The Scrutiny Support Officer presented a report which provided the Panel with the background to this matter and outlined the purpose of the meeting.
The Panel had undertaken a review of neurological services in 2012 and received a number of updates on the implementation of its recommendations and details of new developments in this area.
At its meeting in February 2015, the Panel was informed that although things were improving the significant reorganisation within the NHS could not be underestimated. The Panel had also been advised that nationally there was an issue with specialist community based rehabilitation for children and that there was a gap in provision for children with neurological injuries/illness. Therefore, the Panel wanted to discuss this issue and the wider provision of specialist rehabilitation services further with South Tees Clinical Commissioning Group (CCG).
The following documents had also been circulated:-
Identifying the Economic Value of the Keiro Service Pathway - Final Report of the North East and Cumbria Academic Health Science Network
Services for People with Neurological Conditions: Progress Review - National Audit Office
Project Initiation Document - Community Based Neurological Care - NHS England
The Scrutiny Support Officer advised the Panel that Boda Gallon, Chief Executive of Keiro, had offered the Panel the opportunity of visiting the facilities at Keiro. Keiro operated in two centres in Middlesbrough and Gateshead and provided specialist nursing care and neuro-rehabilitation.
Carole Harrison, Finance Director at Keiro, informed the Panel that the Director of the NHS had visited their facilities and had been impressed with the organisations innovative approach. He had recommended that some independent research be undertaken. Therefore the study by the North East and Cumbria Academic Health Science Network had been commissioned.
The study had found that Keiros community rehabilitation model was cost-effective, compared to providing long term nursing home accommodation for people with neurological conditions and that adopting the Keiro service had "the potential to provide patients with the best possible opportunity to regain and retain their independence and deliver the best outcomes for them and their whole family".
The Chair asked how the Keiro Model was able to achieve financial savings and meet the well being aspects of the Care Act - essentially, how was it able to "add value"? Carole Harrison said that the key was the timeliness of the rehabilitation, which helped people reach their potential. The Model was slower than others, in some respects, but had the benefit of, ultimately, maximising peoples potential for recovery. Therefore, the Model, whilst more expensive than others in the early stages, was more cost-effective in the long term. The same Therapy Team is used, leading to consistency in the service provided and the Model avoided the need for patients to stay in an acute bed.
Carole Harrison added that she had met recently with the Assistant Director for Social Care at Middlesbrough Council, who would be informing the Integrated Executive Group about the Keiro Model. There had been a lot of interest in the Model, with its key focus on what was best for the client.
Doctor Paul McKee, Clinical Director for Neurology, South Tees NHS Foundation Trust, stated that the early phase of rehabilitation was very important following a neurological injury but the Trust was not yet at the point where it would benefit from the Keiro Model. He added that the key was for patients to be accurately assessed and not to be "written off" in any way or incorrectly placed.
Jan Rock, founder of Matrix Neurological, said that when her son had suffered a brain injury the family did not want him to be treated at Walkergate Park as they felt it did not take account of the role of the family. Her sons rehabilitation was undertaken at home.
Doctor Janet Walker, Chair of South Tees Clinical Commissioning Group, said that many patients still chose Walkergate Park, even with the travelling involved, due to the treatment that was provided there. The CCG was developing a rehabilitation Strategy. If they could get this right for neurological rehabilitation it could be used as a basis for other service areas.
The Chair was keen to hear how any gaps in service could be filled.
Doctor Walker stated that the CCG was confident that its Rehabilitation Strategy would achieve this, as it would lead to a whole systems approach and included a single point of access, via a central repository of services.
Doctor Walker then responded to the six questions that the Panel had put to the CCG:-
a) What is the CCGs approach to commissioning specialist neurological support services for children and adults?
NHS Englands Specialised Commissioning Team commissioned in patient neuro-rehabilitation and neurological psychiatry beds at Walkergate Park. There was a national service specification for neurological rehabilitation, but the national neurological psychiatry specification had yet to be finalised. These beds could be accessed by everyone (adults and children) from across the region and also patients from elsewhere in England, if needed.
The direction of travel indicated that some specialist commissioning responsibilities would shift to CCGs in the future. There is currently no information or timescales in relation to the transfer of responsibilities within this financial year.
Lucy Tulloch mentioned that the Keiro Service at the Gateway could be a potential option for children.
b) How are the CCG planning to take on the mandate of being responsible for commissioning rehabilitation and neurological conditions?
The CCG already commissioned neuro-rehabilitation services from South Tees Hospital NHS Foundation Trust as a level 2 service.
