Paper 3

NHS GRAMPIAN

ABERDEENCITY COMMUNITY HEALTH PARTNERSHIP

Redesigned Model of Services and Care for Children with Complex Needs

The Preferred Model

1Introduction

The proposed model is one of an integrated, flexible service, provided by health, education and social care services working closely together in partnership, sharing resources where appropriate - with the child and their family at the core. The service shall embrace the values developed through the redesign process (Appendix A) and shall aim to maximise the benefits agreed by parents, carers, clinicians, managers and partners (Appendix B).

It is recognised that all the benefits will not be fully realised at the outset, but that a development plan will be agreed which shall be progressed as resources allow. Continuous service improvement will form part of the culture of the service.

2Introduction to the Service Model

The health service will be based on a central hub with outreach model.

A “Resource Centre” will provide the focal point of the service and will allow for the central co-ordination of services as well as the direct provision of some of the clinical services when it is not possible to provide the clinical care more locally. The resource centre will be located in the highly specialist provision planned by Aberdeen City Council Education Department (this will be referred to as the ‘Specialist Provision’ throughout this paper). The new provision will provide services for the age group 0 – 18, and will include a significant suite of health service accommodation.

As well as creating a Resource Centre, three specialist multi-disciplinary health teams (MDHTs) will be created and will work closely with other agencies. It is proposed that there will be one team in each geographic area of the City – North, South and Central. In addition to working in the children’s homes, schools etc, these teams have access to accommodation within the additional support need (ASN) bases at BucksburnAcademy (Secondary School age) andMileEndPrimary School. In addition, accommodation for the South MDHT is also being sought.

NHS Grampian will not be replicating the nursery provision that is currently available at Raeden Centre. Developmental Nursery provision will be provided on three local authority sites (in addition to some nursery places available at the Specialist Provision). Discussions are also in place to have a fifth developmental nursery delivered in partnership with the not for profit sector. This fifth centre will be able to offer full time places for working parents who require a combination of educational nursery and child care provision. (See Section 4 for further detail).

3Model Details - Health

3.1Clinical Criteria for Service

This new service will operate a more comprehensive set of clinical criteria than is presently the case in the current Child Development Service operating in Aberdeenshire. The existing model accepts children if they require two or more therapies. The proposed model will include additional conditions such as Autistic Spectrum Disorder and Developmental Co-ordination Disorder. The aim will be to create one seamless service for children with complex developmental needs so as to avoid current difficulties with families having to access different parts of the health service for different conditions. The MDHT will be seen as a flexible resource for all children with complex needs with both medical and Allied Health Professional (AHP) services having a number of children who may attend only one member of the team.

Paediatric AHP services in Grampian operate a clinical management system called ‘Care Aims’. This way of working is accepted nationally as evidence-based good practice, with the overall aim of having the right member of staff delivering the right care. The principle of this is that children have a therapy plan (developed in partnership with parents, school staff, etc) where clear clinical aims are set and blocks of treatment are then delivered in order to achieve these clinical aims. Much of this treatment is done in partnership with parents and other staff such as teaching and educational support staff who are vital to ensure treatment plans are maintained. If the aims are achieved, then the child is effectively discharged from the specific therapy with a route for re-referral if required at any time back to the MDHT.

3.2Resource Centre

The preferred location for the Resource Centre is to be fully incorporated within the proposed Specialist Provision to be built by Aberdeen City Council. The preferred site for this is the present Raeden Centre site. There will be scope for direct clinical provision to take place in this new facility. Children already attending the facility will be able to access medical, nursing and therapy services in that location. Although others may access services in the Specialist Provision, the general principle is to provide care as locally as appropriate.

The Specialist Provision will initially provide accommodation for two of the three MDHTs. This is discussed in more detail under the section 3.5.

The model recognises the benefits of having different teams co-located in the same building. Whilst there may be some day-to-day separation and distinction of the different teams to encourage true multi-disciplinary working around the needs of specific patients, clinicians and managers will ensure that there are scheduled opportunities for staff and the teams to come together for the purposes of training, communication, clinical supervision, audit etc.

The Specialist Provision will have equipment storage which will serve all three MDHTs. This will allow for the storage of larger pieces of equipment in particular that are unable to be stored in other bases.

