plan until this report has been completed and the engagement strategy for the intermediate care review, has been developed. Not withstanding this, the St Helens PPG were invited to participate in a listening exercise at the St Helens PPG meeting on the 19th June. The feedback from this session is attached:

1.4 ACKNOWLEDGEMENTS

Grateful thanks are extended to all of the stakeholders for time given by them and in particular thanks to the staff within 5BPCHS.


1.5 CONSTRAINTS

Availability of existing detailed demand modeling which takes into account the future demands of the St Helens CCG demographic and the recommended access rates;

The current contract arrangements, as the current contract for therapies support to St Helens CCG is part of a block contract it has not been possible to definitively identify financial data, activity data or absolutely accurate staffing levels at a service line level;

Service specifications – it has been acknowledged that most of the existing

service specifications do not accurately represent the current service provision;

Best practice - the best practice literature searches, identified limited available data relevant to the services being looked at.

1.6 OTHER FACTORS

There are a number of factors, which need to be understood and taken into account when reading the report:

History There is a long history of service and organisational reconfiguration, which sits behind the current provider 5BPCHS and which this report does not aim to articulate in detail. However, it should be acknowledged that this history impacts upon the ways in which therapy services are currently managed and delivered at an operational level and also within the current block contract arrangements between St Helens CCG and 5BPCHS.

Block Contract for therapy services The provision of therapy services to St Helens CCG are contracted within a block contract for community services, with no supporting financial service line information. The routine contract monitoring is also at a generic service level and does not represent the ways in which the services are delivered at an operational level, for example dietetics consists of two different service offerings – nutrition support and general community dietetics. The 2013/14, contract schedule is shown below:

Table 1 - Activity Plans - Community Contract 13/14, NHS St Helens CCG

Service ID Team Line Proposed Activity

104 Intermediate Care 13858

104-1 Early Supported Discharge Service 2256

105 District Nurse Liaison Service 5544

109 Specialist Palliative Care 6296

110 Podiatry (Non AQP) 34131

111 Dietetics 3500

112 Adults Speech and Language Therapy 1180

115 Orthotics 1746

000 Decontamination of children’s equipment 200

Total Community 68711


Children’s Services

Service ID Team Line Proposed Activity

405-1 Paediatric Speech and Language 5679

405-2 Paediatric Physiotherapy - Knowsley 2926

405-3 Paediatric Occupational Therapy - Knowsley 1505

Total Children’s Services 10110

Other Contracts / Service Provision In addition to the current block contract arrangements between the CCG and 5BPCHS for community therapy services, there are other contract arrangements for the provision of therapy services across the St Helens CCG locality of which consideration should be taken when reading the report: St Helens and Knowsley Hospitals NHS Trust and 5BPCHS Contract: the therapy

services provided within secondary care are contracted to and provided by 5BPCHS under a block contract arrangement;

Reablement Services Contract: the Reablement service provided within St Helens CCG is purchased by St Helens Borough Council with funding made available from the St Helens CCG through a Section 75 arrangement. The team is also coordinated through St Helens Borough Council. The service is a domiciliary service and structured with service provision from three separate providers: 5BPCHS provide the therapies element of the team; Bridgewater Community Trust provide the nursing element of the team and St Helens Borough Council provide the social care aspect of the team;

Newton Hospital: this is an intermediate care facility provided by Bridgewater Community NHS Trust. The therapy services within the intermediate care facility are provided by 5BPCHS as part of the block contract arrangement with St Helens and Knowsley Hospitals NHS Trust;

Rapid Response Team: the rapid response service provided within St Helens CCG is purchased by St Helens Borough Council (SBC) with funding made available from the St Helens CCG through a Section 75. The team is also coordinated through St Helens Borough Council. The service is structured with provision from two separate providers: Bridgewater Community Trust provides the nursing element of the team and St Helens Borough Council provides the social care aspect of the team;

Duffy Ward (formerly Seddon Suite): this is an intermediate care ward at St Helens Hospital. With the exception of the therapies staff (provided by 5BPCHS under their secondary care block contract with STHK) all staff are provided by STHK;

Brookfields: is a local authority intermediate care unit with therapy services provided by 5BPCHS within the SBC contract for Reablement services.


Other Programmes of Work There area number of other work programmes / reports which are relevant to this report:

The ‘new’ ESD specification and the requirement for increased, dedicated therapy provision;

The Cancer Services review and any requirement identified within that review for domiciliary based therapy support;

The Newton Hospital report, commissioned by BWC;

The ongoing Intermediate Care Review commissioned by the LA and the CCG;

The potential programmes of work within the CCG to develop Pro Active Care

and an Intensive Support Team;

The review of therapy services commissioned by STHK in 2012.

1.7 SUMMARY OF KEY FINDING & CONSIDERATIONS

i. The provision of therapy services within the CCG, either directly or indirectly commissioned, is confusing and a clear picture is not available outlining the services, which provide community therapy, as either a discreet1 or multi disciplinary service. The Directory of Service produced through this review should clarify this position.

ii. The current contract arrangements for therapy services within the CGG, is on a block contract with 5BPCHS. The contract is summary level and does not reflect the services being delivered in terms of activity, finances and staff. The CCG may wish to consider further analysis of the contract for 2013/14 to facilitate contract monitoring at a service line, which includes financial analysis and which reflects the operational delivery of the service. The CMCSU has compiled a first cut financial analysis of this contract and will arrange to meet with the CCG to share the data.

iii. Some of the intermediate care services are provided through multi provider

arrangements with therapy services being provided through a block contract arrangement. This can cause some confusion in terms of provision and in monitoring the service. It can also be reflected in the operational delivery with staff sometimes not clear, about which services they are funded to deliver. On a number of occasions it was mentioned that services seemed to be operating at a service level rather than a pathway level and as such it is difficult to evidence where the patient is at the centre and where there are multiple patient /service interventions difficult to measure outcomes at a complete pathway level. It was also commented that within Reablement the staff can sometimes appear to be

1 For the purposes of this report discreet refers to a service which delivers only one therapy area and does not operate through an MDT approach


operating as individual staff groups working to differing professional and organisational standards. There was also a view that the therapy staff working in the community and the district nursing staff, work quite separately.

iv. Three services were reviewed (desktop analysis only) against the specifications:

Speech and Language Therapy, Dietetics and Podiatry. It is considered these services are being delivered broadly in line with the intent within the specification and waiting times are being met (subject to the impact of the provision of Any Qualified Provider Podiatry during 2013/14). There appear to be some gaps in the provision of monitoring data, both qualitative and quantitative, to that outlined in the service specifications, and these gaps offer an opportunity for the CCG to develop a more in depth understanding of the service and through this to develop new outcome measures which may assure the National Commissioning Board of the CCGs’s progress towards delivering their patient outcome objectives. The CCG may also wish to consider developing therapy specific patient reported outcome measures (PROMs).

