View This Document

ENCLOSURE O

TRUST BOARD – SUMMARY REPORT

Date of Trust Board meeting: 19 July 2006

Name of Report: Review of Progress in Implementing the National Service Framework for Long Term Conditions

Author: Alex Laidler Head of Disability and Rehabilitation Services

Approved by (name of Director):.Rod Craig and Sarah Desai

Presented by: Rod Craig and Sarah Desai

Purpose of the Report:

To explain the requirements of the Long Term Conditions NSF, provide a summary of work to date and highlight good practice and areas for further work.

Action required: To note the contents of the report, which explains progress made so far overall on the Long term conditions NSF, and where further work is required in relation to long term neurological conditions.

Recommendations to the Trust Board: To agree robust governance for delivery of the NSF for people with neurological long term conditions within the context of the wider LTC agenda, including performance monitoring.

Risk Implications & Actions Taken:

Compliance with the LTC NSF is required to demonstrate organisational fitness for services to adults and older people.

Public & User Involvement:

Links in with the agenda of the Physical, Sensory and Neurological Disability Partnership Board, and the Older People’s Project Board.

Equality & Diversity Implications: The most vulnerable and disadvantaged groups are affected by Long Term Conditions, and the NSF seeks to improve standards of service and reduce

1

health inequalities for all.

Southwark Primary Care Trust

Review of Progress in Implementing the National Service Frameworkfor Long Term Conditions

Briefing for PCT Board

About the Long term Conditions National Service Framework

IntroductionThe National Service Framework (NSF) for Long Term Conditions (2005) is a 10-year strategy that specifies 11 quality requirements (Q.R.s) underpinned by evidence-based markers of best practice. The aim is to transform the health and social care services that support people with long-term neurological conditions, and their carers, by promoting quality of life and independence via coordinated, person centred care, easier access to information and support from diagnosis through to end of life. The emphasis is on patient choice, rehabilitation, self care and self management, and case management for those with complex needs.

While this NSF focuses primarily on people with neurological conditions, the guidance applies to people with other long-term conditions. Consequently, much activity across the NHS and social care has been in developing services for people with Chronic Obstructive Pulmonary Disease, Heart Disease, and diabetes, driven by the need to reduce emergency bed days by improved primary care and community services. It is essential, nonetheless that the quality improvements are addressed robustly for people with neurological conditions within the context of the wider long-term conditions programme.

The responsibility for meeting the requirements rests with health and social care services, but the need for a multi-agency approach is recognised in order to meet people's needs for housing, transport, employment, education, benefits and pensions.

Background - what are neurological conditions?A long-term neurological condition arises from disease, injury, or pathology of the nervous system (i.e. brain, spinal cord, and/or peripheral nervous system) which impacts permanently on the individual. Some of the common types of neurological conditions are degenerative and eventually fatal, and include acquired brain injury, spinal injury, stroke, multiple sclerosis, Parkinson's disease, motor neurone disease, and cerebral palsy. (NB: stroke is addressed in the NSF for Older People).

Neurological conditions may produce various problems including physical or motor problems, sensory problems, cognitive/ behavioural problems, communication impairments, and psychological and social difficulties.

How the Long Term Conditions NSF fits in with other strategic requirements. The NSF is one of a broader range of initiatives relating to long-term conditions, and fits with a number of other strategic changes including:

The NHS Improvement Plan; Putting People at the Heart of Public Services; National Standards, Local Action Ð The Health and Social Care Standards and Planning

Framework 2005/6 Ð 2007/8;

2

Supporting People with Long Term Conditions, An NHS and Social Care Model to support local innovation and integration;

Improving the Life Chances of Disabled People, Prime Ministers Strategy Unit The Green Paper; Independence, Wellbeing and Choice. The White Paper; Our Health, Our Care, Our Say.

Quality requirements, targets and assessmentThe NSF sets out 11 quality requirements (QR's) for implementation over a 10-year period. These span diagnosis through to end of life care, and include evidence based markers of best practice to transform the way health and social care services support people with long term neurological conditions to live as independently as possible, and put them a the centre of their care. The needs of families and carers are addressed, and the principles apply to other non-neurological conditions.

The QR's are divided as follows:

QR1: Person centred services

QR2 and QR3 Prompt diagnosis, referral, and treatment

QR4 to QR6 Rehabilitation, adjustment, and social integration

QR7 to QR11 Life long care and support for people with neurological conditions, families and carers

The planning framework requires that the NHS and local authorities be able to demonstrate progress in planning and developing the levels of service quality laid out in the NSF over the course of the initial three year planning period (2005/8).

