Coventry Teaching Primary Care Trust

NHS COVENTRY Business Case Summary Sheet

Section A: For completion by sponsor

Prepared by: Jo Porter and Julie Brotherton Commissioning Andy Bennett Sponsor:

Business Case Summary: Title Improving Access Times for Children’s Occupational Therapy

LDP reference (if 2k (a) and (b) appropriate)* Objectives To address waiting list and pathway development issues in Children’s Occupational Therapy Services.

The proposal is for a waiting list initiative approach in the first instance to address individual patient needs and undertake “live analysis” of how best to meet underlying future demographic needs for children and young people.

Costs (fye) Recurring £ Non Recurring £

£130k rec

* If not leave blank for office to insert unique ID on receipt

Section B: Office use only for Business Case Sub Committee

Business Case Officer Group Review Date:

Business Case Officer Group Comments:

Recommendation(s) to Business Case Sub-Committee: COVENTRY TEACHING PRIMARY CARE TRUST

BUSINESS CASE SUBMISSION – MINI BUSINESS CASE

PROFORMA 2

Title: Improving Access Times for Children’s Occupation Therapy

Submitted by: Jo Porter and Julie Brotherton

On Behalf of: Children & Young People’s Occupational Therapy – Waiting List Initiative

Date: October 2008

1. EXECUTIVE SUMMARY

This business case is directly linked to a proposed redesign of the Children and Young People’s Occupational Therapy (OT) Service which operates across the following patient pathways:

1. Mainstream schools 2. Early Years 3. Services for children with Learning Disabilities 4. Services for children with Physical Disabilities 5. Upper limb splinting services

This LDP business case is in response to a detailed clinical capacity audit and options appraisal. This proposal is to enable a reduction of current waiting times, and, where applicable, meet the 18 week target. This case addresses the requirement to improve both assessment and treatment times within the Children’s OT service.

This business case requests the provision of additional posts and associated costs in order to provide a thorough “waiting list initiative”. Investment is required both to clear the initial backlog of assessments and then to follow through longer term in meeting the ongoing service needs of relevant children.

Given this proposal is being made in-year and there are realistic start-up time implications, this proposal is intended to give a pragmatic interim solution whilst continuing to work up in more detail the final business case in addressing the full capacity issues1.

1 This case is presented against line 2k “OT 18 wks” in application for LDP monies £130k for 08/09 and a further £80k for 09/10 and 2010/11. It is expected that there will be substantial slippage against the 08/09 monies – especially if an interim position is not approved shortly. 2. THE CASE FOR CHANGE

2.1 Strategic Context

This proposal is directly linked to current LDP priorities for the improvement in access time for children’s’ OT and achievement of the 18 week target.

2.2 Current Provision

Occupational therapy services for children and young people in Coventry provide a family centred service which aims to manage or prevent occupational needs resulting from physical, psychosocial and/or learning disability, prematurity or ill health. It aims to promote optimal independence and achievement of potential.

Model of Service Provision The service is divided in to 5 clinical teams based on common diagnoses / areas of occupational performance difficulty. Division into these teams enables an equitable and quality service to groups of families with common difficulties, facilitates specialist service provision and to utilises resources in terms of work load management. These teams are:  Mainstream schools  Early Years  Services for children with Learning Disabilities  Services for children with Physical Disabilities  Upper limb splinting services

Location: Central base at Coventry and Warwickshire Hospital with office and clinical facilities. The team predominantly delivers services out in a variety of community settings i.e. client’s homes and schools.

Current Staffing: The team consists of 12.9 WTE qualified clinical staff, 2.85 WTE unqualified clinical staff, and 1.00 WTE Administration and Clerical staff.

Areas for Service Performance

Best practice is achieved by the following mechanisms:  Use of an evidence based profession specific model, assessment and intervention tools (MOHO)  User involvement  Clearly defined clinical pathways with replicable outcome measures  Use of standardised and OT specific assessments  Use of collaborative goal setting  An established evidence base for all aspects of intervention  Established staff development and training program  Input into current multidisciplinary assessment and intervention forums  Links / to regional and national specialist groups  Regular presenting slots and attendance at relevant national conferences Service Outcomes are measured by the following mechanisms.  Standardised assessment outcomes  SMART goal outcomes  Parental / child feed back  Clinical observations  Standard report format  Audit  Lorenzo

User involvement is achieved by the following mechanisms.  Collaborative goal setting with families  Drop in clinics  Use of standardised assessment which ask for users priorities  User feedback on groups  User feedback on documentation  Parents forum  Helpline for informal discussion / problem solving

