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  1. 1. 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 health inequalities for all. 1
  2. 2. Southwark Primary Care Trust Review of Progress in Implementing the National Service Framework for Long Term Conditions Briefing for PCT Board About the Long term Conditions National Service Framework Introduction The 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
  3. 3. • 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 assessment The 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
  4. 4. 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 appendices Appendix 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 Group Appendix 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
  5. 5. 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
  6. 6. APPENDIX 1 LONG TERM CONDITIONS NSF - PROGRESS ON MEETING QUALITY REQUIREMENTS AND SUPPORTING EVIDENCE Quality Description of Quality Requirement Action completed on-neurological long Action plan Action by/ Requirement term conditions by when QR1: A Person People with long-term neurological The work has focused on developing the role • A nursing review is LTC Centred Service conditions are offered an integrated of Community Matrons (CMs) in each locality. underway to embed Steering assessment & planning of their health & This will provide: CMs into District Nursing Group social care needs. They have information • person centred care teams. The review will to make informed decisions about their • Timely assessment & a care plan also deliver case care & treatment, and where appropriate, involving relevant agencies with a named management training to to manage their condition themselves. contact Band 5 community • Link patients to appropriate agencies e.g. nurses to address LTC Markers of good practice: Social Services, specialist AHP teams, patient needs. CMHTs & plan patients' transition • The Kings Fund PARR • Timely integrated assessment through the health & social care system tool will be used to involving all agencies leading to • Provide information, advice, education & identify patients at risk of individual care plans. support future hospital • A named point of contact for advice • Proactive response to changing disease attendances. This & information for all people with status & social circumstances information will be long-term conditions. • Refer to self management programmes complemented by GP AL • Case managers for people with (generic e.g. Expert Patient Programme); referrals to CMs complex needs. disease specific: diabetes structured • the Bowley Close • Effective transition planning. education e.g. DAPHNE; COPD service needs to comply • Information, advice, education & Pulmonary Rehab; heart failure & CHD with Choose & Book via support. Heart Active implementation of RiO • Capacity to respond to rapidly • Patients with LTCs are given information progressing conditions or changing about options available to them by their needs. GP and via Choose & Book at GP • * Access to education and self- surgeries. management programmes tailored • Care offered to LTC patients is delivered to individual needs and conditions. by appropriately trained staff with support from specialist clinicians where appropriate. 6
  7. 7. Quality People suspected of having a • Training is being delivered to front-line The next stage is to develop LTC Requirement 2: neurological condition are to have prompt staff to support prompt diagnosis. diagnostic services in primary steering Early access to specialist neurological • The Hypertension Toolkit will be piloted care for an expanded range recognition, expertise for an accurate diagnosis and in Peckham & Camberwell locality, & of long term conditions prompt treatment as close to home as possible. will raise awareness address under- diagnosis and diagnosis treatment Markers of good practice include: • Some practices offer diabetes diagnosis but needs to be expanded across the • Improved access to specialist PCT. Pockets of good practice reduce neurological expertise via training, test duplication for diabetes patients protocols, and guidelines to support • The development of primary care early recognition and referral. diagnostics services for heart failure & • Diagnostic services meet NICE COPD and access to spirometry & BNP guidelines. as recommended by NICE • Improved access to available • Rapid Access Clinic for diabetes treatments including those approved patients to offer primary care clinicians by NICE. access to specialist opinion. • Ongoing specialist neurological advice and treatment. • Improved access to treatment review. Quality People needing hospital admission for a No action yet taken. Review/ audit of compliance requirement 3: neurosurgical or neurological emergency with QR3 needed in Emergency and are to be assessed and treated in a timely collaboration with acute acute manner by teams with the appropriate hospital trusts. management neurological & resuscitation skills & facilities. The Head of Intermediate Care & Hosp Discharge is Markers of good practice: working with community nursing & A&E colleagues to • Compliant with NICE guidelines & develop systems to avoid nationally agreed standards. unnecessary hospital • Trained staff, appropriate facilities & admission for people with protocols in admitting hospitals. LTCs • Protocols for head injuries that comply with NICE and national guidelines; protocols for people with 7