The NSF does not have rigid targets and standards to be met, and this means that self-assessment and local interpretation of needs and priorities is possible.

This NSF links to the following Public Service Agreement Targets: To improve health outcomes for people with long term conditions by offering a personalised

care plan for vulnerable people; To reduce emergency bed days by 5% by 2008; The maximum 18 week wait from GP referral to hospital treatment.

Southwark's Approach to Long Term Conditions

In Southwark, the agenda was informed by an analysis of hospitalisation rates over three years carried out by the Kings Fund. This resulted in an initial focus on four specific long-term conditions: sickle cell disease, respiratory conditions, including Chronic Obstructive Pulmonary Disease (COPD) and asthma, and cardiac problems including heart failure and Coronary Heart Disease. Diabetes has been included as demographic analysis has shown that some groups within the Southwark population are particularly susceptible to developing it.

The work is managed by the LTC Steering Group, chaired by Sarah Desai. The Steering Group agreed a strategy for 2005/06 and this year an action plan has been written to deliver against key outcomes. In 2006/07 an Action Plan will form the structure for the LTC programme giving clear and tangible outcomes and identifying key people responsible for delivery of specific actions (currently in draft format).

3

Southwark is making significant progress on integrating health and social care services for adults, and the development of specialist disability and rehabilitation services means that some of the markers of good practice within the QR's are well on the way to being achieved. However, a comprehensive self-assessment and review process that provides evidence of how Southwark is performing for people with long-term neurological conditions needs to be included within the remit of the Steering Group for LTC.

There are 2 appendicesAppendix one sets out the eleven quality requirements with their corresponding markers of best practice, and states how well Southwark complies for physiological long term conditions, based on evidence collected by the Steering GroupAppendix 2 states how well Southwark complies for people with neurological conditions based on feedback from current services and progress reported from the integration programme.

Key Issues for Southwark

Strengths to build on: Recruitment of community matrons and building a case management approach into the

District Nursing workforce (NSF QR1) Co-ordinated and commissionable self-management services for people with non-

neurological long term conditions the Kings Fund analyses of Southwark’s hospitalisation rates there are 3 case managers in the Younger Person's Physical Disability team, a model of

good practice acknowledged in the NSF. However, they serve the entire Lambeth, Southwark and Lewisham area and have capacity only to deal with the most complex clients. There is potential to build on this model and increase capacity to this resource.

Areas for further work:There is a need to ensure ongoing self-assessment and review of all areas of the NSF, but particularly to ensure that the requirements are met robustly for neurological long-term conditions, and that across all long term conditions the following areas will need to be made a priority:

QR6 Vocational Rehabilitation QR10 Supporting Family & Carers QR11 Palliative Care

There is opportunity to spread good practice and learning from the work of the LTC steering group to date, and apply relevant techniques and models to neurological LTCs.

It will be important to address the needs of people with long term mental health conditions, particularly individuals living with schizophrenia, and those living with a combination of mental health and physiological or neurological long term conditions, or learning disabilities and long term conditions.

Work to review the strategy for commissioning and providing health and social care services for people with HIV has started in collaboration with children's services.

Southwark has a large number of people with Multiple Sclerosis. Led by Southwark, the SE London MS Steering Group is a cross PCT, multi-agency group with a remit to plan service improvements and commissioning arrangements. Potentially this group could widen its remit to include other long-term conditions.

4

Recommendations and Next Steps

Whilst the Kings Fund tool highlighted people with LTCs who were frequent users of acute and emergency services, there are many other people with LTCs who are frequent or high dependency users of primary and community health and social care services. For instance, Southwark has one of the highest populations of people with Multiple Sclerosis in the nation, and whilst they are not heavy users of emergency services, they are significant users of community care, wheelchair and special seating services and nursing and continuing care placements. Similarly, people living with HIV and AIDS account for a very high proportion of the PCTs expenditure on prescribing.

As many of the QRs require robust audit and review, methodology used to review progress on the Children's NSF be used to continuously monitor progress and inform planning and priorities for the LTC steering group for 2006/7 to 2009/10.

As we are already one year into the three-year planning period, there is an urgent need to further focusing on neurological conditions, and to incorporate this into the work of the LTC Steering Group. The membership of the Group will be reviewed to ensure appropriate representation and links with related work streams. The neurological work stream will be overseen by the Physical, Sensory and Neuro Disability Partnership Board.

