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									                                                  Agenda Item:      TB(08) 05

                               East Cheshire NHS Trust
                           Board Meeting, 31st January 2008

Report of                           Division of Medicine - Therapy Services
                                    Management Restructure

Paper prepared by                   Ann Draper, Therapy Project Manager

Subject/Title                       Therapy Services, Management Restructure Proposal

Background papers (if relevant)     Attached

Purpose of Paper                    To Agree The Future Management Arrangements For
                                    Therapy Services
                                    Decision Required
Action/Decision required             On Integration Of Management For Adult
                                        Occupational and Physiotherapy Services In ECT
                                     Transfer Of The Management Of Paediatric OT/PT
                                        and Salt Services To CECPCT
Links to:                           NHS Improvement Plan – Modernising Services
    NHS strategies and policy      Reducing Waiting Lists
                                   NSF Long Term Conditions
                                    Childrens’ Plan
                                    Aiming High For Disabled Children
                                    NSF For Young People, Children And Maternity
                                    Safeguarding Children
                                    Inclusion (Education)
Link to:                            To Continuously Improve The Experience Of Patients
    Trust’s Strategic              To Streamline Referrals
       Direction                    Maximise Skill Mix In The Workforce
    Corporate Objectives           To Address Gaps And Duplication In Services
    Healthcare standards           To Share Resources And Improve The Financial
                                    Management Of The Services

                                    Agree transfer of resources to CECPCT for Paediatric
Resource impact                     OT/PT and Salt Services.
                                    Merging Of Resources for Adult OT/PT Services

You are reminded not to use         OT– Occupational Therapy
acronyms or abbreviations           PT– Physiotherapy
wherever possible. However, if      SALT – Speech And Language Therapy
they appear in the attached         CECPCT – Central And Eastern Cheshire Pct
paper, please list them in the      ECT – East Cheshire Trust
adjacent box.

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         DECEMBER 07

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                                TABLE OF CONTENTS

1. Introduction

2. Executive Summary

3. Current Provision

4. Current Management Structure

5. Benefits Realisation – for integrating OT/PT adult services into clinical teams

6. Redesigning the Management Structure of Therapy Services

   a. Proposed changes –adult services OT/PT
   b. Proposed changes - SALT Adult Team
   c. Proposed Changes – Paediatric Services

7. Benefits Realisation – from transfer of management of OT/PT paediatric and
   SALT services to CECPCT

8. Financial Implications of Change

   a. Financial Management of Adult OT/PT integration
   b. Management of the OT/PT paediatric and SALT services

9. Performance – monitoring and governance

10. Human Resource Policy


1. Division of Medicine - Proposed Structure
2. Pro and Cons of SALT Adult Service remaining with ECT
3. Potentially Displaced posts and proposed new posts

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   The purpose of this paper is to brief the Board of East Cheshire NHS Trust (ECT) in
   regard to the proposed changes to the management structure for Therapy Services
   currently provided by East Cheshire NHS Trust.


    Physiotherapy and Occupational Therapy Inpatient/Outpatient/Rehabilitation

    With regard to Department of Health policy and East Cheshire Trust development of
    clinical care pathways/clinical teams and the restructure of the management of the
    Division of Medicine to reflect the changes in services required for modernising delivery
    of care, it is acknowledged that there are many benefits to be realised from integrating
    the Physiotherapy and Occupational therapy services to adult in/outpatients. The
    services are currently managed separately. Integration would deliver improved
    multidisciplinary working, allow flexibility of skill mix within clinical teams, eliminate
    duplication and allow better use of resources.

    The preferred model is for the integrated teams to be managed by a Rehabilitation
    Therapy Services Manager and by an Acute/Outpatient therapy services manager, who
    maintain responsibility for professional leadership. Each manager has a responsibility for
    a number of integrated teams who relate to specific clinical care pathways and provide
    specialist therapy within those pathways.

