NHS GRAMPIAN BOARD

AberdeenCity Community Health PArtnership

Option Appraisal for Health Service Redesign for Children with Complex Needs

Introduction

On 4th November 2008, a brief paper was presented to an NHS Grampian Board Seminar informing the Board of work being undertaken by Aberdeen City Council to consider the options for a SpecialSchool in AberdeenCity providing services for 3-18 year old children with complex development needs. The Board was informed that this had implications for NHS Grampian as this could affect the services provided by Aberdeen City Council at Raeden in the Nursery School. The Board was also informed that the end of the pilot of a Community Child Development Team was approaching, and that there was a general lack of direction within the service which was leading to difficulties in making decisions that had implications for the future.

The Board instructed that an Option Appraisal for the future of services for this group of children should be undertaken and should report back to the April 2009 Board Meeting. An Option Appraisal Steering Group was formed, with representation from Parents, Carers, Clinical Staff (from the community child health service, Royal Aberdeen Children’s Hospital [RACH], Raeden, school nursing and health visiting), management, Aberdeen City Council education and social work services, Corporate Communications and a Non-Executive Board Member. The Scottish Health Council was in attendance.

An Option Appraisal Report was presentedat the April 2009 Board meeting. The Board endorsed the initial appraisal of benefits and the preferred option(s), endorsed the involvement, engagement and consultation process to date for the redesign of health services for children with complex needs in Aberdeen City as a robust comprehensive process, and thanked the parents and staff for their input to the process, agreed that further work should be done to establish the detail and cost of the preferred option(s) with parents, carers, clinicians, managers and partner agencies and to report the outcome of this work to the Board in August 2009.

Aim

This paper is submitted to the Board to

  • Give a progress report on the work undertaken since April 2009
  • Share the working paper on the redesign model for the service
  • Highlight the gaps in the paper, and the work that will be done to address these
  • Share the Integrated Evaluation Report of the Pilot Child Development Team in South Aberdeen.
  • Propose a revised timetable for taking the work to conclusion

Discussion

  1. The original Steering Group continued to lead and drive the process. In addition to Steering Group meetings, at least another 3 workshops were held with an extended membership. These workshops were not easy meetings, and our thanks go to all involved, who have stuck with the process despite this.
  2. The work to create the detail of the preferred options and to evaluate the status quo option was more involved that originally thought and Aberdeen City CHP sought permission from the Chairman to delay returning to the Board until the December 2009 Board meeting. This permission was given and work continued to try and develop a service model that met the values and benefits outlined in the original optional appraisal and to reach a degree of consensus on the most suitable way forward.
  3. Creating the detail of the two preferred options – “Hub and Spoke” and “Specialised Centre with Outreach Teams”, has been incredibly difficult, as despite the groups work to define and clarify things in the early stages, it became clear that different perspectives still remained as to what these were. However, there remained strong commitment to the values and benefits that were identified during the first process and this has kept the group focused on resolving the differences that have arisen from time to time.
  4. This work has made good progress, however new opportunities for much closer joint working with both the Education and Social Care and Wellbeing departments of Aberdeen City Council have become apparent in recent months and although this is extremely welcome and gives the opportunity to create a truly integrated service to meet the needs of children and parents, the detailed work on this has not been able to be taken forward.
  5. A draft paper was prepared on a possible model for future service delivery (Appendix One). Despite there being some areas of agreement on aspects of the model, significant concerns remain across all groups. A significant part of this concern is that there has been insufficient time to discuss the model and that there remains significant gaps within the paper. These gaps are mainly around two areas, the section on Developmental Nurseries (where the paper refers to forthcoming work with Aberdeen City Council to develop a partnership model for this provision), and to the references on the need for Family Support. The need for Family Support was highlighted within the recent Social Care and Wellbeing review of services for this care group, but again the detailed work on how this will be delivered in partnership is not concluded.
  6. Finally, the difficulties around finalising the detail of our possible model for future service delivery have meant that the Steering Group has not yet had the opportunity to do a final appraisal of the options identified to the Board (Hub and Spoke, and Specialised Centre with Outreach Teams) against the status quo.
  7. The Next Steps. As Chair of the Steering Group, I reviewed the risks associated with pressing ahead at this stage, and believe that it would be detrimental to the excellent work done by the group to date to progress to consultation at this stage. The gaps in the model are significant and would very likely become the focus of consultation. I have included a summary from Laura Dodds, Public Involvement Manager on the public involvement process and the issues of concern raised by parents as Appendix Two to this paper.
  1. In September 2009, Dr Suleman Daud, concluded a report summarising the programme of audits set up pro-actively with the inception of the Child Development Team in South Aberdeen. This report is attached as Appendix Three. The Steering Group has not yet had time to discuss this report and it is felt important that lessons learned are incorporated into our model for the future.
  2. Discussions have been held with Aberdeen City Council and it is felt that significant work can be achieved over the next 3 months to fill the gaps that would enable the full option appraisal and discussion paper to return to the Board in April 2010. (This is also the intended timetable for a paper on Developmental Nurseries to progress to Committee at Aberdeen City Council.) Bringing together the three review and planning processes from Health , Social Care and Wellbeing and Education, would respond directly to direct requests from parents that we work together to create a strongly integrated service. There is clear commitment from ourselves and Aberdeen City Council that we wish to deliver on this by aligning our services.
  3. A proposed revised workplan is being developed. This is based on two joint working groups with Aberdeen City Council, the first to develop a partnership plan for Developmental Nurseries (led by the education service), the second to take forward the issue of Family Support Services (including respite). A third work stream will focus within the NHS on the detail of the health service delivery model and the costing of this. The Steering Group will continue to meet and will develop the option appraisal and consultation paper for the April 2010 Board meeting.