5

APPENDIX 1

LONG TERM CONDITIONS NSF - PROGRESS ON MEETING QUALITY REQUIREMENTS AND SUPPORTING EVIDENCE

Quality Requirement

Description of Quality Requirement Action completed on-neurological long term conditions

Action plan Action by/by when

QR1: A Person Centred Service

People with long-term neurological conditions are offered an integrated assessment & planning of their health & social care needs. They have information to make informed decisions about their care & treatment, and where appropriate, to manage their condition themselves.

Markers of good practice:

Timely integrated assessment involving all agencies leading to individual care plans.

A named point of contact for advice & information for all people with long-term conditions.

Case managers for people with complex needs.

Effective transition planning. Information, advice, education &

support. Capacity to respond to rapidly

progressing conditions or changing needs.

* Access to education and self-management programmes tailored to individual needs and conditions.

The work has focused on developing the role of Community Matrons (CMs) in each locality. This will provide: person centred care Timely assessment & a care plan involving

relevant agencies with a named contact Link patients to appropriate agencies e.g.

Social Services, specialist AHP teams, CMHTs & plan patients' transition through the health & social care system

Provide information, advice, education & support

Proactive response to changing disease status & social circumstances

Refer to self management programmes (generic e.g. Expert Patient Programme); disease specific: diabetes structured education e.g. DAPHNE; COPD Pulmonary Rehab; heart failure & CHD Heart Active

Patients with LTCs are given information about options available to them by their GP and via Choose & Book at GP surgeries.

Care offered to LTC patients is delivered by appropriately trained staff with support from specialist clinicians where appropriate.

A nursing review is underway to embed CMs into District Nursing teams. The review will also deliver case management training to Band 5 community nurses to address LTC patient needs.

The Kings Fund PARR tool will be used to identify patients at risk of future hospital attendances. This information will be complemented by GP referrals to CMs

the Bowley Close service needs to comply with Choose & Book via implementation of RiO

LTC Steering Group

AL

6

Quality Requirement 2: Early recognition, prompt diagnosis and treatment

People suspected of having a neurological condition are to have prompt access to specialist neurological expertise for an accurate diagnosis and treatment as close to home as possible.

Markers of good practice include:

Improved access to specialist neurological expertise via training, protocols, and guidelines to support early recognition and referral.

Diagnostic services meet NICE guidelines.

Improved access to available treatments including those approved by NICE.

Ongoing specialist neurological advice and treatment.

Improved access to treatment review.

Training is being delivered to front-line staff to support prompt diagnosis.

The Hypertension Toolkit will be piloted in Peckham & Camberwell locality, & will raise awareness address under-diagnosis

Some practices offer diabetes diagnosis but needs to be expanded across the PCT. Pockets of good practice reduce test duplication for diabetes patients

The development of primary care diagnostics services for heart failure & COPD and access to spirometry & BNP as recommended by NICE

Rapid Access Clinic for diabetes patients to offer primary care clinicians access to specialist opinion.

The next stage is to develop diagnostic services in primary care for an expanded range of long term conditions

LTC steering

Quality requirement 3: Emergency and acute management

People needing hospital admission for a neurosurgical or neurological emergency are to be assessed and treated in a timely manner by teams with the appropriate neurological & resuscitation skills & facilities.


Compliant with NICE guidelines & nationally agreed standards.

Trained staff, appropriate facilities & protocols in admitting hospitals.

Protocols for head injuries that comply with NICE and national guidelines; protocols for people with head injury in the community not admitted to hospital.

Links/ transfer to specialist centres when necessary

Access to inpatient rehabilitation

No action yet taken. Review/ audit of compliance with QR3 needed in collaboration with acute hospital trusts.

The Head of Intermediate Care & Hosp Discharge is working with community nursing & A&E colleagues todevelop systems to avoid unnecessary hospital admission for people with LTCs

7

following discharge form neurosciences centres

Quality Requirement 4: Early and specialist rehabilitation

People with long-term neurological conditions have access to timely, ongoing, high quality rehabilitation services in hospital or other specialist settings. Includes access to timely, ongoing community rehabilitation and support.

Markers of best practice:

Early, high intensity, coordinated rehabilitation from an interdisciplinary team

Seamless transition of care Access to appropriate services for

people with severe and profound disabilities including cognitive and behavioural problems

So far the focus has been on respiratory patients, and patients recovering from Myocardial Infarction. Need to consider needs of people with other LTCs Pulmonary Rehabilitation offers a multi-

disciplinary co-ordinated, stratified programme according to patient need. Patients are referred early in their disease pathway. The service is located at 2 sites across the PCT.