v. The analysis suggests that the current demand for services (SALT and Dietetics)

is being met within the current service specification. However the CCG may wish to carry out more detailed demand analysis for SALT, Dietetics and Podiatry, which takes into account the future health needs of their population.

vi. The current service provider (5BPCHS) has developed a business case to improve

SIP feeding which should reduce the upstream prescribing costs on supplementary feeds. The CCG may wish to explore this with the provider in detail.

vii. The activity and financial impact of the introduction of Any Qualified Provider for Podiatry during 2013/14 should be closely monitored.

viii. There was a consensus view that the community physiotherapy provision within the CCG needs to be improved and as part of this project a new specification has been drafted with specific reference to the provision of chest physiotherapy and services for patients who are housebound and currently not able to access a physiotherapy service either as a GP referral or post hospital discharge. Not withstanding the work to re-specify the service, it is considered that the existing community physiotherapy provision should be able to manage patients who require chest physiotherapy in either a domiciliary or clinic setting. It is suggested that discussions with 5BPCHS to facilitate this, take place.

ix. It was noted that the pathway for female incontinence, does not facilitate direct

GP referral for physiotherapy for incontinence and the CCG may wish to remedy this through discussions with St Helens and Knowsley Hospitals NHS Trust.

x. The CCG and the LA are reviewing intermediate care and developing initiatives to

reduce the urgent care pressures into secondary care, through admission avoidance and long-term condition self-management schemes. During the course of this project two specific initiatives were flagged – the development of the Intensive Support Team and the development of Pro Active Care. The CCG may


wish to consider mapping out the objectives and anticipated benefits associated with these plans with a view to highlighting areas of cross provision.

xi. The review of intermediate care affords the opportunity for the CCG to consider

how the therapies element within this service could best be configured. During this project it was noted that:

a. The current Reablement appointments can be booked very early in the

day and as there is no ‘therapy service’ within the Rapid Response Team, some patients who require the input of therapy services to stay safely in their own home, may be admitted to hospital. As such a user requirement for a rapid response type, therapy service, which delivers care in domiciliary setting, was noted on a number of occasions. This could be part of the community physiotherapy service (which is currently being specified) or it could become part of the new Reablement Rapid Response model, which will emerge from the Intermediate Care Review.

b. Often the options available to RAB / RRT patients were either a hospital pathway of care or a community pathway of care, with no opportunity to provide ‘joint’ pathways of care that involve all sectors. This view was expressed on a number of occasions and a requirement for coordinated care was highlighted.

xii. The CCG may wish to consider opportunities for joint contracting of therapy

services with partners such as neighbouring CCGs and St Helens and Knowsley Hospitals NHS Trust, and which reflect pathways of care. 2

xiii. The nomenclature in relation to the services within intermediate care can mean

different things, to different people / staff groups and terms are often used interchangeably, which can cause confusion. Given there is already the potential for confusion in relation to what the services currently deliver and how these interact / co-depend, it is suggested that as part of the intermediate care review a comprehensive service directory is produced that informs the public, users and referrers, what services are available and how to navigate through these. Consideration will need to be given to maintenance of this service directory.

2 St Helens and Knowsley Hospitals NHS Trust have recently carried out a review of their contracted therapy provision

2.0 EXISTING COMMUNITY THERAPIES PROVISION - DIRECTORY OF SERVICE (DOS)

The first phase of the project was to compile a summary of the existing community therapy service provision, referred to within the project as the community therapy directory of service.

Community Therapy Services Commissioned Directly by the CCG The following community therapy services, providing both a discreet and multi disciplinary team approach, have been identified as commissioned directly by the CCG: General Community Dietetics, Nutrition Support, Specialised Services Podiatry, Any Qualified Provider Podiatry, Orthotics, Pulmonary Rehabilitation Service, Community Speech and Language Therapy and Early Stroke (supported) Discharge.

Community Therapy Services Not Commissioned Directly by the CCG The following community therapy services, providing both a discreet and multi disciplinary team approach, have been identified as available within the CCG but not commissioned directly by the CCG: Weight Management Services, Reablement Team.

Other Therapy Services Not Commissioned Directly by the CCG In addition to the services identified above, therapy services are also available to patients within the CCG either through GP direct access or as part of a secondary care pathway, at St Helens and Knowsley Hospitals Trust and within the intermediate care facilities. A copy of the Directory summarising the available services, is attached:

3.0 REVIEW OF EXISTING SALT, PODIATRY AND DIETETICS SERVICES

A summary of the review in relation to the existing specifications follows. A full copy of the report is attached below:

3.1 CONTRACT AND ACTIVITY DATA

The contract data for St Helens CCG community therapy services is contained within an overall block contract with Five Boroughs Community Health Services (5BPCHS). The 2012/13 outturn positions and the 2013/14 plans are as follows:

Table 2012/13 Activity Outturn

SOURCE: Schedule 5, Part 3, 5 Boroughs Partnership NHS Foundation Trust Community Contract, St Helens CCG.

Service Total Referrals Received

First Contacts Seen

Total Contacts Seen

Total Contact DNA

Total Discharges from Service

Average Caseload

Average number of contacts per month

Dietetics 1267 1091 3500 419 353 NA 292 Adult SALT

538* 315 1010 64 208 6 92

Podiatry 5667 NA 42665 NA NA NA 3555 Orthotics NA 430 1555 55 NA NA 156

* Estimated to full year based upon actuals from June 2012 to March 2013. NA denotes not available

Table 3– 2013/14 Activity Plans

Source: Community Contract 13/14, NHS St Helens CCG

Total Contacts

Dietetics 3500

Adults SALT 1180

Podiatry (Non AQP) 34131

Orthotics 1746


3.2 DIETETIC SERVICES

Service Overview Community dietetic services are provided by 5BPCHS and are contracted as part of the block contract St Helens CCG have with 5BPCHS. At a service level within St Helens the service is split into two discreet community therapy service offerings: General Community Dietetics and Nutrition Support. At an operational level the two discreet services commissioned by the CCG are managed and delivered across the St Helens and Knowsley localities, although staff are notionally allocated to each of the CCGs.

General Community Dietetics The service aims to improve the health of St Helens residents supporting patients and carers, in making positive long-term lifestyle changes to diet, physical activity and behaviours. It also enables patients to better manage symptoms, improve control of their disease/condition (e.g. IBS, Diabetes, CHD, Coeliac Disease) and improve quality of life. The service is based at Puma Court and clinics are provided across the St Helens locality and in some GP practices. Clinics are operated from 8am to 8pm Monday to Friday and fortnightly Saturday clinics are offered. Domiciliary visits are available but only if a specific need is identified. Referral to the service is via Health Care Professional only.