Service Strengths: - Organisation into specialist clinical teams to enable best use of resources and clinical excellence through concentrated provision - Areas of best practice in accordance with guidelines provided by the College of Occupational Therapists, research, expert opinion and benchmarking. - High demand for services - Positive service user feedback - Positive clinical outcomes based on goal setting

Areas of Service Under Performance

The following areas of the service have been defined as being a weakness: - An average waiting time of 8 months. While these waits are in various clinical pathways are as follows (see table below for approximate figures):

Teams Shortest Wait Longest Wait Average Wait Mainstream 4 months 13 months 9 months Early Years 5 months 6 months 5 months Physical Disabilities 4 months 11 months 8 months Learning Disabilities 4 months 18 months 9 months

- With the current service set-up and staffing complement it is anticipated that (where applicable) this service will be unable to delivery the 18 week target aspirations which are likely to include the majority of the community based services in the future.

- Complaints from patients have also demonstrated dissatisfaction with current waiting times.

- Some areas have identified poor performance against best practice guidelines for levels of service delivery 2.3 Drivers for Change/Case for Change

- Poor performance against targets for waiting times to access the service. - Poor performance against best practice guidelines for levels of service delivery for specific groups (qualitative aspects) - Poor patient satisfaction with waiting times (demonstrated by complaints)

2.4 Overall Aim and specific Objectives

Aim: - To improve access to service - To continue to improve the quality of the service delivery and the well-being of Coventry children.

2.5 Proposed Future Service Model

We would recommend partial investment according to the interim plan laid out in Section 4. which would partial investment via a waiting list initiative for the short term. A further evaluation must then take place and agreement with the commissioner as to the longer term capacity needs of the service.

3. OPTION APPRAISAL

3.1 Options Considered

A summary of the options available to address the service weakness are shown below.

Option 1: Do nothing No investment would be made in additional resources and no change made to current service specification.

Option 2: No investment No investment would be made in additional resources. Major revision of current service specification in order improve waiting times and stabilise internal caseloads. This would be achieved by service curtailment for initially 6 month in the following areas to establish impact:  Cease input into MDT assessment forum of CDU (under current CDU system)  Cease post botox splinting provision  No acceptance of all low level referrals  Cease provision of all maintenance and repairs to home and school equipment  Refer all home based equipment need to social care OT department  Provide baseline package of input to all schools (with option to purchase extended packages)

Option 3: Partial Investment (preferred – see Section 4 for detail of proposal)  Department could meet modified service specification with limited investment  Moderate reduction in service’s available resulting in overall quality practice, with best practice services delivered to a limited population  Clear the backlog of assessments by August 2009  To reduce the waiting time for assessments to 2 months (high priority), 4 months (medium priority) and 6 months (low priority)  To analyse longer-term “equilibrium” service against clinical need.

3.2 Evaluation of Options An objective analysis of the strengths and weaknesses of each option.

Option Option Option Benefit Criteria 1 2 3 Do Nothing no investment, partial investment= major significant modification to service modification to specification with some service service cessation specification with significant service cessation Patient Access Targeted referral Targeted referral Targeted referral system system for all system for for moderately reduced significantly limited population population 2 2 5 Referral to Current wait of Will reduce to Will reduce to meet 18 treatment time approximately 10 meet 18 week week target months expected to target increase due to accommodation of current caseloads and projected annual increase of 20% 3 5 5 Quality of Current service Acceptable for Quality for majority, best service offered (Quality for majority, quality for practice for minority majority, best minority practice for minority) expected to diminish due to increased population accessing service. Anticipated increased areas of risk 3 4 3 Compliance with *Does not comply *Complies with *Complies with guidance best practice with guidance to guidance to to eliminate risk guidelines (e.g. eliminate risk to eliminate risk *Complies with all CYP&F, COT, large number due *Complies with guidance regarding quality NSF) to waiting time (this limited guidance practice number will regarding quality * Complies with some increase) practice guidance regarding best *Complies with all *Will not comply practice guidance regarding with guidance quality practice regarding best * Complies with practice most guidance regarding best 4 practice ***Except on waiting times 3 3 Ease of No difficulties Moderate Moderate difficulties implementation anticipated with difficulties with associated with implementation implementation recruitment, except negative around reorganisation of existing impact when negotiation/ resources and informing staff and informing from measurement processes families (therefore stakeholders and of limited value in implementation of the long term) a withdrawal and complaint 4 management process 2 4 Overall Benefit Scores 16 17 19 Ranking 3 2 1

3.3 Preferred Option

Order of preference 1. Option 3 – partial investment 2. Option 2 – no investment 3. Option 1 – do nothing

This case recognises the need to take a pragmatic, first phase step, hence a partial investment (a waiting list initiative as described now in Section 4) prior to a more comprehensive evaluation and business case approval.