Patients with breathlessness affecting functioning are offered PR, preferably before hospital admission. (See also QR5)

The scope of the work needs to be expanded to cover all LTCs

Quality Requirement 5: Community Rehabilitation and Support

People with long-term neurological conditions at home are to have ongoing access to a comprehensive range of rehabilitation, advice & support to meet their continuing and changing needs, increase their independence and autonomy, & help them to live as they wish.


Goal oriented, holistic, individualised programmes of community rehabilitation and support

Integrated community rehab teams with health and social care together and access to specialist neurological expertise

Services provide education, support

Goal-based programmes for patients with pulmonary or heart conditions Community-based pulmonary rehabilitation

by a multi-agency team for patients with respiratory problems, including COPD; and Heart Active for post-MI patients.

Heart Active available as Phase IV rehab programme for post-MI patients by appropriately trained fitness trainers.

Review ref to Pulmonary rehabilitation services are fragmented with complicated referral routes

Project Group recently established to review care and support for people living with HIV to ensure modern, responsive services & strategic commissioning across children's & adult services (health and social care, and supporting people).

8

well being and psychological adjustments

Are proactive to prevent deterioration in progressive conditions

Quality requirement 6: Vocational rehabilitation

People with long-term neurological conditions are to have access to appropriate vocational assessment, rehabilitation & ongoing support to enable them to find, regain or remain in work & access other occupational & educational opportunities. Vocational rehabilitation must include both local services &more specialised neurological rehabilitation services (i.e. cannot be met by local rehabilitation services alone).


Coordinated multi-agency rehabilitation is provided which takes account of agreed national guidance

Local rehabilitation services address vocational needs & work with other agencies to provide assessment, support on return to work and retaining or leaving work

Referral/access to specialist vocational services for people with neurological conditions who have complex occupational needs (including specialist assessment, counselling, vocational rehabilitation)

Many adults with learning disabilities have a LTC. Currently there is vocational support commissioned by the LD Pooled Budget. There is an opportunity to use this model to inform developments for all adults with LTC.

EPP offered to patients via Job Centre Plus Southworks is a county-run service for a

wide range of adults, and is available to people with a LTC

Vocational support is likely to be needed & is often over-looked for people living with sensory impairment, HIV, & long-term musculo-skeletal conditions, & other long-term conditions (e.g. M.E., sickle cell, long term mental health conditions). A review/audit process is needed to assess QR6 robustly

There is a need to raise awareness of the issues affecting people with LTCs, particularly in primary care and hospital settings

Quality requirement 7: Providing equipment and accommodation

People with long-term neurological conditions are to receive timely, appropriate assistive technology/equipment and adaptations to accommodation to support them to live independently, help them with their care; maintain their health and improve their

An integrated community equipment service (ICES) is in place.

tele-healthcare to LTC patients is in progress with roll out pending further funding

The Audit Commission’s review of wheelchair & seating service in 2005 has

Need to review: the provision of equipment

by ICES & Bowley Close to reduce duplication

waiting times, and access to indoor/outdoor power-chairs . Modernisation of

AL

AL

9

quality of life.


Assistive technology/equipment is provided and maintained in accordance with nationally agreed standards and guidelines.

Access to integrated community and specialist Assistive technology/equipment services which work closely with neurology and rehabilitation services.

Assistive technology needs/equipment needs are documented in a persons integrated care plan.

Specific arrangements for joint funding of specialist Assistive technology provision (e.g. communication aids, electric standing frames, special seating aids for non-wheelchair related use)

Social services work closely with housing/accommodation & Supporting People services to provide timely, suitably adapted or purpose built accommodation. Not relevant to most LTC patients

formed the basis of a workplan for Bowley Close, which provides specialist equipment to LSL & other commissioning PCTs in the London area & nationally. Most people using these services have LTCs, both neurological & physiological. Separate workplans for orthotics and prosthetics services are in preparation

Assistive technology services are available for people with severe disabilities at Bowley Close

the service is planned & will include demand & capacity management, & redesign services to fit individual needs.

Quality requirement 8: Providing personal care and support

Health & social care services work together to provide care & support to enable people with long term neurological conditions to achieve maximum choice about living independently at home.

Markers of good practice: Health & social services work together

to provide the full range of accommodation, care and support options and facilities to maximise choice

Plans to implement the integratration of Social Work & District Nursing Teams in localities is ongoing for older & vulnerable adults. Proposals include therapists as part of Partnerships for Older People Project (POPPS).