Nutrition Support The service aims to ensure that those adults who are living within St Helens and who are malnourished or at risk of malnutrition are appropriately recognised and managed. The service provides easily accessible assessment, advice, support and intervention to clients. It supports adult and paediatric clients who require specialist nutritional intervention; including those requiring artificial nutritional support e.g. PEG feeds. The service is predominantly a domiciliary service Monday to Friday 9 to 5 although domiciliary visits outside of these hours are made if required. All referrals are via a Health Care Professional and require a MUST assessment prior to referral. The service is based at Puma Court and all referrals are to Puma Court where they are triaged and the patient allocated to clinic or home appointment. The patient is managed until the service is no longer required.

Weight Management Service (WMS) (for information only) In addition to the two discreet dietetic services, a specialist MDT weight management service, in partnership with the local authority Healthy Living Team is provided with 5BPCHS providing the Allied Health Professional support with a team of dietitians and behavioural therapists. This service is contracted by St Helens Borough Council. The service aims to work with patients, to support them in making long-term lifestyle changes, encompassing diet and behaviour in order to increase longevity and quality of life. The service provides assessment, advice, support and intervention for adults requiring weight management advice.

Cost and Activity Data The services are reported as one line on the community contract. The service is commissioned within the St Helens community block contract and no service specific financial data has been made available


Waiting Times & Staffing General Community Dietetics All patients are offered appointment within 13 weeks but some

choose to wait longer as want to go to a specific clinic location. Nutrition Support No significant wait times are reported. Weight Management Service All patients are offered appointment within 4 weeks but some

choose to wait longer as want to go to a specific clinic location.

Table 4- Staffing Establishments

Staffing General Community Dietetics * WTE

Nutrition Support WTE *

Weight Management Service

Total WTE

Dietitians 1.91 1.90 2.80 6.61 Dietitian Assistants 0.00 1.00 1.00 2.00 Cognitive Behavioural Therapists

1.20 1.20

A&C Support 0.41 0.50 1.81 2.72 * The staffing resource is managed flexibly across St Helens and Knowsley CCG localities and the two discreet services. Staffing is allocated on a notional basis by 5BPCHS as outlined within Table 3.

Benchmarked Rates

Table 5– Benchmarking Rates

NHS Benchmarking Rates3

St Helens CCG Rates

Average WTE per 100,000 population Highest WTE per Lowest WTE per

4.48 WTE 12.14 WTE 0.19 WTE

2.49 WTE

Average cost Highest cost Lowest Cost

£167,891 £567,966 £8,573

Not available

Average activity per WTE 737 728 Average activity per 100,000 population 2536 1810 Average waiting time (weeks) Maximum Waiting time (weeks)

13 Not available

Not available 13 weeks

Average DNA rate 10.67% 11.97% First contact to FU Not available 31.17% Discharge Rate Not available 32.36% Notes: the WTE data used to calculate the St Helens CCG rates is a notional split between the two CCGs and excludes the WMS.

Discrepancies from Specification Based upon the desktop review of the specification and discussions with 5BPCHS and CCG staff, it is considered that the service delivered, is in line with the service specification headings of 1 through to 6: aims; scope; service delivery; referral access and acceptance criteria; discharge criteria and planning; prevention self care and patient and carer information. The specification outlines that staff adhere to appropriate clinical and professional guidance – British Dietetic Association (BDA), the Health

3 Source – NHS Benchmarking July 2012


Professionals Council (HPC), NICE and SIGN guidance. Compliance in relation to this was not checked as part of the project. In relation to the service specification headings 7&8: quality and performance indicators and activity, the view is that there are considerable gaps in the data provided namely relating to: annual assurance of mandatory training, annual service user experience data, audits in relation to personal care planning, staff turnover rates and sickness absence rates (Appendix II). In relation to the service specification heading 9 -: activity, the requirements are broadly satisfied with the exception of routine data in relation to referrals (new per month and inappropriate referrals per month) and response times (Appendix II).

Issues Identified

General Community Dietetics Some views were expressed by GPs about difficulty in accessing one off visits e.g.

the diabetic patient who requires dietetic input outside of the annual review. The CCG should consider specifying this as a requirement for 2013/14.

Service ‘gaps’ have been identified by 5BPCHS to support cardiac rehab services and service provision for Mental Health. The CCG should work with the provider to understand these ‘gaps’ in more detail.

Nutrition Support The service is very busy and some ' inappropriate' referrals continue. Work to

map these referrals should continue.

Weight Management Service A number of GPs are not referring patients directly but informing the patients as

to how they could self refer using the ‘card’ system. Subsequently it is considered that as referrals are slightly down on the plan, not all patients who would benefit from the service are being realised.

Strategic Vision & Opportunities for Improvement

i. The literature search highlighted national commissioning guidance for weight management services.

ii. It is recommended that the apparent gaps in the provision of monitoring data, both qualitative and quantitative, to that outlined in the specification, offer an opportunity to develop a more in depth understanding of the service and through this to develop new outcome measures which may assure the National Commissioning Board of the CCGs’s progress towards delivering their patient outcome objectives. The CCG may also wish to consider developing therapy specific patient reported outcome measures (PROMs).

iii. The current costs of the service provision need to be identified in order to provide effective comparative data for the future. The CMCSU has carried out a first cut analysis and will arrange to meet with the CCG to discuss.

iv. The analysis suggests that the current demand for services is being met within the current service specification but the CCG may wish to carry out more detailed demand analysis, which takes into account the future needs of their population.


v. On the assumption that the current demand is being met, it is not considered viable to reconfigure the service to a more granular level to deliver purely St Helens CCG activity (clinical supervision, cross cover and management). However, the CCG may wish to work with Knowsley CCG and/or STHK (who also commission dietetic services but for secondary care) to understand if there are potential benefits in developing and commissioning a dietetic service that works on a pathway specific basis and which follows the patient across primary and secondary care.

vi. The service provider is looking to tighten up discharge and follow up criteria for new patients e.g. diabetes 6 visits and then annual review etc.

vii. The Service Provider is working with Nursing Homes to train their staff and agree telephone reviews where appropriate rather than domiciliary visits.

viii. The CCG should consider agreeing a service specification for 2013/14, which splits out the contract monitoring data between the two discreet services.

ix. The service provider has developed a business case to improve SIP feeding which should reduce the upstream costs on enteral feeds. The CCG may wish to explore this with the provider in detail as it could reduce prescribing costs within the CCG.

3.3 SPEECH AND LANGUAGE THERAPY SERVICES

Service Overview Speech and Language (SALT) services are provided by 5BPCHS and are contracted as part of the block contract St Helens CCG have with 5BPCHS. 5BPCHS also provide the secondary care SALT services to St Helens and Knowsley Hospitals NHS Trust (STHK) through a block contract arrangement direct with STHK. The service is based at Whiston hospital and provides clinics at Newton Hospital and St Helens Hospital. Domiciliary services are available. The service covers problems with voice, communication and dysphagia. Referrals to the service are via both Health Care Professional and patient / carers. The community element of the SALT service is managed and provided as a joint service across St Helens CCG and Knowsley CCG.