3.3Staffing

Staffing of the three MDHTs will include:

Consultant Paediatrician

Clinical Child Psychologist

Psychiatry/other mental health staffing

Physiotherapy

Speech and Language Therapy

Occupational Therapy

Clinical Support Worker

Health Visiting

Nursery Nursing

Nursing

Dietetics

Special Needs Practitioners

Administrative staff.

Some of these roles will be provided by staff working exclusively in this service. Other staff will be from departments providing this service as part of their overall remit.

Multi-agency support and input will be required and provided from:

Social Work

Educational Psychology

Family Support Teams

The MDHT will provide treatment and care to children and their families from assessment, through diagnosis and treatment and will cover the full age range from birth to 18 years.

Exact details of caseloads cannot be determined for each team at this point in time. Although we can consider the home location of present children in the City this varies regularly as new children enter the service and young adults leave. Also attendance at schools can influence the numbers in each part of the City. Therefore the paper proposes minimum staffing levels for each team and initially will be based on equal staffing in each team. It will remain within the remit of clinical managers to move staffing resource around to ensure all children’s needs are met on an equitable basis according to clinical need.

It is estimated that 25% of children schooled in Additional Support Needs bases will need regular and ongoing NHS input. Within the highly specialist provision this could be as high as 90%, although not all children will be receiving active treatment at any given time.

Geographic boundaries will mean the North Team will include the Bucksburn base in its locality (and the team will be based there); the Central Team will be based at and will include the Specialist Provision; the South Team will include the Mile End base and will initially be based at the Specialist Provision until a location in the south of the City can be found.

It is proposed that clinical services to pupils at the Specialist Provision are not provided by a team dedicated just to that facility, but will be provided by the Central Team who will also have a geographical remit outwith the Specialist Provision. Consideration will be given to the complexity of caseloads when allocating staffing resources to each MDHT.

It is proposed that therapy staff will “follow the child”, with the aim to provide consistency of team support to the child as much as possible. Where there are fixed transition points such as changing schools that necessitate the changing of therapists, this will done in a planned and agreed manner with the family.

3.4Clinical Staff Roles

The roles of the team professionals are broadly as follows:

Consultant Paediatrician: The medical staff will provide the central point of contact for referrals and will provide clinical leadership around accepting referrals and discussions about the handling of referrals. The paediatricians may see children with developmental needs who may not then be accepted as a MDHT child. The role of the paediatrician includes initial assessment, diagnosis and treatment of the child as well as co-ordination of ongoing management and long-term care, in conjunction with other agencies and parents.

Clinical Child Psychology: Psychology input would be provided to undertake joint assessments with other members of the team. It would be desirable to have a Child and Adolescent Mental Health Service (CAHMS) liaison person in each MDHT in order to discuss behavioural and mental health issues. Psychology provide many functions: consultative, training, liaison and joint assessments, as well as taking on individual children as cases. More complex cases can be referred to the overarching CAMHS service in order to access multi-disciplinary mental health support.

Psychiatry: Children with complex needs currently access psychiatry on a referral basis, where they can be seen as part of the general service, the Learning Disability service or, sometimes, as part of the Infant Mental Health Service. These appointments are held in Royal Aberdeen Children’s Hospital. There is no dedicated psychiatry time for the complex needs service. Joint assessments carried out in local settings and including psychiatry input would be a future desire of this service. Both psychiatry and paediatric services manage children with ADHD/ASD.

Physiotherapy: Physiotherapists provide input for those children with movement difficulties through neurological, genetic and medical acquired diseases.

Speech and Language Therapy: There are currently two different types of speech and language therapy input for children with complex needs.

The Additional Support Needs Service provides assessment and intervention for children and young people with communication and/or eating and drinking difficulties. This is provided in partnership with families, schools and other professional staff. This service is provided in community clinics as well as in special schools and ASN bases.

The Specialist Speech Therapy Serviceincludes Raeden, as well as RACH and the Aberdeenshire CDTs. Staff provide specialist assessment, diagnosis and therapy services within multi-disciplinary teams to children with a range of complex communication difficulties. Provision may include a combination of treatment, support, advice and liaison with the child and family.