    Paediatric Therapy services and Speech and Language services

    In the light of local and national priorities for children’s services and the NSF focus on
    integrated planning, commissioning and delivery of co-ordinated children’s services it is
    acknowledged that there are many benefits to be realised from integrating the paediatric
    therapy and SALT services provided by ECT and CECPCT to be in line with the
    commissioning function of CECPCT.

    Integration of these small specialist teams would deliver better utilisation of resources,
    improve multi-disciplinary working, widen service provision, eliminate duplication,
    increase accountability and improve co-ordination across the local population. The
    paediatric therapy and SALT services will be optimised, modernised and developed in
    line with current policy and trends of care in the right place at the right time thus
    becoming more dynamic, competitive, and fit for purpose.

    The preferred model is for the management of Paediatric therapy services which
    includes Physiotherapy, Occupational therapy and Speech and Language therapy of
    both organisations to integrate with CECPCT being the managing and lead organisation,
    agreed and confirmed in a formal service level agreement. The managers appointed to
    the new therapy structure will be employed by CECPCT but all other staff will remain
    within their existing organisations. Any vacancies will be appointed to by CECPCT.
    Financial management of the services would transfer to CECPCT when agreed with
    East Cheshire Trust

    Some deliverable financial saving can be achieved by integration of services but will
    require re-banding/protection of staff under re-organisational policies and therefore it is
    expected this will take 2-3 years to be fully appreciated.

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    A transition plan to achieve this vision has been identified which takes account of
    potential risks that may occur.

    We feel that this is a robust integrated structure which has commitment from senior
    management in East Cheshire Trust and in the case of paediatric therapy and SALT
    services from the senior management of Central and Eastern Cheshire PCT. There is a
    clear and realistic vision with proposed actions for improving productivity and
    performance that will move forward the Therapy services .


   East Cheshire NHS Trust Therapy Services currently include:

   Physiotherapy (PT) Adult Services

   Inpatient Medicine/Surgery, Outpatient Musculoskeletal Services( including GP Direct
   Access referrals), Trauma and Orthopaedics Inpatient and Outpatient, ITU and HDU,
   Rheumatology, Women’s Health, Dermatology, Amputee, Respiratory & Pulmonary
   Rehabilitation, Neurology Outpatient, Rehabilitation Inpatient (including stroke), Palliative
   (at East Cheshire Hospice) and inpatient paediatrics at request of a paediatric consultant.

   The commissioners in Central and Eastern Cheshire PCT (CECPCT) are leading a
   project to develop a service specification for GP Musculoskeletal Outpatient
   Physiotherapy. ECT and CECPCT are involved jointly in this work.

   Occupational Therapy (OT) Adult Services

   Inpatient Medicine/Surgery, Trauma, Orthopaedics Inpatient and Outpatient (including
   customised orthotics), Rheumatology, Rehabilitation Inpatient (including stroke),
   Community Rehabilitation General and Neurology by Consultant and Direct Access
   Referral, Community Hospital Inpatient Rehabilitation, Palliative (at East Cheshire

   Speech and Language Therapy (SALT) Adult Services

   Inpatient Medicine/Surgery, Rehabilitation Inpatient (including stoke), ENT Voice,
   Community Rehabilitation (Consultant and Direct Access referral mostly Neurology) and
   Head/Neck Cancer. A dementia service to those patients not currently under the care of a
   Cheshire and Wirral Mental Health Trust (CWMHT) Consultant Psychiatrist is provided

   Paediatric Therapy Services

   Occupational Therapy, Physiotherapy (including paediatric orthotics), Speech and
   Language Therapy – specialist Community Services. Services are delivered in
   Community settings i.e. schools, special schools, local clinics, patients’ homes etc
   Referrals are received from Paediatric Consultants, School Nurses, and educational

   Total Staffing Adult & Paediatric Services

   WTE = 94.21. Actual staff in post – 148.