Cost and Activity Data The SALT services commissioned by St Helens CCG are contracted within an overall block. However, the service specification indicates that the total cost of the service for St Helens and Knowsley is £173,806, of which £44,951 is the cost for St Helens CCG.

Benchmarked Rates Table 6 outlines the current service provision against NHS Benchmarked rates, across a number of indicators:


Table 6 Benchmarking Rates

NHS Benchmarking Rates4

St Helens CCG Rates

Average WTE per 100,000 population Highest WTE per Lowest WTE per

4.12 17.54 0.47

0.86 WTE

Average cost Highest cost Lowest Cost

£156,747 £1,211,052 £82

£173,806

Average activity per WTE 623 578 Average activity per 100,000 population 2,229 495 Average waiting time (weeks) Maximum Waiting time (weeks)

13.94 Not available

Not available 4

Average DNA rate 3.83% 7.21% First contact to FU Not Available 35.52% Discharge Rate Not Available 62.50% Notes: In order to calculate the rates used to benchmark against the national data set, the activity and staffing levels utilised represent the combined 2012/13-outturn figures for both St Helens and Knowsley CCG.

Discrepancies from Specification Based upon the desktop review of the specification and discussions with 5BPCHS and CCG staff, it is considered that the service delivered is in line with the service specification headings of 1 through to 6: aims; scope; service delivery; referral access and acceptance criteria; discharge criteria and planning; prevention self care and patient and carer information. The specification outlines that staff must be registered with the Royal College of Speech and Language Therapists (RCSLT) and the Health Professionals Council (HPC). Compliance in relation to this was not checked as part of the project. From the information provided and in relation to the information provided under service specification heading 7: continual service improvement and innovation and heading 8: baseline performance targets quality, performance and productivity, the view is that there are considerable gaps in the data provided namely relating to: annual assurance of mandatory training, annual service user experience data, audits in relation to personal care planning, staff turnover rates and sickness absence rates, similarly within service specification heading 9 -: activity, the requirements are broadly satisfied with the exception of routine data in relation to referrals (news per month and inappropriate referrals per month) and response times .

Issues Identified

During discussions with the current service provider it was opined that as the service is ‘new’, referrals are within the plan and as such waiting times are low at a maximum of four weeks compared to specification maximum waiting time of 13 weeks. This position should be kept under review.

The current service is delivered across both St Helens and Knowsley CCG areas and it is not possible to accurately identify the staffing allocated to each CCG.

To try and split the current service of 3.00 WTEs may raise complications in terms of supervision and management and prove problematic in delivering a responsive service, which is able to manage staff absences.

4 Source – NHS Benchmarking July 2012


The 0.30 WTE specified for the SALT element of the ESD service must be factored in.

Strategic Vision & Opportunities for Improvement i. The literature search did not highlight any specific evidence based practice

models for adult, SALT services other than the generic Care Aims / Malcomes Approach. 5BPCHS advise that they work to the Malcolmes/Care Aims approach, within SALT services.

ii. Based upon the discussions with key stakeholders no major opportunities for improvement were identified. However, it is recommended that the apparent gaps in the provision of monitoring data, both qualitative and quantitative, to that outlined in the specification (Appendix III), offer an opportunity to develop a more in depth understanding of the service and through this to develop new outcome measures which may assure the National Commissioning Board of the CCGs’s progress towards delivering their patient outcome objectives. The CCG may also wish to consider developing therapy and pathway specific patient reported outcome measures (PROMs).

iii. The analysis suggests that the current demand for SALT services is being met within the current service specification but the CCG may wish to carry out more detailed demand analysis, which takes into account the future needs of their population.

iv. On the assumption that the current demand is being met, it is not considered viable to reconfigure the service to a lower level to deliver purely St Helens CCG activity (clinical supervision, cross cover and management). However, the CCG may wish to work with STHK (who also commission SALT services but for secondary care) to understand if there are potential benefits in developing and commissioning a SALT service that works on a pathway specific basis and which follows the patient across primary and secondary care.

3.4 PODIATRY AND ORTHOTICS

Service Overview Community podiatry and orthotic services are provided by 5BPCHS and are contracted as part of the block contract. At a service level within St Helens the podiatry service from 2013/14 is split into two discreet community therapy service offerings: Specialised Services Podiatry and Podiatry Any Qualified Provider (AQP). The Orthotics service is a combined service operating across community and secondary care. At an operational level the podiatry services commissioned by the CCG are managed and delivered across the St Helens CCG and Knowsley CCG/ The notional staffing split is considered as 60/40 St Helens to Knowsley CCG.

Specialised Services Podiatry The service provides a complete podiatry service including nail surgery and biomechanical assessments. The service is based at the Whiston Community Resource Centre and all referrals for the service are triaged and appointed here. Clinics are provided across 18 community sites and domiciliary visits including visits to nursing homes, are available. The service is available Monday to Friday 8 to 8 and some Saturday clinics are offered in line with demand.


Referrals are accepted from Health Care Professionals and patients / carers and are assessed in line with the following referral criteria: those adults and children with an increased risk medical need and high or medium Podiatric need (as identified below) are eligible to receive an assessment for Podiatry care.

AQP Podiatry The service is a new offering and offers a full community podiatry service including nail surgery, biomechanical assessments and painful foot conditions. The service is based at the Whiston Community Resource Centre and all referrals for the service are triaged and appointed here. Clinics are provided across 18 community sites and no domiciliary services are offered. The service is available Monday to Friday 8 to 8 and some Saturday clinics are offered in line with demand. Referrals are accepted from Health Care Professionals and patients / carers and are triaged via eligibility criteria for AQP – adults and children with low / no medical need and high medium or low, podiatric need - and then prioritised and appointed.

Orthotics The service provides prescribed orthotics and appliances to aid mobility egg. compression hosiery, neck braces, footwear and insoles. Community orthotic services are provided by 5BPCHS and are contracted as part of the block contract St Helens CCG have with 5BPCHS. In addition to the St Helens CCG contract, STHK have a contract in situ with 5BPCHS for the provision of orthotic services in secondary care. At an operational level, the services are managed and provided as one across the care sectors and the Knowsley and St Helens CCG boundaries. All referrals are sent to St Helens Hospital, where they are appointed to either the community or hospital service. Outpatient services are provided at St Helens Hospital, Specialist Schools and Newton Hospital. Referrals to the service are via a Health Care Professional only.

Cost and Activity Data The services are reported as one line on the community contract. As the service is commissioned on a block basis, no service specific financial data has been made available.

Benchmarked Rates

Table 7-Staffing Establishments

Staffing WTE 33.41

* The staffing resource is managed flexibly across St Helens and Knowsley CCG localities and STHK.

The benchmarked data separates out podiatric surgery and podiatry, in addition the WTE establishment reflects the establishment for St Helens and Knowsley CCG as well as STHK and thus it has not been possible to calculate the St Helens CCG rates and compare these the to NHS Benchmarked rates.