Ongoing integration of adult therapy & SW teams with PD & older people which includes people with LTCs

Care home supp team working with providers and commissioners to drive up quality in care homes

Ongoing integration of health and social care teams across universal & specialist services

Ongoing work to roll out direct payments across all adult care groups.

Externalisation of Aylesbury Day Centre & modernisation of services to adults with LTC

AL

Joint Comm Team

10

Where day or residential care or supported living are provided, they are in suitable settings for people with neurological conditions

Care in all settings is provided by appropriately trained nursing, therapy and care staff with experience in managing long term neurological conditions

Care staff receive support from community rehabilitation and support providers and other specialist neurological, palliative care and rehabilitation services as appropriate

Health & social care services work together to provide programmes of care that help the person to remain as independent as possible as their condition progresses.

People with long term neurological conditions have equitable access to services & are supported by direct payments, fully funded NHS continuing care, adult social care via Fair Access to Care Services scheme based on need, help by Supporting People Programme.

Staff administering assessments are aware of the particular needs of people with neurological conditions.

Health and social care services work in partnership

Teams purchase places in care homes after considering all other options: Social Service indicators demonstrate good performance on care homes placements

Quality requirement 9: Palliative care

People in the later stages of long term neurological conditions are to receive a comprehensive range of palliative care services when they need them to control symptoms; offer pain relief and meet their needs for personal, social, psychological and spiritual support, in line with the principles of palliative care.


Palliative care training is offered to GPs working within the Gold Standard Framework, this will be expanded.

palliative care team is in place offering community support

The PCT is preparing a substantial bid to GSTT Charitable Foundation to scope existing services for non-oncology patients, collect evidence of best practice & explore options for a commissionable service that

Need to agree a review/audit process to assess performance on QR9 robustly

To review Palliative Care for non-cancer patients needs to be a focus in 2006/07.

LTC Steering Group

11

Specialised neurology, rehabilitation, & palliative care MDTs providers work together to provide care for people with advanced long term neurological conditions

Access to specialised and generalised palliative care services which support people in their own home or in a specialised setting according to their choice and needs

Neurologists and neuro-rehabilitation teams are trained in palliative care skills

All staff providing care for people in the advanced stages of neurological illness are trained in both the management of long-term neurological conditions and palliative care.

gives palliative care support in their home or setting of choice

Quality requirement 10: Supporting family and carers

Carers of people with long term neurological conditions are to have access to appropriate support & services that recognise their needs both in their role as carer and in their own right.


Carers are offered a health & social care assessment at diagnosis & all future interactions with information that addresses their needs & offered a written care plan agreed with them.

Carers can choose the extent of their caring role & the kinds of care they provide.

Carers have an allocated contact person.

Carers are treated as partners in care; they are helped to acquire skills to support their caring role, including

Social workers in all settings offer carers assessments, including an allocated contact person

Southwark Carers work with health & social care to offer support to carers, & advocate service improvements

Expert Patient Programme for parents of children with LTCs is being piloted.

A review/audit of compliance with QR10 is needed. Likely to need significant work to ensure compliance. Further work is needed to

ensure assessments are offered consistently & lead to appropriate care plans

A review will identify further ways to support carers

12

moving and handling and use of equipment; they are given opportunity to work in partnership with specialist

rehabilitation and care teams A range of flexible, responsive &

appropriate services is provided for all carers including emergency support, support for high dependency people at short notice, breaks for carers across a range of settings, culturally appropriate support for BME carers.

Carers who need help to adjust to changes especially of a cognitive or behavioural kind have access to support based (where appropriate) on a whole family approach and delivered (where necessary) on a condition specific basis

Carers awareness training for staff; education and training which involves carers in planning and delivery

Quality requirement 11: Caring for people with neurological conditions in hospital or other health and social care settings

People with long-term neurological conditions are to have their specific neurological needs met while receiving care for other reasons in any health or social care setting.


Whenever the person is managed in a general hospital ward or care facility, their neurological care plan is available to all staff and there is close liaison with their usual neurological care team

Arrangements for planned admission establish any special needs including equipment, communication aids and transport;

Protocols for emergency admission

The PCT is implementing ‘Our Health Our Care Our Say ’ & aims to offer patients care in the least intensive setting

PbC will strengthen primary care for LTC patients.

Implementation of RiO will result in care plans being available to approved staff

The commissioning team to work with acute care on the quality of services & reduce admissions. Need to strengthen in-

reach for emergency admissions.

Consider/implement pre-admission interviews with LTC patients, for planned admissions, & effective discharge plans are shared with appropriate community staff, stating equipment needs etc.