Key Risks

Very High

  1. Consulting on the present model without clarifying the detail around family support and developmental nurseries for the 0 – 3 year group will result in the consultation process focusing mainly on this aspect of the model and we shall not be able to engage the public sufficiently in the broader aspects of the paper to assess their views on the proposals for improvement in other areas.
  2. Questions raised around the aforementioned gaps could not be answered at this stage. The services are proposed to be jointly delivered with Aberdeen City Council and therefore NHS Grampian would not be in a position to give appropriate responses. This could be considered wasteful of the public’s time, who if being consulted on something should expect to have their questions answered.

High

  1. Reaching consensus may be impossible to achieve as the topic is highly complex and there are many perspectives on what is most important in the delivery of a safe and effective service.
  2. A high level of joint working is required to conclude these plans. Unexpected pressures on any partner may result in an inability to conclude the work.There may be insufficient capacity to conclude the work within the timescale proposed.
  3. Members of the Steering Group may leave due to the extended time period and failure to reach a conclusion.
  4. As this is a growing client group, it may be difficult to retain the cost of the new service within the cost of the previous service.

Conclusion(s)

It is my firm believe that the way forward is to continue to work within the Steering Group and with the additional joint working groups to develop a fully integrated plan for the delivery of services for Children with Complex Health Needs. There is strong commitment from Aberdeen City Council to progress on this basis and this is very positive news for the service and the children using the services.

The commitment of parents, carers, staff and managers to working through the differences of opinion to find the best way forward is greatly appreciated. There is a possibility that pressing ahead at this point without a greater degree of consensus would undermine that commitment and would be disrespectful of the work done so far.

Recommendations

NHS Grampian Board is asked to:-

  1. Note the work done to date by the Steering Group, including the draft model for future service delivery and recognise that this may change over the next four months.
  2. Approve the revised timetable and agree to the work progressing in partnership with Aberdeen City Council.
  3. Endorse the involvement and engagement process to date and to thank the parents, carers and staff for their ongoing input to the process.