A Specialised Neuro Rehabilitation Health Needs Assessment (HNA) provided further information. This HNA reviewed the epidemiology, activity data, estimated need and current services and presented recommendations based on the findings.
c) With regard to the delays in people being discharged from Walkergate Park, what are the clinical reasons for this and what role does the CCG play in facilitating discharge?
d) Is it an issue that there is no financial incentive to discharge patients from Walkergate into the Community, as the receiving authority then become responsible for the patient and, if so, what could be done to overcome this?
Response (covering c) and d))
The Clinical Reference Group, led by UK specialist Rehabilitation Outcomes Collaborative (UKROC), had developed a weighted bed day tariff on the basis that the more complex patients required more input and therefore cost more, so services should be reimbursed fairly for this. The weighted bed day currency was mandatory. There was an indicative national tariff. The Panel were advised that further detail was available on the UKROC website.
The CCG did not have concerns that Walkergate Park were attempting to discharge people before they were clinically appropriate. The delayed discharges appeared to arise from issues identifying and agreeing funding for the next placement.
The CCG had recently held a meeting with the Clinical Leads from Walkergate Park. It became evident that the terminology used by the Consultants had caused confusion, meaning that patients were unable to be appropriately assessed using the CHC Decision Support Tool (DST). A solution had been accepted and would be implemented for all future discharges. This meant that those patients who were appropriate for a CHC package of care would receive this without any unnecessary delay in patient discharge.
Jan Rock commented that the patient should be put first, with the funding issues being addressed afterwards.
Doctor McKee commented that funding was crucial and there needed to be an overarching Strategy.
The Chair felt that there should be a clear pathway in place for patients.
e) What does the CCG see as the role of GPs in terms of, for instance, co-ordinating rehabilitation from acquired brain injuries and how will they facilitate this role?
GPs were well paced to refer patients onto a wide range of services but did not have the expertise or experience of acquired brain injury to be in a co-ordinating role. Other case managers could be better placed to do this.
Jan Rock commented that assessment should be an on-going process and that it was key for people to have a Case Manager.
f) How does the CCG intend to respond to the specific recommendations for CCGs as outlined in "The Invisible Patients - Revealing the state of neurology services" - the report produced by the Neurological Alliance?
The CCG would review this report and discuss with appropriate colleagues, including NHS England and the Strategic Clinical Network. The CCG had met with the Tees Valley Neurological Alliance around broader neurological needs assessment and would benefit from their wealth of knowledge with raising awareness, identification of need, and when shaping future service development.
Nicola Chater, Network Clinical Lead for Neuro Rehabilitation, informed the Panel of an initiative that the Strategic Clinical Network was involved in. The Network operated across North Yorkshire to Cumbria, with the aim of helping people work together across different groups and services. Information and good practice was shared, building on the different models that existed. The Network worked to an agreed Action Plan with shared priorities.
The goal was to focus on the individual and what they needed to help manage their condition, rather than the individual having to fit around existing services. This would involve a shift in culture. A set of core principles, based on self-management, had been agreed.
Jan Rock cautioned that self-management of certain conditions might not be appropriate - for example, people with acquired brain injuries. Nicola Chater stressed that it was more about how services could best support the individual.
The Chair summed up by saying that, whilst improvements had been made, it was clear that there were still some gaps. He thanked people for attending - particularly given the calls on their time - and for their helpful contributions to the discussion.
a) That, having listened to the views of experts and people with real life experience of dealing with neurological conditions, the Panel make a number of recommendations for inclusion in the final report, which are as follows:-
i. That South Tees CCG and Middlesbrough Councils Adult Social Care Service work together to develop a process whereby people with a neurological condition are assessed at the earliest point possible and that, notwithstanding the need for on-going review, the assessment should be medium to long term to help ensure seamless transfer/progression, thereby increasing the likelihood that the patient will reach their full potential.
ii. To agree an approach on funding that ensures discussions as to who is responsible for funding do not cause delays to an individuals care/support.
The Panel also heard about the South Strategic Clinical Networks Strategic Commissioning Guidance which assists commissioners in understanding their responsibilities. From this, the Panel further recommend:
iii. That South Tees CCG and Middlesbrough Councils Adult Social Care Service consider adapting the principles in the South East Coast Strategic Clinical Networks Strategic Commissioning Model for cancer, for use in Neurological Services.
b) That a future meeting of the Panel be held at Keiro, Gateway, to enable Members to view the facilities there.