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Wynford House
Lufton Way
Lufton
Yeovil
Somerset
BA22 8HR
Tel: 01935 384000
Fax: 01935 384079
enquiries@somersetccg.nhs.uk
26 January 2016
Dear Colleagues,
Integrated Paediatric Therapy Services
We are writing to inform you of changes in the provision of the Integrated Paediatric
Therapy Service for schools. Somerset Clinical Commissioning Group and Somerset
County Council have been working together to identify how we can address the
increasing demands on the service. Since 2014/15 the number of referrals to the service
has increased by over 90%. As commissioners we do not have additional resources to
invest in the service to increase capacity in line with the increasing demand. We have
jointly taken the decision to remove the Local Authority funding from this service to allow
the Local Authority to make separate provision for the work that the service was
previously completing for the statutory SEN+D work required by Education Health Care
Plans and tribunals. Any Local Authority contribution now will be over and above the
core therapy service provision. This separation will provide clarity for the Local Authority
around the expenditure on this element of statutory work and will allow for a wider review
of all provision of therapies in schools in Somerset.
In light of the increasing activity demands on the service, there will be a slight increase in
the acceptance thresholds of the service. The current service model will continue to
operate in both school settings and clinics aiming to achieve the best outcomes for our
children and young people in Somerset. This includes the provision of advice and
guidance to partners working with children and young people for whom referral into the
service may not be appropriate. All schools and early years providers have received
“Fact Files” which enable those working with children and young people to identify and
address needs at an early stage prior to referral. By increasing some of the thresholds
we are seeking to ensure that those children and young people with the most need are
able to access appropriate levels of intervention to gain best therapeutic benefit and
achieve their outcomes. Details of the inclusion criteria for the service have been
included at Appendix 1.
Within the LA, discussions are taking place to identify how the Children’s Disability
Service OT team may be able to help with equipment assessments, and we are aware
that many schools are already buying in additional therapy provision.
Chair: Dr Matthew Dolman | Managing Director: David Slack
Clinical Leadership to Improve Health
www.somersetccg.nhs.uk
Somerset Clinical Commissioning Group and Somerset County Council remain
committed to ensuring that the Children and Young People of Somerset are able to
access services in a timely fashion and achieve their outcomes and aspirations, and will
continue to work closely together to ensure that this can be achieved.
In October, the multi–agency SEND Strategy Board agreed to initiate a review across
health and education of the total resource available to meet the needs of children and
young people in Somerset with communication, sensory and or physical needs who
require and receive support through a range of services and providers. This review is
starting imminently.
The commissioning of this review is an extremely positive development and is being
undertaken in particular to look at capacity, but also to ensure we benefit from properly
integrating our approaches. We are hopeful that the review will form the basis for
establishing a long term solution to the current situation.
For any further queries please contact either Laura Wilson via
Laura.Wilson@somersetccg.nhs.uk at Somerset Clinical Commissioning Group or Rick
Beaver via RBeaver@somerset.gov.uk at Somerset County Council.
Yours sincerely
Ann Anderson
Director of Clinical &Collaborative
Commissioning Development, Somerset
Clinical Commissioning Group
Sue Rogers
Deputy Director of Education
Somerset County Council
Appendix 1
Integrated Therapy Service for Children and Young People
Physiotherapy Provision
The overall purpose of the proposed changes to service delivery is to reduce the ongoing review
caseload and thereby release time for therapists to carry out direct therapy with children who
have complex, high level needs and where timely and skilled intervention is essential for them to
make good progress. It will result in a smaller core service with the potential for external
organisations to commission additional services from the ITS.
Presentations not accepted at referral
The Integrated Therapy Service (ITS) will not accept referrals for children with the following
presentations or in the following situations:
Physiotherapy
Children with normal variations in their gait or skeletal structure (e.g flat feet, in-toeing / outtoeing)
Idiopathic toe-walkers
Skills are commensurate with overall developmental level
Chronic Pain where the referral indicates that this is long-standing and predominantly
psychological in nature and needs a multi-disciplinary team involvement.