  8. 8. 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 Quality People with long-term neurological So far the focus has been on respiratory The scope of the work needs Requirement 4: conditions have access to timely, patients, and patients recovering from to be expanded to cover all Early and ongoing, high quality rehabilitation Myocardial Infarction. Need to consider LTCs specialist services in hospital or other specialist needs of people with other LTCs rehabilitation settings. Includes access to timely, • Pulmonary Rehabilitation offers a multi- ongoing community rehabilitation and disciplinary co-ordinated, stratified support. programme according to patient need. Patients are referred early in their Markers of best practice: disease pathway. The service is located at 2 sites across the PCT. • Early, high intensity, coordinated • Patients with breathlessness affecting rehabilitation from an functioning are offered PR, preferably interdisciplinary team before hospital admission. (See also • Seamless transition of care QR5) • Access to appropriate services for people with severe and profound disabilities including cognitive and behavioural problems Quality People with long-term neurological Goal-based programmes for patients with • Review ref to Pulmonary Requirement 5: conditions at home are to have ongoing pulmonary or heart conditions rehabilitation services are Community access to a comprehensive range of • Community-based pulmonary fragmented with Rehabilitation rehabilitation, advice & support to meet rehabilitation by a multi-agency team for complicated referral and Support their continuing and changing needs, patients with respiratory problems, routes increase their independence and including COPD; and Heart Active for • Project Group recently autonomy, & help them to live as they post-MI patients. established to review wish. • Heart Active available as Phase IV rehab care and support for programme for post-MI patients by people living with HIV to Markers of good practice: appropriately trained fitness trainers. ensure modern, responsive services & • Goal oriented, holistic, individualised strategic commissioning programmes of community across children's & adult rehabilitation and support services (health and 8
  9. 9. • Integrated community rehab teams social care, and with health and social care together supporting people). and access to specialist neurological expertise • Services provide education, support well being and psychological adjustments • Are proactive to prevent deterioration in progressive conditions Quality People with long-term neurological • Many adults with learning disabilities have Vocational support is likely to requirement 6: conditions are to have access to a LTC. Currently there is vocational be needed & is often over- Vocational appropriate vocational assessment, support commissioned by the LD Pooled looked for people living with rehabilitation rehabilitation & ongoing support to enable Budget. There is an opportunity to use sensory impairment, HIV, & them to find, regain or remain in work & this model to inform developments for all long-term musculo-skeletal access other occupational & educational adults with LTC. conditions, & other long-term opportunities. Vocational rehabilitation • EPP offered to patients via Job Centre conditions (e.g. M.E., sickle must include both local services &more Plus cell, long term mental health specialised neurological rehabilitation • Southworks is a county-run service for a conditions). A review/audit services (i.e. cannot be met by local wide range of adults, and is available to process is needed to assess rehabilitation services alone). people with a LTC QR6 robustly Markers of best practice: There is a need to raise awareness of the issues • Coordinated multi-agency affecting people with LTCs, rehabilitation is provided which takes particularly in primary care account of agreed national guidance and hospital settings • 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) 9
  10. 10. Quality People with long-term neurological • An integrated community equipment Need to review: requirement 7: conditions are to receive timely, service (ICES) is in place. • the provision of AL Providing appropriate assistive technology/ • tele-healthcare to LTC patients is in equipment by ICES & equipment and equipment and adaptations to progress with roll out pending further Bowley Close to reduce accommodation accommodation to support them to live funding duplication AL independently, help them with their care; • The Audit Commission’s review of • waiting times, and maintain their health and improve their wheelchair & seating service in 2005 has access to indoor/outdoor quality of life. formed the basis of a workplan for power-chairs . Bowley Close, which provides specialist Modernisation of the Markers of best practice: equipment to LSL & other commissioning service is planned & will PCTs in the London area & nationally. include demand & • Assistive technology/equipment is Most people using these services have capacity management, & provided and maintained in LTCs, both neurological & physiological. redesign services to fit accordance with nationally agreed Separate workplans for orthotics and individual needs. standards and guidelines. prosthetics services are in preparation • Access to integrated community and • Assistive technology services are specialist Assistive available for people with severe technology/equipment services disabilities at Bowley Close 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 Quality Health & social care services work • Plans to implement the integratration of • Ongoing integration of AL requirement 8: together to provide care & support to Social Work & District Nursing Teams in health and social care Providing enable people with long term neurological localities is ongoing for older & teams across universal personal care conditions to achieve maximum choice vulnerable adults. Proposals include & specialist services 10
  11. 11. and support about living independently at home. therapists as part of Partnerships for • Ongoing work to roll out Older People Project (POPPS). direct payments across Markers of good practice: • Ongoing integration of adult therapy & all adult care groups. • Health & social services work SW teams with PD & older people which • Externalisation of Joint together to provide the full range of includes people with LTCs Aylesbury Day Centre & Comm accommodation, care and support • Care home supp team working with modernisation of Team options and facilities to maximise providers and commissioners to drive up services to adults with choice quality in care homes LTC • Where day or residential care or • Health and social care services work in supported living are provided, they partnership are in suitable settings for people • Teams purchase places in care homes with neurological conditions after considering all other options: Social • Care in all settings is provided by Service indicators demonstrate good appropriately trained nursing, performance on care homes placements 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. Quality People in the later stages of long term • Palliative care training is offered to GPs Need to agree a review/audit LTC 11