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       Head of Physiotherapy (8b)
       Head of Paediatric Physiotherapy (8a) – responsible to Head Physiotherapist
       Acting Head of Occupational Therapy (8b)
       Head of Paediatric Occupational Therapy (8a)
       Head of Speech and Language Therapy (8c) – Adult and Paediatric Services

                                  Divisional Manager

       Head PT               Head OT               Head SLT               Head of
       Band 8b               Band 8b                Band 8c             Paediatric OT
                                                 (Paeds & Adult)          Band 8a

Head of Paediatric
    Band 8a

   Currently Team Leaders are responsible to each Head of Service and lead teams within
   their own profession.


   Current levels of productivity and skill mix suggest that further action can be taken to
   improve performance and efficiency and to maximise opportunity from understanding
   shared activity in OT/PT adult services

   Integration of the adult OT/PT services into clinical teams would improve services to
   patients in appropriate settings and within acceptable waiting times to reflect the
   changing needs of the clinical users of the services. It will improve the flow of patient
   care pathways in line with future healthcare and provide a greater sense of teamwork and

   The following improvements can also be delivered from an integrated OT/PT clinical team

   Service Management

       Shared resources
       Reduce bureaucracy and duplication in administration
       Reduce gaps and duplication in services
       Develop the correct skill mix and career framework
       Provide opportunity to develop extended services and widen service provision
       Increase clinical output through more flexible services

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       Patient Management

          Streamlined referrals
          Develop integrated care pathways
          Standardise patient management approach
          Reduce waiting times for patients
          Improve, monitor and manage productivity levels

       Financial Benefits

          Flexible use of staff
          Consistent approach to policies/procedures/risk management across therapies
          Standardise staff performance/competencies – utilising KSF and Skills for Health
          Shared training
          Improved cover for sickness/absence/holidays
          Streamline the skill mix required in each team.

       The benefits will ensure that Therapy Services can be modernised in line with current
       policy and trends of delivering care, which is competitive and fit for purpose.


6.i    Proposed Changes - Adult Services OT/PT

       The following proposal provides for a management restructure which has clear lines
       of accountability for service delivery but maintains clear professional leadership for
       the individual professions. It provides clear governance and structure for the strategic,
       operational and professional delivery of therapy services.

       The adult OT/PT therapy services would be integrated into clinical teams under two
       newly appointed managers within the restructure of the Division of Medicine
       management. A manager for Acute & Outpatient Therapy Services and a manager
       for Rehabilitation Therapy Services.

       The two managers would be responsible for:

          the operational management of the teams under their control and initially for the
           integration of the clinical teams in line with patient care pathways and
          covering each other in case of absence.
          accountable/reporting to the Service Manager Rehab Specialities and the Service
           Manager Other (Appendix 1 Division of Medicine structure) attend Divisional
           meetings and be representative of Therapies as required and directed by these
          representing and providing professional leadership to staff within therapies
           (OT/PT) or establish clear lines of professional leadership within the therapy

6.ii   Proposed Changes - Speech and Language Therapy Adult Team

        It is requested that further consideration is given to the adult Speech and Language
       Therapy staff and where they are best managed. This team is currently managed by
       the SALT Manager alongside the SALT paediatric services. The proposal is that they

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        should be managed by the SALT manager from the CECPCT alongside all the other
        SALT services.

        The CECPCT also has a small adult Speech and Language Therapy Service and
        greater cohesive integrated working might improve the flexibility and skill mix within a
        very small and specialist workforce. This service currently has a waiting list up to 20
        weeks. Fragmenting the services further by leaving this team with ECT would deny
        them professional support as there would be no SALT manager in ECT. (Appendix 2
        Pros and Cons for service remaining with ECT)
6.iii   Proposed Changes - Paediatric Services

        The proposal is for the management of paediatric therapy services which includes
        Physiotherapy, Occupational Therapy and Speech and Language Therapy to be
        transferred to CECPCT.

        The current model in CECPCT is a manager of SLT services (paediatric & adult Band
        8b) and a manager of an integrated paediatric OT/PT service Band 8b (refer to
        structure below). The two managers are accountable/report to the CECPCT Therapy
        Services Manager.