All acute MSK referrals of 8 years and over
Hypermobility without significant pain or functional restriction
Plagiocephaly with no restriction of movement, unless failed to respond to health visitor
advice.
Chronic fatigue
Co-ordination difficulties with no evidence of additional school support eg Learn to Move
training having been accessed and implemented by the school
Scoliosis with no co-morbid factors
Children with known neurological or MSK conditions who need referral to orthotics
If insufficient information has been provided in the referral to enable clinical triage, it will be
rejected back to the referrer with guidance on the information that is needed for a re-referral to be
made.
Re-Referral
Re-referral following previous involvement by the ITS will follow the criteria for initial admission.
In addition:
a) No re-referral will be accepted within 6 months of discharge unless there have been
significant changes in the child’s needs
b) The referrer must gather and provide evidence of how ITS advice has been used
(including improvements made or reasons for no change) and/or details of any new
concerns that have not previously been addressed
c) There may be specific limitations on re-referral signalled in the discharge report
d) The child and family may be offered an initial review clinic rather than a full initial
assessment.
Acceptance for Assessment
Following acceptance of a referral, families will be asked to opt-in to the service by contacting the
local area base to request an appointment. When they do so, this will activate the referral and
start the waiting time clock. If they do not contact the service within three weeks the referral will
be returned to the referrer.
Core Service following Admission
Assessment and advice will continue to be offered, while ongoing provision will be available for
specific conditions as outlined below.
Assessment and advice only – to be outlined in a leaflet sent with IA invite.
Assessment and advice only will be provided for the following groups of children:
Physiotherapy
Difficulty
Provision
Any child referred with mild difficulties in their Clinic assessment unless home or school
gross motor skills
assessment is indicated. This may be a joint
assessment with another therapy where
Mild
neurological
or
musculoskeletal
required.
conditions
Further assessment / observation in clinic,
home or school by the assessing therapist.
This will not be required in all cases.
Report and guidance sent within 6 weeks of
the last assessment session being
completed. An ‘advice plan’ will be issued as
appropriate.
Discharge.
Assessment and Short-term Intervention
Specific children will receive a time-limited period of intervention as follows (leaflet outlining this
pathway will be provided by the therapist):
Physiotherapy
Difficulty
Provision
Diagnosed conditions that require Care Plan
a short burst of therapy / advice in
Up to 8 sessions with Physiotherapist /Therapy
order to train others to manage a
Support Practitioner (TSP). This could be 1:1 or group
child’s condition.
therapy.
Physiotherapists to provide and
assess outcome of a specific Telephone review on request by the parent within 3
therapy intervention. For example months. If concerns identified, will be offered a review
neurological,
rheumatological, clinic appointment.
musculoskeletal or respiratory Discharge
conditions.
This will include children likely to
receive a diagnosis during this
period of intervention.
Assessment and Ongoing Intervention
Ongoing intervention will be provided for the following conditions:
Physiotherapy
Difficulty
Complex conditions likely to
respond to intervention or
necessary
to
maintain
skills/function such as some
cases
of
cerebral
palsy,
degenerative neurological (i.e
DMD) and chronic respiratory
conditions.
Provision
Care Plan
Block of treatment sessions with Physiotherapist /
Therapy Support Practitioner.
Review of needs and care plan is discussed in
supervision at least every 6 months.
Discharge at the appropriate point for example when the
risk is managed by parents / school. Clinical decision
made in conjunction with parents / child or young person.
Complex
musculoskeletal
(MSK) conditions conditions
that have a predicted frequent
return within a 6 month window
of time for example osteogensis
imperfecta, arthrogryposis.
Post trauma – MSK / acquired
neurological
conditions
for
rehabilitation.
Children with complex needs as
above and close to transition
points.
Integrated Therapy Service for Children and Young People Occupational Therapy
provision
The overall purpose of the proposed changes to service delivery is to reduce the ongoing review
caseload and thereby release time for therapists to carry out direct therapy with children who
have complex, high level needs and where timely and skilled intervention is essential for them to
make good progress. It will result in a smaller core service with the potential for external
organisations to commission additional services from the ITS.