Comm team

13

ensure liaison with the persons community care team and any relevant specialist team

Effective consultation with the person and their family/ carers about their management

Specialist neurosciences, rehabilitation and spinal cord injury services are involved in providing training for staff in general hospital and care settings

14

APPENDIX 2LONG TERM CONDITIONS NSF - PROGRESS ON MEETING QUALITY REQUIREMENTS AND SUPPORTING EVIDENCE

Quality Requirement

Description of Quality Requirement Action completed Action Plan Action by/by when

QR1: A Person Centred Service

People with long-term neurological conditions are offered an integrated assessment & planning of their health & social care needs. They have information to make informed decisions about their care & treatment, & where appropriate, to manage their condition themselves.


Timely integrated assessment involving all agencies leading to individual care plans.

A named point of contact for advice & information for all people with long-term conditions.

Case managers for people with complex needs.

Effective transition planning. Information, advice, education &

support. Capacity to respond to rapidly

progressing conditions or changing needs.

* Access to education and self-management programmes tailored to individual needs and conditions.

Action plan in place & good progress towards integrating adult therapy, physical disability social work, & Younger Persons Physical Disability Team(YPDT).

MS Specialist Nurses in place. Clinical specialist neuro OT and Physio

in place in Adult Therapy Team. Neuro specialist Case Managers in

YPD team. The Stroke Modernisation Project

underway to transform the stroke pathway; this will benefit people with all neurological conditions.

Goal setting undertaken with patients & carers in the adult therapy team

Good progress towards better transition planning of people with childhood onset neurological conditions.

An outreach service provides individually tailored support to help people access local community services & promotes inclusion.

To develop a social work role specialising in neuro-disability in the Adult Therapy Team & to develop a panel to make decisions based on robust holistic assessment of people with complex needs to avoid placement & optimise support to live independently in the community.

Identify access to psychology and counselling support.

Improve access to outreach & advocacy services.

Alex Laidler/ Disability and Therapy Executive Group

March 2007/08

Quality Requirement 2: Early recognition, prompt diagnosis and treatment

People suspected of having a neurological condition are to have prompt access to specialist neurological expertise for an accurate diagnosis and treatment as close to home as possible.

Markers of good practice include:

No work undertaken in this area so far. MS Specialist Nurses Team are a

nationally recognised example of good practice

Some local charities employ specialist nurses but with limited capacity e.g. Huntingdon's Disease Association

Undertake audit/review to assess performance particularly in relation to early identification in GP practice/ primary care

LTC Steering Group March 2007/8

15

Improved access to specialist neurological expertise via training, protocols, and guidelines to support early recognition and referral.

Diagnostic services meet NICE guidelines.

Improved access to available treatments including those approved by NICE.

Ongoing specialist neurological advice and treatment.

Improved access to treatment review.

Quality requirement 3: Emergency and acute management

People needing hospital admission for a neurosurgical or neurological emergency are to be assessed & treated in a timely manner by teams with the appropriate neurological & resuscitation skills & facilities.


Compliant with NICE guidelines & nationally agreed standards.

Trained staff, appropriate facilities & protocols in admitting hospitals.

Protocols for head injuries that comply with NICE & national guidelines; protocols for people with head injury in the community not admitted to hospital.

Links/ transfer to specialist centres when necessary

Access to inpatient rehabilitation following discharge form neurosciences centres

No work undertaken in relation to QR3 to date.

Review/ audit of compliance with QR3 needed in collaboration with acute hospitals and London neuroscience centres.

LTC Steering Group

2008/9

16

Quality Requirement

Description of Quality Requirement Action completed Action Plan Action by/by when

Quality Requirement 4: Early and specialist rehabilitation

People with long-term neurological conditions have access to timely, ongoing, high quality rehabilitation services in hospital or other specialist settings. Includes access to timely, ongoing community rehabilitation and support.


Early, high intensity, coordinated rehabilitation from an interdisciplinary team

Seamless transition of care Access to appropriate services for

people with severe and profound disabilities including cognitive and behavioural problems

YPD Case Managers assess neurological patients in hospital & arrange transfer to specialist neuro-rehabilitation facilities where required. Also provide review & re-access to specialist inpatient rehabilitation where necessary

Frank Cooksie Unit provides NHS inpatient rehabilitation for people with a range of neurological conditions

arrangements from adult therapy team to enable seamless transfer & continuous rehabilitation in the community following inpatient care.

