MUSCULOSKELETAL OUTPATIENT PHYSIOTHERAPY SERVICES DEVELOPING A PROPOSAL FOR A SINGLE MANAGEMENT STRUCTURE

Transcription

1 MUSCULOSKELETAL OUTPATIENT PHYSIOTHERAPY SERVICES DEVELOPING A PROPOSAL FOR A SINGLE MANAGEMENT STRUCTURE 1. INTRODUCTION 1.1 The joint CH(C)P and Acute Directors group commissioned an initial review of management arrangements for outpatient physiotherapy because of variations in practise, waiting times and differential skill mix and support. This short paper details the current service provision for physiotherapy musculoskeletal services within Greater Glasgow and Clyde, issues in relation to that provision and makes a proposal for detailed work on future management arrangements. 1.2 This paper does not include physiotherapy services provided within domiciliary services, community teams, specialist or paediatric services. Detailed work on the proposal would be related to the existing programme of work to look at service design and waiting times. 2. CURRENT MANAGEMENT OF PHYSIOTHERAPY SERVICES 2.1 CH(C)Ps The service is managed within each CH(C)P by Physiotherapy Managers. The exceptions to this being the service provided within Inverclyde CHP which is managed by the acute service and the Lomond area of West Dunbartonshire where the outpatient service in the Vale of Leven Hospital is managed by the CHP. The physiotherapy staffing levels within each CH(C)P also vary considerably (Appendix 1). The Physiotherapy Managers are directly managed by RES Managers or equivalent or Heads of Health and Community Care in CH(C)Ps. 2.2 Acute Services The services provided by the Acute Division are delivered on 8 sites and managed by 5 Team Leaders on a geographic basis (North East, West, South, RAH and IRH). The Team Leaders are managed by Clinical Services Managers. As noted above the IRH service provides the physiotherapy service on behalf of the CHP. The physiotherapy staffing levels are detailed in Appendix Professional Leadership Although the role of AHP Lead has been established in each CH(C)P there is no overall physiotherapy professional leadership and limited work or consistency across CH(C)Ps or with Acute. Practice development support is provided by 1 wte to Glasgow City CH(C)Ps Professional support is provided to all physiotherapists within Greater Glasgow and Clyde acute adult services by the Physiotherapy Professional Lead with 1 wte practice development support. 1

2 It should be recognised that Managers and Team Leaders have worked together in an attempt to agree a consistent approach to services delivered throughout the Board area. Despite this, services have developed incrementally, either due to local demand or individuals personal interest. In the absence of leadership across all sectors consistency has been difficult to achieve. 3. ISSUES 3.1 Waiting Times There is no national waiting time target for access to physiotherapy and there is currently a wide variation in waiting times with no consistency throughout Greater Glasgow and Clyde. Various reasons are cited including increased referral rates and staffing levels/issues. We know waiting times are a major issue for patients and a brief analysis is set out in Appendix 3 to this paper. 3.2 Staffing Resources Staffing levels are variable within each service. Although staffing in CH(C)Ps had previously been allocated to each geographical area in direct relation to the referral pattern and workload, with the introduction of LHCCs and latterly CH(C)Ps, local management have had varying priorities which has resulted in investment in physiotherapy services in some areas more than others. Hospital staffing also reflects similar variations. This has also applied to the allocation of administration staff. Where administration staff have been appointed, physiotherapists have been able to focus on clinical duties. Where there is a lack of administration staff, skilled clinicians are required to undertake admin duties with a direct impact on their clinical availability and therefore waiting times. 3.3 Self Referral Self referral has been successfully implemented throughout all services in CH(C)Ps and Acute services. However, depending on where they access the service, patients will receive different outcomes to their contact. Initial contacts may consist of: - telephone triage with advice and exercise; - telephone triage; - face-to-face triage. The above variations have resulted as there has been no strategic view as to the model of service which should be delivered consistently within NHSGGC. To access this service currently, patients require to directly contact their local department which requires physiotherapy staff in each CH(C)P and acute service spending time answering phones taking messages from answer phones, etc. Patients can be offered appointments in a range of locations if they request an appointment nearer their place of work for example but this requires multiple phonecalls to arrange. 2

3 As self referral services are provided in a number of locations there have been instances where services have closed their waiting lists due to staffing pressures and directed referrals to other departments within the Board. Whilst from a local perspective this may be appropriate failure to manage the impact across the whole system simply displaces pressure. This has also resulted in patients requiring to travel to a service. Under a whole system management arrangement the staffing resource could be flexed to take the service to the patients. 3.4 Specialties Throughout the Board area, different specialist care is available within the musculoskeletal outpatient departments, eg, rheumatology classes, continence services, etc. This duplication of services in some areas and gaps in others as these services have in part developed in response to practitioners particular skills and interests will require a system-wide approach to agree the core service provision and, where additional services are currently provided, it should be clear if the provision is in direct relation to an identified need and if so whether this is provided equitably throughout the Board area. 3.5 Interpretation of Activity The work currently being undertaken in relation to AHP waiting times has determined that although all services are submitting monthly statistics there is wide variation in interpretation which has resulted in an inability to accurately determine actual workload based on current information. It is clear however that there are variations in the numbers of appointments offered for a course of treatment. A revised local data set and definitions have been developed and training to support implementation is underway with support from ISD. 4. SOLUTIONS FOR CONSIDERATION 4.1 CH(C)P Directors initial consideration of the issues outlined above have led us to conclude that there is real merit in developing a detailed proposal to consider a move to a single system management arrangement with the following parameters - these proposals relate only to musculoskeletal outpatient physiotherapy services; - the whole system management arrangements would be expected to deliver us efficiencies in terms of reduced management costs, increased frontline capacity and more consistent and effective administrative systems and support, ensuring therapists would concentrate on delivering care; - we would expect to achieve consistent models of service delivery, in short timescales; - services would continue to be delivered at a wide range of locations although there may be duplication in some areas between acute and CH(C)P services which would be addressed; - the service would be designed to ensure resources are deployed across the Board area on the basis of need and to respond to inequalities of access, rather than simply to meet expressed demand. We would expect the management system to demonstrate a high level of responsiveness to socio- 3