Discrepancies from Specification Based upon the desktop review of the specification and discussions with 5BPCHS and CCG staff, it is considered that the service delivered is in line with the service specification headings of 1 through to 6: aims; scope; service delivery; referral access


and acceptance criteria; discharge criteria and planning; prevention self care and patient and carer information. In relation to the service specification headings 7&8: quality and performance indicators and activity, the view is that there are considerable gaps in the data provided namely relating to: annual assurance of mandatory training, annual service user experience data, audits in relation to personal care planning, staff turnover rates and sickness absence rates. In relation to the service specification heading 9-: activity, the requirements are broadly satisfied with the exception of routine data in relation to referrals (news per month and inappropriate referrals per month) and response times.

Issues Identified

Podiatry – Specialised Services The service has had non-recurrent funding for the last two years in order to

maintain maximum waits below 18 weeks. As such the 2013/14 contracted levels includes an additional 2013 appointments as funded through the £44K non-recurrent funding for the first 6 months of 2013/14. Monthly contracted levels will decrease from October 2013 unless a recurrent solution is identified and in all probability wait times will increase.

The service is exploring Liverpool Care Aims (Malcolmes) approach further and to implement NICE guidance as issued.

The service is looking to develop Diabetes UK Pyramid of care

Podiatry – Any Qualified Provider The potential issue within AQP relates to the potential for a new demand to be

created given the service is now opened to low podiatric need and self-referral. As a minimum it is likely all self-referrals that meet the criteria will have at least one appointment, which will be chargeable at the tariff rate estimated at c £40.

Orthotics

The main issue in orthotics relates to the lack of suitably qualified staff as and when vacancies arise or cover is required.

Strategic Vision & Opportunities for Improvement

i. The literature search did not highlight any specific guidance for podiatry or orthotic services.

ii. It is recommended that the apparent gaps in the provision of monitoring data, both qualitative and quantitative, to that outlined in the specification, offer an opportunity to develop a more in depth understanding of the service and through this to develop new outcome measures which may assure the National Commissioning Board of the CCGs’s progress towards delivering their patient outcome objectives. The CCG may also wish to consider developing therapy specific patient reported outcome measures (PROMs).

iii. The current costs of the service provision to St Helens CCG and as a whole need to be identified in order to provide effective comparative data for the future. The CMCSU has carried out a first cut analysis and will arrange to meet with the CCG to discuss.


iv. 5BPCHS have developed a proposal to remodel podiatry services with a view to developing a sustainable solution to the potential waiting times issues. A copy of this document is attached:


4.0 OUTLINE SPECIFICATION FOR COMMUNITY PHYSIOTHERAPY

4.1 CURRENT SERVICE OVERVIEW

The current physiotherapy service is delivered by the therapy staff working within the Reablement Service with a notional 0.60WTE staffing allocated to the service.

4.2 DRAFT OUTLINE SPECIFICATION FOR SERVICE


5.0 REABLEMENT SERVICES AND RAPID RESPONSE SERVICES

5.1 BACKGROUND

This section of the report summarises the output of Phase 3 of the project brief (Developing Therapy Services) developed and agreed with St Helens Clinical Commissioning Group (St Helens CCG): ‘The CSU will provide a summary report to articulate the ‘as is’ situation for the current therapy service operational model and pathways into the Reablement and Rapid Response services. This report will inform the work that the CCG are planning, to review intermediate care services and the remaining engagement event will be developed with the CCG once the engagement requirements are known, as these will emerge from the intermediate care review.’

5.2 INFORMATION SOURCES

The information within the report has been taken from meetings with key stakeholders, existing reports, contract-monitoring returns, service specifications and from the attendance at the intermediate care mapping event held on the 1st May 2013. For the purposes of this project, the key stakeholders were identified by St Helens CCG as:

Five Boroughs Partnership Community Health Services (5BPCHS);

St Helens Council (SHC);

Lead GPs (Steve Cox and Julie Whittaker) within the CCG and the CCG quality lead (Lynda Carey);

Bridgewater Community Healthcare NHS Trust (BWC) - as they provide the

nursing elements within the St Helens Rapid Response Team and the Reablement Team;

St Helens and Knowsley Hospitals NHS Trust5 as they commission therapy

services from 5BPCHS for their hospitals. Meetings and / or telephone discussions took place with these stakeholders during late March 2013. The information exchange and comments made during the meetings/discussions was taken in good faith and as such has not been validated. In reading this summary report, cognisance should be taken that the information contained within the report which was derived from key stakeholders during March

5 Comprising St Helens Hospital and Whiston Hospital


2013, was within the context of the Developing Therapy Services Project and the project brief at that juncture. Thus the primary aim from the meetings / discussions with key stakeholders was, ‘to carry out a baseline review of the current community therapy services provision; to identify and determine and scope existing contracted services; to include summary of current services, contract management, and governance and performance.’ As such, detailed information relating to the operational aspects of the Reablement Team and the Rapid Response Team was not sought and the existing service specification (dated April 2010 to March 2013) was the primary data source for the information within sections 2.1, 2.4, 3.1 and 3.3, of the ‘as is’ report. Not withstanding this primary aim, some information in relation to Reablement and to a lesser extent the Rapid Response Team, which was not specific to therapy services, was derived, and this information is noted within the report. As part of the Developing Therapies Project, an outline picture of the community therapies available to the CCG was developed. The outline picture of the therapy services provided within the auspices of Intermediate Care is appended (Appendix 1).

5.3 REABLEMENT ‘AS IS” POSITION

Overview Reablement services (RAB) within St Helens CCG are commissioned by St Helens Council under a Section 75 partnership agreement. The service is a multi disciplinary team and comprises of therapies staff from 5 Borough Partnership Community Health Services (5BPCHS), nursing staff from Bridgewater Community Hospitals NHS Trust (BWC) and social care staff (social workers and care assistants) from the Local Authority, St Helens Council. The RAB aims6 to:

Promote the independence of service users Reduce avoidable7 admission to acute beds; Facilitate timely discharge from acute beds; Minimise premature or avoidable dependence on long term care institutional

settings; To support recovery from illness.

It is commissioned to provide a non-crisis response to an avoidable admission and to provide a short-term intervention usually lasting no longer than 6 weeks, although some leeway can be given to provide services up to 8 weeks. The service is delivered in a domiciliary type environment, that is, it is delivered in the patients’ residence whether permanent or temporary, including the Brookfields Reablement Unit, which is staffed 24/7.