Alex Laidler/ Disability and Therapy Executive Group working jointly with Specialist Commissioner

Quality Requirement 5: Community Rehabilitation and Support

People with long-term neurological conditions at home are to have ongoing access to a comprehensive range of rehabilitation, advice & support to meet their continuing & changing needs, increase their independence & autonomy, and help them to live as they wish.


Goal oriented, holistic, individualised programmes of community rehabilitation and support

Integrated community rehab teams with health & social care together & access to specialist neurological expertise

Services provide education, support

Adult Therapy Team uses goal setting with individuals & families/carers.

Planned modernisation of day services for people with physical disabilities will increase support to people in the community & include outreach services.

Open referral/self re-referral for people with neurological conditions needing further rehabilitation by the adult therapy team.

Education group run by Adult Therapy Team for people recently diagnosed with Parkinson's disease.

Develop specialist SW role in adult therapy team.

Explore/identify access to consultant level neuro-rehabilitation expertise for community patients & teams.

Identify access to psychology within the community team

Improve responsiveness of adult therapy team to hospital discharge using service improvement techniques.

Alex Laidler/ Disability and Therapies Executive Group

March 2008

17

well being & psychological adjustments Are proactive to prevent deterioration

in progressive conditions

Quality requirement 6: Vocational rehabilitation

People with long-term neurological conditions are to have access to appropriate vocational assessment, rehabilitation and ongoing support to enable them to find, regain or remain in work and access other occupational and educational opportunities. Vocational rehabilitation must include both local services & more specialised neurological rehabilitation services (i.e. cannot be met by local rehabilitation services alone).


Coordinated multi-agency rehabilitation is provided which takes account of agreed national guidance

Local rehabilitation services address vocational needs & work with other agencies to provide assessment, support on return to work and retaining or leaving work

Referral/access to specialist vocational services for people with neurological conditions who have complex occupational needs (including specialist assessment, counselling, vocational rehabilitation)

OTs in the Adult Therapy Team address vocational needs as part of assessment/ rehabilitation, provide support to return to work/ retain work, in partnership with Disability Employment Advisor & employer

Access to Rehab UK specialist vocational rehabilitation service for people with acquired brain injury via YPD case managers or via therapist/SW referral and spot purchasing agreed by commissioning

Need to strengthen strategic and operational links between commissioners & providers with JobCentre Plus, employers, NHS Plus, independent and voluntary sector organisations.

Lead Commissioner Specialist Services

Quality requirement 7: Providing equipment and accommodation

People with long-term neurological conditions are to receive timely, appropriate assistive technology/ equipment & adaptations to accommodation to support them to live independently, help them with their care; maintain their health and improve their quality of life.

Assistive Technology Team (Bowley Close) provides assessment & prescription for specialist & custom built equipment

Wheelchair service provides special seating to prevent postural deterioration.

Plans to include Bowley Close in the

Clarify funding for provision of specialist assistive technology prescribed by Bowley Close

Roll out Trusted Assessor Training to enable more health & social care staff

Alex Laidler/ Disability and Therapy Executive

March 2008

18


Assistive technology/equipment is provided and maintained in accordance with nationally agreed standards and guidelines.

Access to integrated community and specialist Assistive technology/equipment services which work closely with neurology and rehabilitation services.

Assistive technology needs/equipment needs are documented in a persons integrated care plan.

Specific arrangements for joint funding of specialist Assistive technology provision (e.g. communication aids, electric standing frames, special seating aids for non-wheelchair related use)

Social services work closely with housing/ accommodation and Supporting People services to provide timely, suitably adapted or purpose built accommodation. Not relevant to most LTC patients

development of a 5-10 year rehabilitation strategy for Southwark that will integrate specialist equipment/ technology services with therapy & social care services for people with neurological and physical disabilities.

A housing OT role has been developed which reviews void properties & recommend those suitable for adapting for people with disabilities.

to prescribe basic home equipment from ICES.

Review / streamline the OT support and funding for adaptations in the housing pathway for people with disability

Quality requirement 8: Providing personal care and support

Health & social care services work together to provide care & support to enable people with long term neurological conditions to achieve maximum choice about living independently at home.

Markers of good practice: Health & social services work together

to provide the full range of accommodation, care & support options & facilities to maximise choice

Where day or residential care or supported living are provided, they are

Plans & good progress on integrating therapy, social work, & YPD case managers (see Q.R.'s 1,5,7)

YPD case managers commission long term care for people with neurological conditions & complex care needs including continuing care placements.

YPD case managers & commissioners in LSL work jointly with providers to improve quality & value of placements for people with neurological conditions.

