NHS
Partnership Commissioning Unit
Report To: / Hambleton, Richmondshire and Whitby CCGReport Title: / Commissioning Intentions – Regional tier 4 Stammering service
Report From: / Helen Billson
Report Status: / Open
1.0Background
1.1Leeds Stammering Support Service is a tier 4 service for children and adults with a stammer and is provided by Leeds Community Healthcare NHS Trust.
Originally commissioned on a collaborative basis by the Yorkshire and Humber Children’s collaborative, with NHS Leeds nominated as lead commissioner. Cost per PCT was £9,000 per annum for block funding of 3-5 cases, and some training support, per PCT per annum.
1.2In February 2013, Leeds Community Healthcare NHS Trust and NHS Leeds South and East CCG wrote to CCG’s in the Yorkshire and Humber area seeking agreement to continue funding for the Regional Stammering Support Service going forward. North Yorkshire and York CCG’s were omitted in error from the distribution list and this letter was only located by Partnership Commissioning Unit on 15.05.13.
1.3The letter proposed that Leeds Community Healthcare NHS Trust will invoice each CCG for £5,850 in April 2013. As this is a specialist tier 4 service, we would question whether the commissioning responsibility actually sits with NHS England, rather than CCGs.
1.4Over a number of months the Partnership Commissioning Unit (PCU) has been liaising with the Service, CCGs and NHS England to conclude this matter.
2.0Where are we now?
2.1 With the support from Simon Cox, Chief Operating Officer, Scarborough and Ryedale CCG, the PCU has challenged:
- Leeds Stammering Support Service - regarding the transparency of service offer within the proposed block, and inconsistencies identified in their communication.
- NHS England – clearly setting out the rationale as to why the CCGs and PCU believe this to be a tier 4 service which would be the responsibility of NHS England to commission. The response from NHS England indicates
“Ministers decide whether a service should be commissioned by NHS England rather than by CCGs. They take advice from the Prescribed Specialised Services Advisory Group (PSSAG), a multi-disciplinary committee that includes clinical, NHS England and CCG representation. As you have noted in your letter, PSSAG bases its recommendations to Ministers on the four ‘factors’. The other questions that PSSAG considers are:
-How would activity be separately identified?
-How many provider contracts would there likely to be?
- Which elements of a service would be commissioned by NHS England and which by CCGs.
I am happy to put this forward to my DH colleagues who run PSSAG. However, reading through your letter, I think we might run into a number of issues: there will need to be really clear criteria for those individuals who would access such a service, given that stammering is a relatively common condition. I think the other stumbling block will be that the service is not national; all other services in the Manual are provided on a national basis. … Are there other centres in the UK that provide a similar service? Finally, the costs are relatively low compared to the other services in the Manual.”
2.2In light of the above, and that there are a few tier 4 centres across the country, the value of challenging this issue further is questioned.
2.3Meeting with locally commissioned providers of tier 1 to 3 adult and children stammering services to understand how needs can be met locally and where potentially there are gaps across North Yorkshire and York.
2.4The PCU has obtained activity data from Leeds Stammering Support service to support CCG consider their commissioning intentions. In addition prevalence figures have been sought to indicate what the expected level of demand on services might be.
2.5Whilst these discussions continue, the PCU have agreed with the CCGs that should a tier 4 referral be required in the meantime, the request would be discussed between PCU and CCG and proceed as a spot purchase if agreed through the IFR panel.
3.0 Currency and Tariff Options
3.1Following the challenges to the service, a much clearer pathway and tariff payments has been developed. (Appendix 1 page 2). The service can be accessed via two pathway options – block or tariff. Within the tariff there are a number of assessment and therapy options, and also training and development, which can be commissioned on a ‘mix and match’ basis.
3.2 Following discussions with the service, credit notes have been raised against the previously raised invoices whilst the CCGs consider their commissioning intentions and options.
4.0 Prevalence (Need) in children and adults
4.1It is expected that 5% of children under the age of 5 will go through a phase of stammering (twice as many boys than girls stammer). Up to one in four of these children are at serious risk of developing chronic stammering without intervention.
4.2In school age children (5 to 16 years) research estimates that 1.2% of school age children stammer.
4.3 In adulthood 1% of the population stammers. It is understood that figures are remaining consistent worldwide and across all cultures and social groups.
4.4 Using the ONS 2012 mid year population estimates by health geography, and the prevalence reported above, the table below reports the incidence of stammering within each of the four North Yorkshire CCG populations.
Table 1.ONS Mid year estimates 2012 by Health Geography
Populations / Under 5s / 5 - 16 yrs / 17 years + / Total
NHS Hambleton, Richmondshire and Whitby / 7,653 / 19,313 / 126454 / 153,420
NHS Harrogate and Rural District / 8,687 / 22,174 / 127,749 / 158,610
NHS Scarborough and Ryedale / 5,734 / 13,628 / 91,126 / 110,488
NHS Vale of York / 18,332 / 43,166 / 284,556 / 346,054
Totals / 40,406 / 98,281 / 629,885 / 768,572
Prevalence / 5% / 1.20% / 1%
Expected incidence of stammering / Under 5s / 5 - 16 yrs / 17 years + / Total
NHS Hambleton, Richmondshire and Whitby / 382.7 / 231.8 / 1264.5 / 1878.9
NHS Harrogate and Rural District / 434.4 / 266.1 / 1277.5 / 1977.9
NHS Scarborough and Ryedale / 286.7 / 163.5 / 911.3 / 1361.5
NHS Vale of York / 916.6 / 518.0 / 2845.6 / 4280.2
Totals / 2020.3 / 1179.4 / 6298.9 / 9498.5
Risk of developing a chronic stammer without intervention
Under 5s
1:4
NHS Hambleton, Richmondshire and Whitby / 95.7
NHS Harrogate and Rural District / 108.6
NHS Scarborough and Ryedale / 71.7
NHS Vale of York / 229.2
Totals / 505.1
4.5Stammers tend to develop during childhood, usually beginning at around the age of 3 ½ years. A stammer is less likely to be totally eliminated in children greater than 6 years. Early referral is key as Speech and Language therapists are trained to identify those who may need therapy. Stammering that persist beyond age 6 tends to be more challenging to resolve.