6 The Service Specification outlines that the RAB and the RRT are commissioned with joint aims although it maybe that some of the aims are more relevant to either or service. For example it maybe that the RAB is more likely to aim to facilitate timely discharge from acute beds and the RRT to reduce ‘avoidable’ admissions to acute beds. 7 Specification states ‘available’ admissions


To be eligible for referral to RAB the user must be:

A resident of St Helens or registered with a St Helens GP; Aged 18 or over Medically stable and / or predictable Wiling and able to participate in a structured programme of activity Able to understand and follow simple instruction Able to benefit within a short timescale

RAB domiciliary visits are usually made during Monday to Friday, 8.45am to 5.15pm. The RAB service is based out of Parr House and all referrals are sent via Parr House. Referrals to RAB can be made by health and social care professionals from local hospitals including Whiston, St Helens (predominantly via the Integrated Discharge Team) and Newton, primary care, the independent and voluntary sector and patients / carers. All referrals are screened by staff at band 5 and above against the eligibility criteria and prioritised according to whether they are a hospital discharge; at high risk of falls / injury at home; live on their own without adequate support. The standard within RAB is to contact the referrer / client on the day of referral by phone. If the referral is accepted, an assessment is undertaken within 5 working days. Therapy and non-therapy staff can undertake the initial assessment. If it is the latter a second assessment by the relevant therapy specialism may be required and in this scenario clients are referred for therapies which can take up to two weeks from the initial assessment for physiotherapy and longer for occupational therapy. Following the initial assessment a care plan is developed and may include a range of interventions delivered by the RAB team. Weekly monitoring meetings and four weekly review meetings are held and an exit plan developed for each patient. As a minimum all RAB clients receive three specialist therapy contacts - one at initial assessment, one at mid review and one at final review – plus support worker contacts. Typically clients within RAB will receive 5 therapy contacts and 10 support worker contacts.

Staffing

Description Staff Type Employing Organisation

WTE

Reablement Team Manager

Social Care SHC 1.00

Reablement Nurses Nursing & Midwifery

BWC 3.00

Care Managers Social Care SHC 2.00 Assistant Practitioners


Reablement Community Psychiatric Nurse

Nursing & Midwifery (shared post with Newton Hospital)

BWC 0.50


Support Workers Social Care SHC 15.20 Reablement Manager Social care SHC 1.00 Team Leader Social care SHC 4.00 Home Carers Social care SHC 8.00 Reablement Assistants

Social care SHC 2.00

Admin and clerical support


Therapy assistants AHP 5BPCHS 1.83 Occupational Therapist

AHP 5BPCHS 2.66

Physiotherapist AHP 5BPCHS 3.45 The therapy staff within the RAB service also deliver the current community physiotherapy service, within St Helens CCG.

Financials The therapies element of the RAB is estimated to cost £234,701 (2012/13), with 30% of this cost borne by St Helens Council. The total cost of the RAB was not accessed as part of the developing therapies work.

Capacity The RAB has the capacity to manage a maximum of 80 patients at any one time. The working assumption is:

50% of these will be complex cases and require interventions from two or more ‘professional’ team members plus three or more weekly visits by support workers

50% of these will be simple cases and require intervention from not more than two ‘professional’ team members and two or less weekly visits by support workers.

During 2012/13 there were 1,065 appropriate referrals to RAB, and 105 referrals which were considered inappropriate. Table 8 Referrals to Reablement (source quarterly Reablement reports)

Month Appropriate Referrals

Inappropriate Referrals

April 2012 85 14 May 2012 81 6 June 2012 66 9 July 2012 100 6 August 2012 99 6 September 2012 81 6 October 2012 89 11 November 2012 93 13


December 120 80 4 January 2013 82 11 February 2013 115 5 March 2013 94 14 TOTAL 1,065 105

July and August 2012 and February 2013, demonstrated appropriate referrals significantly in excess of the annual mean and June 2013, significantly less.

Summary of Feedback During the course of the Developing Therapies Project no information was shared that suggests the current Reablement service deviates from the service specification, other than the validated staffing list (section 2.2) which does not outline any pharmacy staff within the RAB team, whilst the service specification does. However, a number of comments and observations were made in relation to the current RAB provision and operations, during the course of the Developing Therapies Project. These are summarised as:

There seems to be a disconnect between waits as perceived by referrers and waits as reported; referrers report that referrals to RAB, other than a hospital discharge, can take up to eight weeks to be seen. This is a particular issue for patients being referred on from the ESD service who are often being kept on the ESD books for longer than is considered best practice, whilst RAB report that all patients are assessed within 5 working days of the referral and ‘treatment’ commences within a maximum of 3 weeks from assessment.

It was noted by both referrers and RAB, and is the priority outlined within the

service specification, that the priorities for the RAB service were discharges from hospital and as such referrals not related to a hospital discharge wait longer. It is considered that this has had a particular impact this year (likely to be related to the significant non elective pressures). The view is that this prioritisation manifests in terms of longer waits for home based patients which then has a potential to result in increased referrals to the RRT and / or ultimately, increased acute admissions.

The RAB team felt under resourced to deliver during times of acute pressure

such as those experienced this winter.

It was thought that individual professions’, definitions and understanding of ‘duty of care’ vary. As such, it was considered that care is not always being transferred to non-qualified or non-specialist staff when it could be.

The team is ‘managed’ and ‘coordinated’ by St Helens Council, but the staff

within the team are employed by three separate organisations – St Helens Council, Five Borough Community Partnership Health Services and Bridgewater Community Healthcare Trust. This can create some friction and also some duplication of data entry in terms of activity reporting and some minor


operational type issues such as attendance reporting and appraisals etc. One example is the RAB therapy contact data, which is collected by individual therapy team members and reported monthly to 5BPCHS.

Any generic Standard Operating Procedures (SOPs) used by the RAB team have

to meet the requirements of the three employing organisations. However, specialist therapy assessments are carried out in line with 5BPCHS SOPs.

It was noted that the methods for obtaining / documenting consent for therapy

interventions within 5BPCHS are different than those utilised within BWC and SHC.

The therapy staff within RAB provide the current community physiotherapy

service, although this is not ‘managed’ or reported within the RAB contract. This can cause some issues with the RAB team manager not always being fully aware of the community physiotherapy commitments and in reporting and managing this activity.

There have been some instances with RAB therapy staff commenting that they

are not resourced to see patients at Brookfields and other intermediate care facilities.

The service specification outlines that Euroquol scores are collected for all RAB

Clients at the start and end of therapy input and are reported three times per year. These reports were not made available during the project.

5.4 RAPID RESPONSE ‘AS IS’ POSITION

Overview Rapid Response (RRT) within St Helens CCG are commissioned by St Helens Council under a Section 75 partnership agreement. The service is a multi disciplinary team and comprises of nursing staff from Bridgewater Community Hospitals NHS Trust (BWC) and social care staff (social workers and care assistants) from the Local Authority, St Helens Council (the LA). The RRT does not comprise any therapy staffing. The RRT aims to:

Promote the independence of service users; Reduce avoidable 8admission to acute beds; Facilitate timely discharge from acute beds; Minimise premature or avoidable dependence on long term care institutional

settings; To support recovery from illness.