Plans to introduce joint assessment & review by therapy, YPD & SWs

Need to raise SW staff awareness of deteriorating neuro conditions so placement/ care decisions consider ability of provider to detect and respond to change.

Need to review/ assess compliance with best practice on training of care staff.

Alex Laidler/ Disability and Therapies Executive Group

March 2008

19

in suitable settings for people with neurological conditions

Care in all settings is provided by appropriately trained nursing, therapy & care staff with experience in managing long term neurological conditions

Care staff receive support from community rehabilitation & support providers & other specialist neurological, palliative care & rehabilitation services as appropriate

Health & social care services work together to provide programmes of care that help the person to remain as independent as possible as their condition progresses.

People with long term neurological conditions have equitable access to services & are supported by direct payments, fully funded NHS continuing care, adult social care via Fair Access to Care Services scheme based on need, help by Supporting People Programme.

Staff administering assessments are aware of the particular needs of people with neurological conditions.

Work ongoing to promote direct payments. No info at present on uptake by clients with neurological conditions.

Modernisation of Aylesbury Day Services will address these best practice requirements

Quality requirement 9: Palliative care

People in the later stages of long term neurological conditions are to receive a comprehensive range of palliative care services when they need them to control symptoms; offer pain relief and meet their needs for personal, social, psychological and spiritual support, in line with the principles of palliative care.


Specialised neurology, rehabilitation,

Community palliative care team support people with neurological conditions at home during the end of life stage.

Good transfer arrangements between community therapy & YPD teams, & the palliative care team.

Access to hospice care for end of life care where appropriate but no information to comment on whether this is specific to needs of people with neurological conditions.

A review/ audit process is needed to assess QR9 performance robustly

Need to map/review links between adult therapy team & consultant neurologists & ensure good joint working at key stages in palliative stage e.g. introducing ventilation & PEG feeding


March 2008

20

and palliative care MDTs and providers work together to provide care for people with advanced long term neurological conditions

Access to specialised and generalised palliative care services which support people in their own home or in a specialised setting according to their choice and needs

Neurologists and neuro-rehabilitation teams are trained in palliative care skills

All staff providing care for people in the advanced stages of neurological illness are trained in both the management of long-term neurological conditions & palliative care.

Need to ensure Independent Mental Capacity Advocates are involved in supporting key decisions where the person's capacity to consent is limited

Quality requirement 10: Supporting family and carers

Carers of people with long term neurological conditions are to have access to appropriate support & services that recognise their needs both in their role as carer and in their own right.


Carers are offered a health & social care assessment at diagnosis & all future interactions with information that addresses their needs and offered a written care plan agreed with them.

Carers can choose the extent of their caring role & the kinds of care they provide.

Carers have an allocated contact person.

Carers are treated as partners in care; they are helped to acquire skills to support their caring role, including moving & handling & use of equipment; they are given opportunity to work in

Social workers in all settings offer carers assessments.

Adult therapy team involves carers & family members in goal setting & design & delivery of community rehabilitation.

YPD case managers involve, consult & support carers/families as part of the service.

To ensure that carer assessments are offered consistently & lead to appropriate care plans & support

Explore/ identify access to psychology for family work in families where an adult has a severe neurological condition

There is a need to review training to assess best practice standard in relation to carer awareness training.


March 2008

21

partnership with specialist rehabilitation & care teams

A range of flexible, responsive & appropriate services is provided for all carers including emergency support, support for high dependency people at short notice, breaks for carers across a range of settings, culturally appropriate support for BME carers.

Carers who need help to adjust to changes especially of a cognitive or behavioural kind have access to support based (where appropriate) on a whole family approach and delivered (where necessary) on a condition specific basis

Carers awareness training for staff; education & training which involves carers in planning and delivery

Quality requirement 11: Caring for people with neurological conditions in hospital or other health and social care settings

People with long-term neurological conditions are to have their specific neurological needs met while receiving care for other reasons in any health or social care setting.


Whenever the person is managed in a general hospital ward or care facility, their neurological care plan is available to all staff and there is close liaison with their usual neurological care team

Arrangements for planned admission establish any special needs including equipment, communication aids and transport;

Protocols for emergency admission ensure liaison with the persons community care team and any relevant specialist team

No work undertaken on this requirement to date.

Need to agree a review/ audit process to measure performance against QR11, & undertake this with colleagues in acute hospitals & other provider services.

LTC Steering Group

March 2008

22

Effective consultation with the person and their family/ carers about their management

Specialist neurosciences, rehabilitation and spinal cord injury services are involved in providing training for staff in general hospital and care settings

23

Documents

View This Document