  12. 12. requirement 9: neurological conditions are to receive a working within the Gold Standard process to assess Steering Palliative care comprehensive range of palliative care Framework, this will be expanded. performance on QR9 robustly Group services when they need them to control • palliative care team is in place offering symptoms; offer pain relief and meet their community support • To review Palliative Care needs for personal, social, psychological • The PCT is preparing a substantial bid to for non-cancer patients and spiritual support, in line with the GSTT Charitable Foundation to scope needs to be a focus in principles of palliative care. existing services for non-oncology 2006/07. patients, collect evidence of best practice Markers of best practice: & explore options for a commissionable service that gives palliative care support • Specialised neurology, rehabilitation, in their home or setting of choice & 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. Quality Carers of people with long term • Social workers in all settings offer carers A review/audit of compliance requirement 10: neurological conditions are to have assessments, including an allocated with QR10 is needed. Likely Supporting access to appropriate support & services contact person to need significant work to family and that recognise their needs both in their • Southwark Carers work with health & ensure compliance. carers role as carer and in their own right. social care to offer support to carers, & • Further work is needed to advocate service improvements ensure assessments are Markers of best practice: • Expert Patient Programme for parents of offered consistently & children with LTCs is being piloted. lead to appropriate care • Carers are offered a health & social plans care assessment at diagnosis & all • A review will identify future interactions with information further ways to support 12
  13. 13. that addresses their needs & offered carers 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 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 People with long-term neurological • The PCT is implementing ‘Our Health The commissioning team to requirement 11: conditions are to have their specific Our Care Our Say ’ & aims to offer work with acute care on the Comm Caring for neurological needs met while receiving patients care in the least intensive setting quality of services & reduce team people with care for other reasons in any health or • PbC will strengthen primary care for LTC admissions. 13
  14. 14. neurological social care setting. patients. • Need to strengthen in- conditions in • Implementation of RiO will result in care reach for emergency hospital or Markers of best practice: plans being available to approved staff admissions. other health • Consider/implement pre- and social care • Whenever the person is managed in admission interviews settings a general hospital ward or care with LTC patients, for facility, their neurological care plan planned admissions, & is available to all staff and there is effective discharge plans close liaison with their usual are shared with neurological care team appropriate community • Arrangements for planned staff, stating equipment admission establish any special needs etc. needs including equipment, communication aids and transport; • Protocols for emergency admission 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
  15. 15. APPENDIX 2 LONG TERM CONDITIONS NSF - PROGRESS ON MEETING QUALITY REQUIREMENTS AND SUPPORTING EVIDENCE Quality Description of Quality Requirement Action completed Action Plan Action by/by Requirement when QR1: A Person People with long-term neurological • Action plan in place & good progress • To develop a social Alex Laidler/ Centred Service conditions are offered an integrated towards integrating adult therapy, work role specialising in Disability and assessment & planning of their health & physical disability social work, & neuro-disability in the Therapy social care needs. They have information Younger Persons Physical Disability Adult Therapy Team & Executive to make informed decisions about their Team(YPDT). to develop a panel to Group care & treatment, & where appropriate, to • MS Specialist Nurses in place. make decisions based manage their condition themselves. • Clinical specialist neuro OT and on robust holistic March Physio in place in Adult Therapy assessment of people 2007/08 Markers of good practice: Team. with complex needs to • Neuro specialist Case Managers in avoid placement & • Timely integrated assessment YPD team. optimise support to live involving all agencies leading to • The Stroke Modernisation Project independently in the individual care plans. underway to transform the stroke community. • A named point of contact for advice pathway; this will benefit people with • Identify access to & information for all people with long- all neurological conditions. psychology and term conditions. • Goal setting undertaken with patients counselling support. • Case managers for people with & carers in the adult therapy team • Improve access to complex needs. • Good progress towards better outreach & advocacy • Effective transition planning. transition planning of people with services. • Information, advice, education & childhood onset neurological support. conditions. • Capacity to respond to rapidly • An outreach service provides progressing conditions or changing individually tailored support to help needs. people access local community • * Access to education and self- services & promotes inclusion. management programmes tailored to individual needs and conditions. Quality People suspected of having a • No work undertaken in this area so • Undertake audit/review to LTC Steering Requirement 2: neurological condition are to have prompt far. assess performance Group Early recognition, access to specialist neurological expertise • MS Specialist Nurses Team are a particularly in relation to March 2007/8 prompt diagnosis for an accurate diagnosis and treatment nationally recognised example of early identification in GP and treatment as close to home as possible. good practice practice/ primary care • Some local charities employ 15