RRT is commissioned to provide a crisis response to support reductions in avoidable admissions to an acute bed and to provide support of up to 7 days, in the event of unexpected main carer breakdown. To be eligible for referral to RRT the user must be:

A resident of St Helens or registered with a St Helens GP; Aged 18 or over; Clinically assessed as not requiring admission to A&E or an acute hospital bed; Needing support to stay in the community following the unexpected breakdown

of main carer support; Not requiring support for mental health as the primary reason for referral; Not have drug / alcohol issues.

RRT operates 8am to 10pm, 7 days a week. Health and social care professionals, including ambulance staff, can make referrals to RAB. All referrals are screened against the eligibility criteria and prioritised as either high priority or other. Inappropriate referrals are signposted elsewhere. The standard within RRT is to screen all referrals within one hour of receipt and to commence an assessment for high priority referrals within two hours of the receipt of the referral and for all other referrals, the same day or next day.

8 Specification states ‘available’ admissions


Following the assessment a support package will be provided as:

Domiciliary support in the clients’ own home; Admission to a residential or nursing home bed; Admission to an Intermediate Care Unit

All clients are reviewed by telephone after two to three days of the commencement of the support package and are referred to the LA Adult Social Care Team if ongoing support is required.

Financials The total cost of the RRT was not accessed as part of the developing therapies work.

Capacity Capacity within the RRT is forecast at 907 appropriate referrals during 2013 and is limited to no more than ten referrals in a day. In reality it is considered within the specification that the sustainable level is 6 referrals per day and if the service peaks at 10 or more referrals for four consecutive days, commissioners will be alerted with a view to agreeing increased support.

Summary of Feedback During the course of the Developing Therapies Project detailed information in relation to the RRT was not sought, as it was advised at the onset of the Developing Therapies Project that the RRT does not consist of any therapy staff and this staffing mix is in line with the current service specification Section 7. Not withstanding this, where information and comments were offered as part of the discussions / meetings, these are contained within the report. No comments were made that suggest the current service being delivered within RRT deviates from the service specification.

It was commented that the RRT slots are often full by the time evening surgery occurs and thus there is sometimes no other option than to refer / admit to hospital.

The requirement for the RRT to include therapy staff that could provide acute

therapy support in a domiciliary setting was mooted by most of the key stakeholders.

There appears to be no readily available communication available to staff and

patients outlining what the RRT does and what the CCP staff do.

Difficulties in obtaining responsive patient transport (if admission is required) were mentioned.


5.5 FOR FURTHER CONSIDERATION

These bullet points represent areas that the CCG may wish to explore / consider in more detail and summarise, some of the areas that were highlighted by stakeholders during the course of discussion with them in relation to RAB and RRT:

It was mooted that often the options available to RAB / RRT patients were either a hospital pathway of care or a community pathway of care with no opportunity to provide ‘joint’ pathways of care that involve all sectors. This view was expressed on a number of occasions and a requirement for coordinated care was highlighted.

Feedback was that the RRT slots are often full by the time evening GP surgeries

are being held and therefore extended opening times to midnight or additional slots, may need to be explored. It was also suggested that the RAB service should be a seven-day service.

The current referral triage process for RAB, affords priority to patients requiring

discharge from hospital facilities. This can mean patients who are home based wait longer for RAB services and this may ultimately result in patients being admitted to hospital and / or requiring the services of the RRT. In developing the specification for Intermediate Care the CCG may wish to reconsider this referral prioritisation and understand whether the view opined by some stakeholders that these delays ultimately result in up stream hospital admissions, is correct.

The CCG may wish to consider developing service aims and linked outcomes,

which are specific to each of the services as the current service specification outlines joint service aims.

It was mentioned on a number of occasions that services seemed to be operating

at a service level rather than a pathway level and as such it is difficult to evidence where the patient is at the centre in multiple patient interventions and outcomes at a complete journey level.

It was commented that within RAB the staff can sometimes appear to be

operating as individual staff groups working to differing professional and organisational standards.

There was a view that the therapy staff working in the community and the

district nursing staff work quite separately.

The nomenclature in relation to the services within intermediate care can mean different things to different people / staff groups and terms are often used interchangeably, which can cause confusion. Given there is already the potential for confusion in relation to what the RAB, RRT and CCP services currently deliver and how these interact / co-depend, it is suggested that as part of the intermediate care review a comprehensive service directory is produced that


informs the public, users and referrers, what services are available and how to navigate through these.

The CCG and the LA are reviewing intermediate care and developing initiatives to

reduce the urgent care pressures into secondary care through admission avoidance and long-term condition self-management schemes. During the course of this project two specific initiatives were flagged: the development of the Intensive Support Team and Pro Active Care. It may help in developing these ideas further, to map out the aims and objectives of each of these initiatives and to look for cross cutting themes, potential areas of duplication and service gaps.

During a number of discussions, it was flagged that there is a requirement to

provide a rapid response type therapies service such as urgent chest physio. This could be part of the community physiotherapy service (which is currently being specified), or it could become part of the RAB/RRT model which will emerge from the Intermediate Care Review.

The current staffing arrangements (staff are employed by three different

organisations) and some of the comments arising from this situation should be probed further and it is suggested that this is done through the review of intermediate care.


6.0 OTHER POINTS FOR CONSIDERATION

Uro – Gynaecology Physiotherapy The current pathway of care requires that a patient who is considered by a GP to need specialist uro- gynaecology physiotherapy, needs to be seen first in a Consultant outpatient clinic. Protocols which facilitate GP direct access to this service, should be agreed and established, as from both a financial cost and service experience perspective, this is not best practice.

Chest Physiotherapy The existing community physiotherapy service should be able to manage patients who require chest physiotherapy in either a domiciliary or clinic setting. It is suggested that discussions with 5BPCHS to facilitate this, take place.

Models of care St Helens and Knowsley Hospitals NHS Trust have recently reviewed therapy services within secondary care. This review and recommendations and the outputs within this report, should be consolidated and opportunities to jointly commission services going forward, considered.

Contract Monitoring The information used to monitor compliance with contract specifications varies and work to determine the routine qualitative monitoring data is suggested.

Secondary Care Therapy Services The work to produce the DOS within this review outlined that some services provided within secondary care and contracted through St Helens and Knowsley Hospitals NHS Trust, provide domiciliary services. A greater understanding of the pathways that this is relevant to, should be fostered.

Criteria for Domiciliary Care The criteria for this provision for therapy services from secondary care should be consistent with that utilised to access therapy services in the community.


Appendix I – Project Brief for Developing Therapy Services (Updated project plan – May 2013).

1. Background

Project review meetings were held on April 11th 2013, April 25th 2013 and May 1st 2013.

This updated project plan reflects the discussion and decisions taken at these meetings.

2. Project summary

To work with stakeholders across the CCG to produce a strategic vision and options for

delivery, for the provision of community therapies for St Helens.

Deadline for delivery – 31st May 2013

3. Project resources

CSU Project lead(s):

Anne Tattersall (HoCO) will oversee the delivery of the overall project. A part time

project lead (Jennifer Butterworth) has been contracted by the CSU. The CSU Head of

Patient and Public Voice (Jackie Robinson) will develop and oversee the PPI and staff

engagement work, which is yet to be defined.

