` 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