  16. 16. Markers of good practice include: specialist nurses but with limited capacity e.g. Huntingdon's Disease • Improved access to specialist Association 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 People needing hospital admission for a No work undertaken in relation to QR3 to Review/ audit of compliance LTC Steering requirement 3: neurosurgical or neurological emergency date. with QR3 needed in Group Emergency and are to be assessed & treated in a timely collaboration with acute acute manner by teams with the appropriate hospitals and London 2008/9 management neurological & resuscitation skills & neuroscience centres. facilities. Markers of good practice: • 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 16
  17. 17. Quality Description of Quality Requirement Action completed Action Plan Action by/by Requirement when Quality People with long-term neurological • YPD Case Managers assess • arrangements from Alex Laidler/ Requirement 4: conditions have access to timely, neurological patients in hospital & adult therapy team to Disability and Early and ongoing, high quality rehabilitation arrange transfer to specialist neuro- enable seamless Therapy specialist services in hospital or other specialist rehabilitation facilities where transfer & continuous Executive rehabilitation settings. Includes access to timely, required. Also provide review & re- rehabilitation in the Group ongoing community rehabilitation and access to specialist inpatient community following working jointly support. rehabilitation where necessary inpatient care. with Specialist • Frank Cooksie Unit provides NHS Commissioner Markers of best practice: inpatient rehabilitation for people with a range of neurological conditions • 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 Quality People with long-term neurological • Adult Therapy Team uses goal • Develop specialist SW Alex Laidler/ Requirement 5: conditions at home are to have ongoing setting with individuals & role in adult therapy Disability and Community access to a comprehensive range of families/carers. team. Therapies Rehabilitation rehabilitation, advice & support to meet • Planned modernisation of day • Explore/identify access Executive and Support their continuing & changing needs, services for people with physical to consultant level Group increase their independence & autonomy, disabilities will increase support to neuro-rehabilitation and help them to live as they wish. people in the community & include expertise for community March 2008 outreach services. patients & teams. Markers of good practice: • Open referral/self re-referral for • Identify access to people with neurological conditions psychology within the • Goal oriented, holistic, individualised needing further rehabilitation by the community team programmes of community adult therapy team. • Improve responsiveness rehabilitation and support • Education group run by Adult of adult therapy team to • Integrated community rehab teams Therapy Team for people recently hospital discharge using with health & social care together & diagnosed with Parkinson's disease. service improvement access to specialist neurological techniques. expertise • Services provide education, support 17
  18. 18. well being & psychological adjustments • Are proactive to prevent deterioration in progressive conditions Quality People with long-term neurological • OTs in the Adult Therapy Team • Need to strengthen Lead requirement 6: conditions are to have access to address vocational needs as part of strategic and Commissioner Vocational appropriate vocational assessment, assessment/ rehabilitation, provide operational links Specialist rehabilitation rehabilitation and ongoing support to support to return to work/ retain between commissioners Services enable them to find, regain or remain in work, in partnership with Disability & providers with work and access other occupational and Employment Advisor & employer JobCentre Plus, educational opportunities. Vocational • Access to Rehab UK specialist employers, NHS Plus, rehabilitation must include both local vocational rehabilitation service for independent and services & more specialised neurological people with acquired brain injury via voluntary sector rehabilitation services (i.e. cannot be met YPD case managers or via therapist/ organisations. by local rehabilitation services alone). SW referral and spot purchasing agreed by commissioning Markers of best practice: • 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) Quality People with long-term neurological • Assistive Technology Team (Bowley • Clarify funding for Alex Laidler/ requirement 7: conditions are to receive timely, Close) provides assessment & provision of specialist Disability and Providing appropriate assistive technology/ prescription for specialist & custom assistive technology Therapy equipment and equipment & adaptations to built equipment prescribed by Bowley Executive accommodation accommodation to support them to live • Wheelchair service provides special Close independently, help them with their care; seating to prevent postural • Roll out Trusted March 2008 18