Additional resources:

• Support will be provided by the CMCSU Business Intelligence and Contracting

teams who will link directly to the CCG analysts to access data which they are

unable to source.

• From the CCG – Anne Marie Curran has been identified to support the

undertaking of PPI and staff engagement work, under the leadership of the CSU

Head of Patient and Public Voice and supported by the CCGs Communication and

Engagement Facilitator, Philippa Rowley.

4. Proposed approach – Phases 2b, 3 and 4

Phase 1 and 2a were completed end March 2013 and involved delivery of the following:

Phase 1:

• An update report to the CCG, outlining any key findings to date and the project

plan; • A summary document of the baseline review;

Phase 2a:

• First draft of the service picture for each of the therapy service;

• An outline engagement plan for the more formal staff listening exercises planned

for April;


The following phases have been revised following discussion with the CCG project

lead (Ruth Hunter) in light of the findings/conclusion from Phase 1 and 2a.

Phase 2b– to be completed by the 30th April 2013

• SALT, Podiatry and Dietetics

The core service delivery will be reviewed against the existing service

specification to include:

a comparison of cost vs activity

highlight any discrepancies/issues

identify a vision for what quality services could look like and provide

options for the CCG to consider

As agreed with the CCG – this element of the project will not involve any specific

public or staff engagement activity

Community Physio – to be completed by the 31st May 2013

An outline specification will be developed to describe what a 'discreet'

community physio service should look like in order to meet current and future

demands (to include Chest Physio service). The specification will define ways of

delivering this service for the CCG to consider.

This phase will not involve engagement with providers as this may compromise

any future tendering process.

The model detailed in the outline specification will be tested by the CCG with GP

members.

The model will also be tested with patients/public/carers/potential users of the

service once it has been internally agreed. This will be undertaken by the CSU as

part of the two engagement events agreed and if required, will take place after

the 31st May 2013 (i.e. beyond the project completion date). The CSU will lead on

the methodology and deliver it. During May the model for community physio will

begin to emerge and the CSU will consider this in developing the engagement

plan. The engagement actions will take place in phase 3 with the date to be

agreed on completion of the findings and proposal for change. The CCG will

assist with practical tasks eg booking rooms, sending out invitations etc under

the leadership of the CSU.

Phase 3 – to be completed by 31st May 2013

Reablement / Rapid Response


The CSU will provide a summary report to articulate the ‘as is’ situation for the

current therapy service operational model and pathways into the Reablement

and Rapid Response services,

This report will inform the work that the CCG are planning, to review

intermediate care services and the remaining engagement event will be

developed with the CCG once the engagement requirements are known, as these

will emerge from the intermediate care review.

• Project management

Given the timescales and deadlines involved with this project, gateway reviews will take

place between the CSU (Head of Client Operations) and the CCG at the conclusion of each

of the phases of work to ensure rigorous project management. These meetings will be

used to consider:

• Delivery of the phase;

• Signing off the delivery of that phase from both the CCG and CSU;

• Confirmation of timescales and deliverables for the forthcoming phase.

The CCG has identified internal resource to undertake and support the patient and

public engagement work, under the direction of the CMCSU Head of Patient and Public

Voice. This will include:

Preparation and delivery of engagement activity involving key stakeholders (staff

and patient) across the Community Physio and Reablement services as defined

following completion of Phase 3.

The Project lead will undertake weekly contact and ad hoc meetings with the

CCG/provider during April and May, updating project documentation and

delivery of a weekly written report outlining the findings and conclusions.

• Project Cost

The CSU completed Phase 1 and Phase 2a by 31st March 2013 at no direct cost to the

CCG. The cost to deliver Phases 2b, 3 and 4 was agreed as £7975, to be funded from the

CCG development fund.

In addition, the CSU will absorb the costs of planning and delivering staff and public

engagement sessions (up to a maximum of two). The details of these will be developed

in conjunction with the CCG and once all the phases are completed.


7. Points for consideration

• Timely access to clinical and managerial leads and current service providers is

essential

• Access to activity data essential

• Any modelling work will be based on existing data and should be considered as a

basic approach. More comprehensive modelling can be undertaken and the CSU

would be interested in working with the CCG and Local Authority Public Health

expertise to develop this. However, the timescales would likely extend beyond

the deadline set for this piece of work.

• The CCG will facilitate access to CCG leads where needed however the CCG would

expect CSU staff to actively contact required stakeholders to avoid delays due to

availability

• The CCG will inform stakeholders of the work that is taking place and the outputs

to be generated.

Anne Tattersall

Head of Client Operations

15.5.13


Appendix II – Schedule of Meetings / Discussions Held with Key Stakeholders Category Organisation Who Date Method Purpose

Service Provider

5BPCHS Chris Masikane & Sam Ashton Mort

7/3/13 Meeting To develop understanding of podiatry and orthotic services

Service Provider – 5BPCHS

5BPCHS Chris Masikane & Sarah Haworth

7/3/13 Meeting To develop understanding of Reablement therapy services/ community physiotherapy and pulmonary rehabilitation service

Non Patient User

St Helens CCG Julie Whittaker

13/3/13 Call To develop understanding of non patient user views of therapy services

Non Patient User

St Helens Council

Barry Harrison & Carole Kilshaw

14/3/13 Meeting To develop understanding of Reablement therapy services

Service Provider

5BPCHS Chris Masikane and Nicky Hill

15/3/13 Meeting To develop understanding of dietetic services

Service Provider

5BPCHS Chris Masikane

15/3/13 Meeting To scope staff and public engagement

CCG St Helens CCG Lynda Carey

18/3/13 Call To develop understanding of any quality issues for therapy services

Patient Users

St Helens PPG 19/3/13 Meeting To begin to understand user views of community therapy services

Non Patient User

St Helens CCG Steve Cox 20/3/13 Call To develop understanding of non patient user views of therapy services

Non Patient User

St Helens and Knowsley Hospitals Trust

Donna Mac Laughlin and Ian Stewardson

22/3/13 Meeting To develop understanding of non patient user views of therapy services and relationships across secondary care therapy services and intermediate care facilities

Non Patient User

5BPCHS Gill Holmes 26/3/13 Meeting To develop understanding of non patient user views of therapy services and relationships across secondary care therapy services

Non Patient User

Bridgewater Community Healthcare Trust

Colin Scales 26/3/13 Call To develop understanding of non patient user views of therapy services and relationships across intermediate care facilities

Service Provider

5BPCHS Sara Haworth

26/3/13 Meeting To discuss and develop engagement approach for 5BPCHS staff

Service Provider

5BPCHS Chris Masikane & Sara Haworth

18/4/13 Meeting To update on amendments to project brief and sign off Directory of Service

Services, Final Summary Report prepared on behalf of...

Documents

Transcript of Services, Final Summary Report prepared on behalf of...