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                                     Crewe & Nantwich
                            Locality General Manager/AHP Lead

Community             Community              Wheelchair            Therapy Services
Services              Services               Services              Manager 8B
Manager 8A            Manager 8A             East & Central
Crewe                 Nantwich
(Health               (Health
Visiting DN)          Visiting DN)

               Paed OT        Physio         OT         Podiatry    SLT           Dietetics
               & Physio       Manager        Manager    Manager     Manager       Manager
               8B             8B             8B         8B          8B            8B

               Outpatient            Inpatient
               Physio                Rehab
               Lead                  Physio
               Manager               Lead
               8A                    Manager 8A

Staffing CECPCT

Speech and Language Therapy           WTE = 32.51 Actual staff in post = 50
Paediatric Physiotherapy              WTE = 18.77 Actual staff in post = 32
Paediatric Occupational Therapy       WTE = 3.74 Actual staff in post = 6
(See Appendix 3 for potentially displaced posts and proposed new structure posts)


    Service Management

       Widen service provision by uniting small & specialist services to allow increased
        flexibility across the locality.
       Integrate resources – one provider organisation negotiating with commissioners of
        services and in the case of SALT with Cheshire County Council Childrens’ Services
       Reduce gaps and duplication in services
       Develop the correct skill mix within teams

    Patient Management

       Streamline referrals - currently boundaries of each area cause difficulties where a
        child for instance lives in the central area but attends a school in the eastern area.
       Standardise patient management approach

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          Develop integrated care pathways


8.i        Financial Management of Adult OT/PT Integration

           The change in role of the two therapy managers within the Division of Medicine is
           likely to achieve savings dependent on AfC job matching. Further savings are likely
           to be achieved over the next two years by integrating the teams and restructuring the
           appropriate skill mix to reflect the needs of the patient pathways e.g. one team leader
           for each integrated team.

8.ii       Management of the OT/PT Paediatric & SALT Services

           Management of the services would transfer to CECPCT. The newly appointed
           managers to the above services would be employed by CECPCT. The clinical staff
           within the paediatric and SALT teams currently employed by ECT would remain
           employed by this trust with their existing terms and conditions. As vacancies occur
           new appointees would be employed by CECPCT.

           The total saving on the SLT manager post is £60583. We propose that any savings
           will initially be split 50/50. Savings to this Trust are approx £30,000.

           The total saving on the OT/PT managers’ posts is £6322 affording a saving to this
           Trust of £3000.

           Currently the income for these services is received from CECPCT for direct access to
           the service and in the case of SALT is additionally received from their contracts with
           Cheshire County Council Children’s services. Approximately £25,000 has been
           removed from that income in this financial year due to local government savings
           targets and further savings are likely to be required over the coming financial year
           when the Surestart services are absorbed into the main education contracts. This is
           likely to result in a reduction to SALT paediatric staffing.

           A Service Level Agreement would need to be agreed between CECPCT and ECT
           prior to transfer of services.


           Clear governance arrangements need to be established in order to support the
           delivery of service and any staffing issues. This will be confirmed in a formal Service
           Level Agreement.

              Monitoring – Performance shall be monitored by the Divisional Manager for
               Medicine (ECT) and Director of Provider Services (CECPCT).
              Appropriate clinical governance arrangements will be developed by CECPCT to
               ensure continuation and quality of service, business continuity plans, identification
               and notification of any risks. These will be identified through a programme of audit
               and review. Complaints and clinical incidents for Paediatric Therapy Services will
               be managed and reported within the CECPCT systems. Regular reports will be
               provided for ECT.
              CECPCT will comply with performance targets designated as key to the delivery
               of the service and which will be agreed by ECT and CECPCT.
              CECPCT will use appropriate procedures to recruit, employ, train and support
               staff and to deliver service.
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       Human Resource policy for managing change will need to be applied throughout the
       restructure and integration process.