Presentations not accepted at referral
Occupational Therapy
Skills are commensurate with overall developmental level
Dyslexia with no additional difficulties
Referrals requesting sensory input indicating predominantly behavioural, anxiety or conduct
difficulties Pilot study for phone screening Oct 15
Coordination difficulties with no evidence of additional school support e.g. Learn 2 Move
training having been accessed and implemented by the school
Equipment for children whose long term condition or needs at home or in school should be
addressed by Children’s Social Care
No functional difficulties highlighted
If insufficient information has been provided in the referral to enable clinical triage, it will be
rejected back to the referrer with guidance on the information that is needed for a re-referral to be
made.
Re-Referral
Re-referral following previous involvement by the ITS will follow the criteria for initial admission.
In addition:
a) No re-referral will be accepted within 6 months of discharge unless there have been
significant changes in the child’s needs.
b) The referrer must gather and provide evidence of how ITS advice has been used (including
improvements made or reasons for no change) and/or details of any new concerns that
have not previously been addressed
c) The child and family may be offered an initial advice/review clinic rather than a full initial
assessment. This will include newly referred children with an existing diagnosis of ASD or
Developmental Coordination Disorder
Acceptance for Assessment
Following acceptance of a referral, families will be asked to opt-in to the service by contacting the
local area base to request an appointment. When they do so, this will activate the referral and
start the waiting time clock. If they do not contact the service within a month, the referral will be
returned to the referrer.
Core Service following Admission
Assessment and advice will continue to be offered while ongoing provision will be available for
specific conditions as outlined below.
Assessment and Advice Only – to be outlined in a leaflet sent with IA invite
Assessment and advice only will be provided for the following groups of children:
Occupational Therapy
Difficulty
Provision
Any child referred with
functional difficulties
Mild neurological conditions
mild
Clinic assessment unless home or school assessment
is indicated. This may be a joint assessment with
another therapy where required.
Further assessment/observation in clinic, home or
school by the assessing therapist. This will not be
required in all cases.
Report and guidance sent within 6 weeks of the last
assessment session being completed. An ‘advice plan’
will be issued as appropriate.
Discharge
Assessment and Short-term Intervention
Specific children will receive a time-limited period of intervention as follows (leaflet outlining this
pathway will be provided by the therapist):
Occupational Therapy
Difficulty
Diagnosed conditions including
neurological,
sensory
processing
disorder
and
developmental
coordination
disorder.
Provision
Care Plan
Up to 8 sessions with Occupational Therapist / Therapy
Support Practitioner. This will be 1:1 or group therapy
(e.g. ALERT group, Sensory Integration group for
Parent/Carers, Coordination group, zones of regulation)
This will include children that Telephone review on request by the parent within 3
are likely to receive a diagnosis months. If concerns are identified, will be offered a review
during this period of intervention
clinic appointment.
Discharge
Assessment and Ongoing Intervention
Ongoing intervention will be provided for the following conditions only:
Occupational Therapy
Life limiting/threatening condition
Care Plan
Treatment sessions as needed with Occupational
Complex conditions e.g. some cases of Therapist / Therapy Support Practitioner
specific cerebral palsy, neurological
conditions, ASD
Post
traumatic
rehabilitation
episode
for Review of needs and care plan is discussed in
supervision at least every six months
Discharge at the appropriate point
Integrated Therapy Service for Children and Young People
Speech and Language Therapy Provision
The overall purpose of the changes to service delivery is to reduce the ongoing review caseload
and thereby release time for therapists to carry out direct therapy with children who have
complex, high level needs and where timely and skilled intervention is essential for them to make
good progress. It will result in a smaller core service with the potential for external organisations
to commission additional services from the ITS.
Presentations not accepted at referral
The Integrated Therapy Service (ITS) will not accept referrals for children with the following
presentations or in the following situations:
Speech and Language Therapy
RE1
Children with speech and language levels within the normal range for their age
RE2
Children with speech and language skills in line with their general developmental
level
Children who are showing a delay but general strategies have not yet been tried –
the service will advise on general strategies and ask for re-referral once these have
been implemented if they do not result in improvement
Children with a diagnosis of Autistic Spectrum Disorder (ASD) whose
communication difficulties arise from their ASD and not from a specific speech or
language disorder
Children learning English as an additional language if they have normally
developing speech and language skills in their home language
RE3
RE4
RE5
If insufficient information has been provided in the referral to enable clinical triage, it will be
rejected back to the referrer with guidance on the information that is needed for a re-referral to be
made.