4. DESCRIPTION OF PREFERRED OPTION

Option 4 – partial investment

**DESCRIPTION OF PREFERRED OPTION**

Waiting list initiative (1st phase) (Recruitment of two Band 6 OT’s and procurement of additional staff hours and temporary staff where available)

Current Patient Activity Levels:

- Number of children currently on the waiting list = 125 - Longest wait for assessment = 12 months - Current average wait for an assessment = 5 months (high priority), 6 months (medium priority), 8 months (low priority) - Current average number of referrals pa = 312 - Current average number of assessments completed pa = 276 - Total active patients on existing caseloads = 795

Projected Patient Activity Levels:

Based upon the employment of additional temporary staffing (mix of locum staffing and additional hours), the following could be reliably achieved:

- Based upon a static referral rate pa = 312 - Projected number of assessments for to clear current waiting list backlog and respond to new referrals received 2009 = 437 - Projected number of active patients on caseloads by end of 2009 = 795 + 437 = 1232 - 1232 – 386 (annual discharges) = 846

Therefore resulting in an additional 51 cases in total.

1. Clear the backlog of assessments by August 2009. 2. Reduce the waiting time for assessments to 2 months (high priority), 4 months (medium priority) and 6 months (low priority)

These figures do not take into account the impact of urgent complex care referrals and the impact that this has on waiting lists and current caseloads. The impact of separate investment for children with complex care needs should serve to improve the situation further; however it is important to note that this bid incorporates elements of service development that will generate additional referrals. 4.1 Patient Pathway

Clinical pathways for all 5 service elements (provided under current service specification) are available. The pathways cover:

1. Mainstream schools 2. Early Years 3. Services for children with Learning Disabilities 4. Services for children with Physical Disabilities 5. Upper limb splinting services

Clinical pathways would require modification depending on option chosen.

4.2 Stakeholder Support

For the purposes of this proposal, we have not held any specific stakeholder consultation as improvement in access time and movement towards 18 wks RTT is a government directive for all services.

However our main areas of complaint are regarding waiting times; these are both formal and informal complaints – hence stakeholder engagement but from a negative perspective.

We have also received informal feedback from education regarding the practicality and usefulness of OT, and also that the services are perceived as scarce.

4.3 Workforce Implications

A varied skill mix would make the best use of resources available; this mix would depend upon the number of posts available. The skill mix would include both qualified members of staff requiring Health Professions Council registration (bands 5 – 7) and unqualified staff (bands 3 – 4).

All staff would require some additional training in accordance with the departmental training grid. This is linked to acquirement of internal competencies and KSF outlines. Both the departmental training grid and the KSF’s will include skills update plans.

Supervision will be provided in accordance with the departmental structure (based on College of Occupational Therapy guidance).

4.4 Accommodation Requirements

In line with waiting list initiative approach (see section 4.). No substantial additional accommodation requirements.

4.5 Implications for Other Providers

There is no anticipated de-stabilisation, increase of demand or negative impacts to other services. 4.6 Implementation Plan

Please see waiting list initiative information.

4.7 Management Capacity There are anticipated time and resource costs primarily to principal OT.

Principal OT – - modification of service specification - lead in recruitment of qualified staff - support in recruitment of unqualified staff - re-organisation of staffing resources - oversee implementation of training and support mechanisms - roll out of change to other services / agencies - oversee organisation of resource procurement

Head of Child & Family Health - - guidance regarding modification of service specification - present service specification to commissioners - support roll out of changes to other services / agencies

Team leads - - support in recruitment of senior staff - lead in recruitment of support staff - support in providing training and support mechanisms

4.8 Expected Benefits

Objective Expected Outcome Indicator Improvement in access 1. Clear the backlog Departmental data base time for patients to be of assessments by assessed and treated. August 2009 2. To reduce the waiting time for assessments to 2 months (high priority), 4 months (medium priority).

4.9 Proposed Procurement Route/Contract Type Employment by PCT and procument of additional staffing hours where suitable and available. 4.10 Equality Impact Assessment

Option Affect Option 1 – do nothing whole population will be disadvantaged due to long and increasing wait

Option 2 – no investment Significant areas of population disadvantaged due to specified factor e.g. risk, location, age, diagnosis Options 3 – waiting list initiative Waiting list issues addressed in short/medium term and analysis about longer-term implications.

5. FINANCIAL EVALUATION OF PREFERRED OPTION

5.1 Operating Costs

Preferred option is number 3 above – waiting list initiative.