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                                                                                                                              Appendix 1


        Head of                                                            Divisional Manager
                                                                                                          Divisional                    HR Manager
        Division                                                                                          Accountant

               Service Manager                Service Manager                                              Service Manager          Service Manager
               Rehab Specialties                  OTHER                          Service Manager                Acute               Women’s Services
                                                                                   Urgent Care

   Clinical                        Therapy services                                                  Acute Matron                Paediatric
    Leads                          acute wards and               Urgent Care Matron                                               Services

     Rehab Matron                                                                                       MNP’s                 Paediatrics Matron
                                    Dermatology                      A&E Coordinators

     Older Peoples
                                                                                                   Cardio Respiratory             Paediatrics
                                     Respiratory                      MIU- CWMH                           Dept                  out-patient dept

   Stroke Co-ordinator                                                                               Cardiac Rehab               Paediatrics
                                                                      Governance Lead                   service                Specialty nurses

       Neurology                                                                                   Cardiology Nurse
                                     Nephrology                         Admin Lead                    Specialist             Community paediatric
                                                                                                                                nursing team

                                                                                                   Haemodialysis Unit
     Rheumatology                   Lung Cancer                                                                               Child development

                                                                                                    Divisional Lead
     Rehab Therapy                      EEG

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                                                                                     Appendix 2


      PROS of staying with Acute                       CONS of staying with Acute

    SLT more likely to be part of Rehab.            Lose SLT Manager and professional
     Strategy – more direct lines of                  lead
    Team more likely to retain and maintain         Lose flexibility across teams and
     links with other therapies.                      opportunity for under recruitment.
    Acute/Rehab. SLTs will have more                Loss of Clinical Governance and CPD
     influence on Stroke/Rehab. Issues, as            opportunities as a whole group.
     well as integrating to ITU/HDU/ENT               E.g. Audits
     areas.                                                Outcome measures
                                                           Care aims
                                                           Professional issues developments
    Who would decide how much SLT time              Loss of structure and, therefore,
     indicated in any new developments at             opportunities for movement within
     East Cheshire when in PCT?                       department for junior therapists, i.e.
                                                     Any rotational posts which may be
                                                      developed will not function with just a
                                                      small clinical team rather than as part of
                                                      a larger department.
                                                     Responsibilities of Band 8 posts would
                                                      change      significantly.     ?     more
                                                      management responsibilities e.g. ?
                                                      budgetary control, H.R. issues and
                                                      therefore a decrease in clinical time
                                                     Reporting to a non SLT Manager – the
                                                      success and development of the Adult
                                                      Team may to a great extent depend on
                                                      who it is managed by and their
                                                      understanding and appreciation of what
                                                      is often a poorly understood role.
                                                     Community part of adult team may
                                                      benefit from being in PCT because of
                                                      greater links with Primary care and
                                                      GPs, as well as community PTs and
                                                      dietetics and nursing homes etc.

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                                                                               Appendix 3


The proposed changes will create displacement of some current managerial posts and will
lead to the reorganisation of Team Leader and Clinical Specialist posts within all the
professions The structure will be discussed and consulted on once the new management
structure is identified and new managers in post

Where an individual is displaced as a result of the implementation of this proposal it is
expected that suitable alternative employment will be offered within Therapy Services. Posts
which may be displaced from this initial consultation process and new posts, which would be
available within the new structures are detailed below.

Existing Post                                                     Displaced Potentially

Head of Physiotherapy ECT       Band 8b                                  Yes

Head of Occupational Therapy ECT Band 8b                          ( Retirement in Nov 07 )

Head of Speech and Language ECT        Band 8c                           Yes

Head of Speech and Language Therapy CECPCT Band 8b               postholder retired July 07

Head of Paediatric Physiotherapy ECT Band 8a                             Yes

Head of Paediatric Occupational Therapy ECT Band 8a                      Yes

One Paediatric Occupational Therapy/Physiotherapy Manager post will be available. Two
Band 7 posts to combine clinical specialism and team leadership have been accounted for
using vacancies to absorb the management element of the current posts which at present
have a large clinical component.


ECT Adult Services

Acute& Outpatient Therapy Services Manager Division of Medicine
Rehabilitation Therapy Services Manager Division of Medicine

CECPCT Paediatric Services

Head of SALT services
Head of OT/PT services

Banding of all posts would be dependent on AfC job matching of new roles

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