Re-Referral
Re-referral following previous involvement by the ITS will follow the criteria for initial admission.
In addition:
e) No re-referral will be accepted within 6 months of discharge unless there have been
significant changes in the child’s needs
f)
The referrer must gather and provide evidence of how ITS advice has been used
(including improvements made or reasons for no change) and/or details of any new
concerns that have not previously been addressed
g) There may be specific limitations on re-referral signalled in the discharge report
h) The child and family may be offered an initial review clinic rather than a full initial
assessment.
Acceptance for Assessment
Following acceptance of a referral, families will be asked to opt-in to the service by contacting the
local area base to request an appointment. When they do so, this will activate the referral and
start the waiting time clock. If they do not contact the service within three weeks the referral will
be returned to the referrer.
Core Service following Admission
Assessment and advice only
If assessment shows these children meet the following criteria with no other difficulties with
communication that warrant a higher level provision they will receive advice and be discharged
from follow-up
Difficulty
AO1
AO2
AO3
Speech and Language Therapy
Provision
Children
with
social
Clinic assessment unless home visit indicated.
communication difficulties
Further assessment/observation in clinic, home
or school by the assessing therapist in a few
Selective mutism
cases.
School-age children
normally
developing
delayed language
Report and guidance sent within 6 weeks. A
with Care Plan will not be required.
but
If multidisciplinary Autistic Spectrum Disorder
diagnosis is pending, may need to keep the case
open for a period of liaison
Discharge
Assessment and Short-term Intervention
Specific children will receive a time-limited period of intervention as follows:
Speech and Language Therapy
Provision
Care Plan
Speech sound delay in pre- One set of speech sound groups with parent only
Difficulty
AS1
schooler with child intelligible session at first group or short block of individual /
in context
paired sessions of therapy or one review on
request
Review on request following block of intervention
Discharge
Care Plan
AS2
Language delay in pre- Parents and staff from pre-school setting are
schooler
invited to an adult workshop to go through the
DVD of strategies and personalise them to their
child OR child and parent attend one set of
language groups.
One follow-up telephone or face to face review
ion request to personalise the strategies
Discharge
Care Plan drawn up and demonstrated if
AS3
Speech sound delay at necessary to school staff. This could be a couple
school-age
of sessions from a Therapy Support Practitioner.
Child is put on review on request with requirement
for the school to come back to the service with
results of their intervention in order to request
further provision.
Reviews could be in clinic unless school visit
more convenient
Discharge
Assessment and Ongoing Intervention
Ongoing intervention will be provided for the following conditions:
OI1
OI2
OI3
OI4
Speech and Language Therapy
Ongoing caseload with Care Planned provision
Fluency difficulties
Delegated programme OR periods of direct
therapy with Speech and Language Therapist /
Therapy Support Practitioner
Dysphagia
– physical Review on request of care plan in most cases so
difficulties with eating, timescale can be fitted to the needs of the child
drinking and swallowing
and dependent on the activities having been
carried out on a regular basis. Discharge with
Voice disorder
advice if no support for care plan
.
Some cases will resolve quite quickly and be able
to be discharged, e.g. voice disorders, while
Speech Disorder including others will be on the caseload for a longer period
Cleft Palate
of time
OI5
Severe
speech
delay Clinic reviews/therapy for some of these if parents
where
child
is
not are supporting the intervention or school are not
providing support.
intelligible even in context
OI6
Language Disorder
Any child on the caseload for over a year must be
discussed in supervision
OI7
OI8
Children with no or very Discharge at the appropriate point
limited
functional
communication skills includes those needing
PECS (Picture Exchange
Communication System or
AAC
(Alternative
or
Augmentative
Communication)
Persistent specific speech
process delay in older
children