The cost for a waiting list initiative via additional staff hours and locum staffing would be:

Pay cost at Band 6 level for 150 additional hrs per week @ at a cost of approx £18/hr, up to a maximum 12 month period (estimated 48 weeks)

Total proposed costs = £130,000 (LDP bid value)

5.2 Funding of Capital Costs N/A

5.3 Funding of Start Up Costs

N.B. It is anticipated that the time lapse between provision of funding and successful recruitment will have accrued monies to facilitate non re-occurring start up costs.

[N.B. the section on sensitivity analysis and impact on activity / costs has not been completed at this level of business case request.] 6. EVALUATION

6.1 Performance Reporting to PCT

Requirement How met Minimum Data Set Reported via Lorenzo and departmental data base Waiting times – referral to first From existing departmental data base reported to contact head of child and family health Waiting times – referral to From existing departmental data base reported to treatment head of child and family health

6.2 Clinical Quality

1. Audit to demonstrate achievement of 18 week wait 2. Best practice is achieved by the following mechanisms:  Use of an evidence based profession specific model, assessment and intervention tools (MOHO)  User involvement  Clearly defined clinical pathways with replicable outcome measures  Use of standardised and OT specific assessments  Use of collaborative goal setting  An established evidence base for all aspects of intervention  Established staff development and training program  Input into current multidisciplinary assessment and intervention forums  Links / to regional and national specialist groups  Regular presenting slots and attendance at relevant national conferences

3. Service Outcomes are measured by the following mechanisms.  Standardised assessment outcomes  SMART goal outcomes  Parental / child feed back  Clinical observations  Standard report format  Audit  Lorenzo

4. User involvement is achieved by the following mechanisms.  Collaborative goal setting with families  Drop in clinics  Use of standardised assessment which ask for users priorities  User feedback on groups  User feedback on documentation  Parents forum  Helpline for informal discussion / problem solving

6.3 Patient Satisfaction - modification of existing feedback form - reduction in complaints (informal and formal) related to waiting times to access service - complaints will continue to be dealt with in accordance with the PCT’s policy 6.4 Achievement of Objectives - Audit from information gained from existing departmental data base

7. RISK ANALYSIS / CONTINGENCY PLAN Please see completed risk template - Appendix 2.

8. EXIT STRATEGY

This proposal is regarding the development of existing resources to improve the waiting times under current service specification. Therefore, the non-approval of funding for these additional posts would necessitate a service re-design in accordance with commissioning intentions or the continuation of highly unsatisfactory waiting times. The implications of further re-design upon patients and staff would depend upon the level of re-design required. It is however anticipated that a further re-design would diminish confidence in the service. The risks surrounding the “exiting” from a waiting list initiative are not material. Appendix 1 - Provisional implementation plan

BUSINESS CASE:

PROVISIONAL IMPLEMENTATION PLAN

TARGET KEY MILESTONE LEAD COMPLETION MEASURE OF DATE SUCCESS

Recruitment adverts in place Principal OT Within one month of Adverts in place monies being allocated (November anticipated) Staff recruited to department Principal OT Within 2 – 3 months of Additional staff within (two band 6’s) and advert being out department procurement of additional hours / temporary staffing hours. Achieve internal stabilisation Principal OT Within 3 months of new Waiting list reduced. of caseloads, waiting list staff starting AND/OR Case load monitoring initiative work underway, and within 3 months of forms demonstrate analysis of caseload. alterations to service stability. specification being agreed - Clear the backlog of Principal OT August 2009 Additional staff within assessments by August 2009 department; service specification evaluated. - To reduce the waiting time Case load monitoring for assessments to 2 months forms demonstrate (high priority), 4 months stability (medium priority) and 6 months (low priority)

Evaluation of Phase 2 service Asst. July 2009 Phase 2 plan and redesign and full evaluation of Director for capacity audit capacity issues Clinical completed and agreed. Service Redesign Appendix 2 – Initial risk matrix

BUSINESS CASE:

RISK IDENTIFIED LIKELIHOOD MITIGATING ACTION LEAD (H/L/M) Failure to recruit key staff Medium - use of development posts for existing Principal OT experienced band 6’s within the department - links with university to create joint posts such as lecturer / practitioner and researcher / practitioner - use of annualised hours to attract term time only posts to school based elements of service Higher than anticipated Low to medium - annual review of service specification Principal OT in demand for service - modification of service delivery pathways in line conjunction with Head with evidence based practice and current of Child & Family guidelines Health and - further roll out of current consultation model commissioners Unplanned absence of key Low to medium - current system of teams leads under principal OT Principal OT with staff enables understanding of key tasks and support from Head of opportunity for delegation to more than one Child & Family Health experienced OT