4 economic inequalities and inequalities of physical access, for example, through the appointment clearing arrangement we might restrict out of area access to some services where we want to provide rapid access for the local population; These points are amplified further below. 4.2 Management Costs By introducing a streamlined management structure across NHSGGC there is the potential to reduce management time which could potentially be reinvested in clinical activity and administration support. This would ensure that there is improved access to patients and that clinicians could focus on clinical rather than managerial tasks. Detailed work on this approach would need to be developed with alignment to work on management and leadership arrangements for the rehabilitation framework. On review of the current staffing there are currently 9 managers with some degree of responsibility for wte within CH(C)Ps. These managers also manage domiciliary services. Of these 9 managers, 7 are banded at 8a with one 8b and one band 7 Of the 77.3 available manager sessions only 35.3 are clinical sessions with 42 sessions per week relating to management activity, ie, 4.2 wte Within the acute musculoskeletal outpatient services there are currently 3 Team Leaders for wte within Glasgow. The Team Leaders also manage other outpatient staff and in some instances manage rotational staff. Clyde services are managed by a senior member of staff within each outpatient department with an overall Physiotherapy Team Leader for the hospital Of the 3 Team Leaders in Glasgow, 2 are banded at an 8a and one Band 7. Of the 26 available sessions 17 are clinical resulting in the equivalent of 0.9 wte relating to management activity. 4.3 Staffing Allocation An immediate task for revised management could be a review of staffing allocated across the Board to ensure that there is an equitable distribution of staff. This should be implemented using an agreed resource allocation model. Consideration should also be given to the current skill mix as historically physiotherapy as a profession has not supported Band 5 workers delivering services without direct supervision. However this is not the case in other AHP professions and different models of support should be explored to allow a greater use of Band 5 posts. This will also assist with the current surplus of physiotherapy graduates. 4.4 Single Point of Access The implementation of a single point of access to physiotherapy via a central telephone triage, advice and booking/scheduling service should be explored with immediate effect. This would allow maximum flexibility of appointments and release of clinical staff from multiple systems of triage. 4

5 The current pilot of the use of NHS24 within Lothian NHS Board for physiotherapy direct access should be closely monitored and a review of the centralised podiatry booking system at GEMS and the Glasgow Weight Management Service call centre undertaken to determine if either of these models could be implemented within NHSGGC 5. ISSUES FOR CONSIDERATION ON REPORTING LINES 5.1 If we move to a single management arrangement for musculoskeletal outpatient physiotherapy one manager would have overall responsibility for this physiotherapy service throughout the Board and be supported by an appropriate team leadership structure. 5.2 This manager could then report to a CH(C)P senior manager or the AHP Director in the Rehabilitation and Assessment Directorate. 5.3 The Rehabilitation and Assessment Directorate also provides services that will be part of both rehabilitation and enablement and currently manage services across NHSGGC. There is also an existing professional leadership structure across the Board area for its services. 5.4 It is also possible that we could adopt a sector/geographical leadership of services with the local leaders reporting to one overall manager. 5.5 Both of these models on the reporting and leadership arrangements for a whole system structure offer the potential for: - a clear strategic vision for Physiotherapy services ensuring consistent models of service delivery across NHSGGC; - focused service delivery ensuring services targeting local needs with reduced duplication; - the ability to utilise the staffing resources appropriately across the sector; - reduced duplication of management activity. 6. CONCLUSIONS 6.1 It is proposed that this paper provides a basis for comment and discussion in APF and local staff partnership prior to establishing a steering group to develop the proposal further. C M Renfrew 15/06/09 5

6 APPENDIX 1 PHYSIOTHERAPY STAFFING LEVELS - CH(C)P CH(C)P 8b 8a Mgmt 8a Clin Total East Glasgow West Glasgow South West Glasgow South East Glasgow North Glasgow West Dunbartonshire (includes VOL staffing) East Dunbartonshire Renfewshire East Renfrewshire Camglen Total NB - staffing figures exclude domiciliary, COPT, GBPS and continence services. Inverclyde CHP not shown as service managed by the Acute Division 6

7 PHYSIOTHERAPY STAFFING LEVELS - ACUTE APPENDIX 2 Acute North East Team Lead GRI 8a Mgmt 8a Clin Mgmt 7 Clin 6 Static 6 Rot Static Rot 2 1 Total Stobhill West Team Lead GGH WIG South Team Lead SGH Victoria RAH clinic sessions IRH (includes Inverclyde staffing) Total NB - staffing figures exclude GBPS, ESPs, pain, occupational health, hydrotherapy and continence services

8 PHYSIOTHERAPY REFERRALS/WAITING TIMES APPENDIX 3 CH(C)P Referrals/Appointments Waiting Times Month GP Self Acute Other Total Follow Ups DNAs Discharges No Waiting Over 5 Weeks Max Wait Weeks North Glasgow Jan Feb Mar West Glasgow Jan Feb Mar East Glasgow** Oct Nov Dec South East Glasgow South West Glasgow** Jan Feb Mar Jan Feb Mar Inverclyde Jan Feb Mar Renfrewshire Jan Feb Mar East Renfrewshire West Dunbartonshire East Dunbartonshire Jan Feb Mar ** Figures relate to Oct-Dec 08 All others relate to Jan-Mar 09 Jan Feb Mar Jan Feb Mar