Heather A Kelman

General Manager

Aberdeen City CHP, NHS Grampian

22nd November 2009

Appendix One – Draft Three Working Paper

Redesign of Health Services for Children with Complex Health Needs

Draft Service Model and Design

The Service for Children with Complex Health Needs

Specialist Child Development Services in Grampian for the assessment, diagnosis and treatment of complex health needs and in particular complex neuro-disability are provided by a multi-disciplinary team of highly skilled professionals, working alongside the parents, carers and families and in close partnership with social work and education services. The health staff group includes paediatric medical consultants (neuro-disability trained), mental health professionals including psychiatrists, psychologists, a broad group of therapists (includes physiotherapists, occupational therapists, speech and language therapists, dieticians, orthotists, and others as necessary), nursing staff (community paediatric nurses, nursery nurses) and all need to be supported by effective administration support. This broad group of professionals work together in multi-disciplinary teams and as single professionals to meet the needs of the child and family from diagnosis throughout childhood. Much of the work of the teams and staff can be done in home, community or health environments, but some services require access to specialist locations such as hydrotherapy pools, gait (walking) analysis laboratories, or a large therapeutic space.

Therefore there are two short appendices (A & B) to the main paper, which attempt to describe Entry to Services and how this can be improved, and the process of initial referral for assessment and diagnosis. These provide background to the more service design focused components of the main paper.

Central Hub and Outreach

This model aims to retain the key strengths of the existing services and to build on these to fill the gaps and weaknesses that have been identified in the service.

The key features of the design are as follows:-

  • There is a key focal point for the service (referred to throughout this paper as the Resource Centre – this is only a working title not the eventual name). The Resource Centre will not only co-ordinate services and provide some services, but will enable potential users of the service to find a way into service regardless of their knowledge or understanding of how the service functions. Parents and carers should find it easy to access specialist Child Development Services.
  • This base will function on a multi-agency basis. NHS Grampian and Aberdeen City Council (Education and Social Care and Wellbeing staff) will be co-located within this base and work together in an extended team to provide co-ordinated services and support for the children and their families and carers. Parents and carers will feel supported by a seamless and integrated service.
  • Balancing this central focal point, will be three teams of specialist staff who are working flexibly, at the central base, at appropriate locations within communities and within the family home. Children will be assessed and treated in the location most appropriate to their needs.
  • The entire service will be available for children from birth to school leaving age. For some children the service will be required continuously but other children they may ‘take a break’ from requiring the service for a period of time, but the service will be there if their needs change and they can re-enter as and when required. There will be continuity of service for children and their families.
  • The service within the City will be inclusive and available on a non-discriminatory basis for children with complex health needs. Educational placement, geographic location of home, economic status of parents or any other possible cause of discrimination shall not have any influence on access to the services that the child requires. Children with equal need will be given services of equal benefit.
  • There will be a clear resource within the service focussed on communication and information. This resource will also provide co-ordination of services for parents and carers if necessary and act as an ongoing point of contact during breaks from the service. Parents and potential users will find it straight forward to obtain accurate and relevant information about services, the range of conditions, available support from other agencies and other pertinent information.
  • The service will continue as an ‘expert’ service, providing teaching for staff in training and learning and development opportunities for community staff working with this client group. Staff will continue to have opportunities to participate in research, audit and evaluation. The service will continue to fulfil its role as part of a teaching and training facility. Children will continue to have assessment and treatment by specialist staff.

The Resource Centre

Role and Functions

It is anticipated that this building will function at 8 levels.

  1. A single point for enquiries and referrals from parents, carers, professionals, other parent supports. (Note this would not replace the current established route for referrals to medical staff).
  2. A staffed information and communication point.
  3. An assessment and treatment base in the City for children requiring services that cannot be delivered in a more local/community service.
  4. A base for specialist assessment in the City when required.
  5. Assessment and treatment base for the children attending the attached school.
  6. A resource centre to support parents and families, enabling group sessions, peer support networks, links to other support agencies etc.
  7. A base for all the specialist teams working in the City.
  8. A central location for equipment and resources.

It is not intended that this building will provide a focus for all specialist equipment, or assessment facilities as this would be inefficient. However, the centre will provide an access point to these facilities for children and families across Grampian and support the child and their family to access and use these services.

Physical Location

The preferred location is to co-locate with the highly specialised school being planned by Aberdeen City Council. The Lead Officers are willing to extend the age range of the facility from birth to school leaving age to enable NHS Grampian to locate the main focus for our services within and alongside this school.