Work is ongoing at managerial level in the respective speech and language therapy departments to streamline the management of the service, to make the overall provision more cohesive. The ultimate aim will be to reduce any current duplication and to make the service more understandable and accessible to families.

Occupational Therapy: Occupational Therapy develops children’s independence within the occupational performance areas of self care: productivity (play/school/work) and leisure/social activities to their capability level. Occupational therapists assess and treat childrento help them develop and maintain their skills in relation to these areas.

Clinical Support Worker: These posts are essentialto provide support to qualified AHP staff in the provision of therapy programmes. These staff are not independent practitioners but undertake work prescribed by a therapist. Qualified staff set programmes in conjunction with parents and multi-agency partners; this will then often be delivered by the Clinical Support Worker in the most appropriate setting for the child. Clinical supervision is provided by qualified AHP staff.

Health Visiting: Health Visitors are qualified nurses with special training and experience in child health, health promotion and education. Advice is given on everyday difficulties, immunisation and behaviour management. They refer and liaise with other professionals and agencies when appropriate. The Health Visitor will work closely with the Nursery Nurse in the team who will provide intensive support for children and families and will provide early identification and intervention.

Nursery Nursing: Nursery nurses will provide the early support tofamilies required when children are first referred to the service. Nursery nurses can assess children for developmental stages and prepare children and families for further assessments as part of the referral process. Children can also be assessed jointly by nursery nurses and other professionals eg speech and language therapists. There may be some children who will require only nursery nurse input and will not need to be seen by the rest of the team.

Paediatric Nursing: This nursery nursing support should ideally be in addition to the creation of a community based paediatric nursing team for the City. This would allow for community nursing support for children in post-acute stages of treatment and also for children with chronic conditions that would not be included as part of the MDHTremit.

Dietetics: Dietetics provide nutritional assessment and intervention to children identified by medical and other members of the multi-disciplinary team. Children with complex needs frequently have difficulties around feeding and achieving adequate nutrition. A percentage of children require more intensive support including gastrostomy feeding. This service is organised with the Nutrition Support Nurse. Of the 90 children on home enteral feeding in Grampian, around 65% have a primary diagnosis of cerebral palsy or other neurological problem.

Special Needs Practitioners: This team of four clinical staff provides a service to AberdeenCity only and they provide support to children and families with complex needs. This team of staff have specialist knowledge in AHP and nursing, and also have knowledge of Child and Adolescent Mental Health. Targeted programmes of care are provided to the children who are referred and who often have behavioural issues, as well as other co-morbidities. They work with children with neurodevelopmental disorders in general and children with Autistic Spectrum Disorder children specifically.

3.5Referral Routes

The referral route for health professionalsinto the medical component of the Community Child Health Service will remain as it is currently. Referrals will be sent to Royal Aberdeen Children’s Hospital and will then be allocated appropriately.

It is proposed that all referrals for theMDHTs will come to the relevant administrative person for each team, for discussion at team meetings. Theadministrative support will receive referrals from GPs, Health Visitors, Child and Adolescent Mental Health Services, Educational Psychology etc. These referrals willbe discussed at the regular multidisciplinary team meetings where decisions will be made on the acceptance, allocation and clinical planning of these referrals.

When a referral is received, the team will discuss whether it is appropriate and will make a decision on the nature of the assessment required. This will include which staff should be involved and where the assessment will take place. These discussions will be held in partnership with the family. The majority of assessments will take place in community settings, which are familiar environments for the child. The level of involvement from services will vary dependent on the needs of the child and their stage of development.

Referrals to the Child Development Team Service in Aberdeenshire are in paper format. In the future, there will be a requirement to have an IT system which will allow for electronic referrals and electronic data to be held. In addition, an electronic appointment system should be in place, with the capability to deal with referrals from all agencies.

There will not be a direct referral route toAHP services as part of the MDHT. All referrals will be made to the team and will be considered accordingly.

3.6Team Locations

The team covering the Northwill be based at BucksburnAcademy. There are excellent clinical and administrative facilities there for the team to be largely self-sufficient. However, there will remain the need for some hot-desking facilities at the Specialist Provision for these staff to access when they are at scheduled staff training, meeting days etc. The administrative person for the team will be based in Bucksburn on a permanent basis.

The team covering the Central area will be based at the in the Specialist Provision.