  19. 19. maintain their health and improve their deterioration. Assessor Training to quality of life. • Plans to include Bowley Close in the enable more health & development of a 5-10 year social care staff to Markers of best practice: rehabilitation strategy for Southwark prescribe basic home that will integrate specialist equipment from ICES. • Assistive technology/equipment is equipment/ technology services with • Review / streamline the provided and maintained in therapy & social care services for OT support and funding accordance with nationally agreed people with neurological and for adaptations in the standards and guidelines. physical disabilities. housing pathway for • Access to integrated community and • A housing OT role has been people with disability specialist Assistive developed which reviews void technology/equipment services properties & recommend those which work closely with neurology suitable for adapting for people with and rehabilitation services. disabilities. • 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 Quality Health & social care services work • Plans & good progress on integrating • Need to raise SW staff Alex Laidler/ requirement 8: together to provide care & support to therapy, social work, & YPD case awareness of Disability and Providing enable people with long term neurological managers (see Q.R.'s 1,5,7) deteriorating neuro Therapies personal care conditions to achieve maximum choice • YPD case managers commission conditions so Executive and support about living independently at home. long term care for people with placement/ care Group neurological conditions & complex decisions consider Markers of good practice: care needs including continuing care ability of provider to March 2008 • Health & social services work placements. detect and respond to together to provide the full range of • YPD case managers & change. accommodation, care & support commissioners in LSL work jointly • Need to review/ assess 19
  20. 20. options & facilities to maximise with providers to improve quality & compliance with best choice value of placements for people with practice on training of • Where day or residential care or neurological conditions. care staff. supported living are provided, they • Plans to introduce joint assessment are in suitable settings for people & review by therapy, YPD & SWs with neurological conditions • Work ongoing to promote direct • Care in all settings is provided by payments. No info at present on appropriately trained nursing, uptake by clients with neurological therapy & care staff with experience conditions. in managing long term neurological • Modernisation of Aylesbury Day conditions Services will address these best • Care staff receive support from practice requirements 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. Quality People in the later stages of long term • Community palliative care team A review/ audit process is Alex Laidler/ requirement 9: neurological conditions are to receive a support people with neurological needed to assess QR9 Disability and Palliative care comprehensive range of palliative care conditions at home during the end of performance robustly Therapy services when they need them to control life stage. Executive symptoms; offer pain relief and meet their • Good transfer arrangements • Need to map/review Group needs for personal, social, psychological between community therapy & YPD links between adult and spiritual support, in line with the teams, & the palliative care team. therapy team & March 2008 principles of palliative care. • Access to hospice care for end of life consultant neurologists 20
  21. 21. care where appropriate but no & ensure good joint Markers of best practice: information to comment on whether working at key stages in this is specific to needs of people palliative stage e.g. • Specialised neurology, rehabilitation, with neurological conditions. introducing ventilation & and palliative care MDTs and PEG feeding providers work together to provide • Need to ensure care for people with advanced long Independent Mental term neurological conditions Capacity Advocates are • Access to specialised and involved in supporting generalised palliative care services key decisions where the which support people in their own person's capacity to home or in a specialised setting consent is limited 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. Quality Carers of people with long term • Social workers in all settings offer • To ensure that carer Alex Laidler/ requirement 10: neurological conditions are to have carers assessments. assessments are Disability and Supporting access to appropriate support & services • Adult therapy team involves carers & offered consistently & Therapy family and carers that recognise their needs both in their family members in goal setting & lead to appropriate care Executive role as carer and in their own right. design & delivery of community plans & support Group rehabilitation. • Explore/ identify access Markers of best practice: • YPD case managers involve, consult to psychology for family March 2008 & support carers/families as part of work in families where • Carers are offered a health & social the service. an adult has a severe care assessment at diagnosis & all neurological condition future interactions with information • There is a need to that addresses their needs and review training to offered a written care plan agreed assess best practice with them. standard in relation to • Carers can choose the extent of their carer awareness caring role & the kinds of care they training. provide. • Carers have an allocated contact 21
  22. 22. 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 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 People with long-term neurological No work undertaken on this requirement Need to agree a review/ audit LTC Steering requirement 11: conditions are to have their specific to date. process to measure Group Caring for people neurological needs met while receiving performance against QR11, with neurological care for other reasons in any health or & undertake this with March 2008 conditions in social care setting. colleagues in acute hospitals hospital or other & other provider services. health and social Markers of best practice: care settings • 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 22
  23. 23. 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 • 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

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