4.6In adult/late onset, the stammer can be a result of a severe head injury, stroke or progressive neurological disease. It can also be caused by certain types of drugs/medication, psychological or emotional trauma (acquired stammer).
5.0 Demand
5.1 Activity figures have been provided by the Leeds Stammering Service for the periods 2010/2011 and 2011/2012. As the activity relates to the NHS North Yorkshire and York geographic footprint, referring GP was requested so that activity could be aligned to the new CCG footprints. The activity is presented in tables 2 and 3.
Table 2Referrals to the service (activity of each referral is unknown) 2011/2012
CCG / HRW / HaRD / VoY / SR / AWC / Total
Children / 1 / 8 / 1 / 0 / 1 / 11
9% / 72% / 9% / 9%
Adults / 1 / 1 / 1 / 2 / 1 / 6
17% / 17% / 17% / 33% / 17%
Total Referrals (all ages) / 2 / 9 / 2 / 2 / 2 / 17
Referrals to the Service 2011/2012
Table 3.Referrals to the service (activity of each referral is unknown) 2012/2013
CCG / HRW / HaRD / VoY / SR / AWC / Total
Children / 2 / 7 / 3 / 1 / 0 / 13
15% / 54% / 23% / 8%
Adults / 1 / 0 / 1 / 1 / 0 / 3
33% / 33% / 33%
Total Referrals (all ages) / 3 / 7 / 4 / 2 / 0 / 16
Referrals to the Service 2012/2013
5.2The highest volume of referrals is from HaRD CCG. Rather than higher prevalence or inability to manage patients locally, this might be a reflection of the closer proximity and accessibility of the tier 4 service compared for example to Scarborough population.
6.0 Commissioned Provision
6.1 Table 4 maps service provision currently commissioned across the county. All localities have tier 3 dysfluency provision. Services in Scarborough and Ryedale localities report waiting times of up to 12 weeks. Other services adopt drop in clinics which negate the development of waiting lists.
Table 4. Commissioned services in North Yorkshire and York
Provider / Locality / Group / Commissioner / Dysfluency (stammering) Service DescriptionHarrogate and District NHS Foundation Trust / Hambleton and Richmondshire / Adult / HRW CCG /
Lead:Stephanie Verity.
Individual assessment session followed by therapy: dysfluency therapy on a 1:1 basis, and solution focused brief therapy (CBT). Currently around 4 on caseload.
No waiting list.
Harrogate and District NHS Foundation Trust / Hambleton and Richmondshire / Child / HRW CCG / Lead: Vander Clayton
Early years and school aged pathways in place. Children generally seen within 8 weeks.
1 session per week.
20 children on caseload
Harrogate and District NHS Foundation Trust / Scarborough, Whitby and Ryedale / Adults / SR CCG / Lead: Val Birch
Adult Acquired Service.
Difficult aetiologies.
Signpost and advice
5 on the caseload.
No waiting list.
Harrogate and District NHS Foundation Trust / York
Harrogate / Adults / HaRD CCG
VoY CCG / Jane Denman
(1 afternoon a week).
Low numbers – 5 a year York, 3 in Harrogate.
Acquired stammers receive advice and signposting but do not sit on a caseload.
No waiting list.
Harrogate and District NHS Foundation Trust / Harrogate / Child / HaRD CCG / Lead : Ben Bolton
Approximately 20 on caseload
1 session per week
No waiting list.
York Teaching Hospitals NHS Foundation Trust / Scarborough, Whitby and Ryedale / Child / SR CCG
HRW CCG / Lead: Judith Baigent.
0-18 years
General clinic therapists can see children aged 0 to 7yrs 11 months with support from the Specialist S<. All dysfluency referrals aged 7 yrs 11+months up to 18 go direct to the Dysfluency Specialist Therapist. DST covers SWR in 2 sessions per week, including training support to schools and some direct input into the complex young children.
Children also supported by Teaching Support Staff.
(nb longer waits for assessment in older age group).
York Teaching Hospitals NHS Foundation Trust / York / VoY CCG / Lead: Judith Baigent.
0 -18 years.
Dysfluency care pathway in place.
0-5 year olds access point via drop in service.
No waiting list for advice under 5s, but short wait for assessment.
Over 5s – 4-5 weeks wait.
7.0Conclusions
7.1From the mapping information received to date, it would suggest that there is good tier 3 dysfluency service provision for children and adults within the 4 North Yorkshire and York CCG geographic footprints. It is noted that children may experience longer waiting times for the Scarborough, Whitby and Ryedale Dysfluency service.
7.2The service gap would appear to be for local therapy groups.
7.3Early intervention is key and the impact of stammering on families can be considerable in terms of psychological aspects, educational attainment and development, anxiety and social isolation.
7.4There is a clinical need for some individuals to access the tier 4 regional stammering service. This might be for further assessment and individual therapy. In addition the individual and/or the local Therapist might consider that referral for group therapy is beneficial.
7.5Service providers have also reported the value of the tier 4 service on their Continuing Professional Development and supporting Clinical Supervision. It is expected that providers would be responsible for any financial and organisational arrangements to support this. Any provider training previously delivered by the tier 4 service will have been commissioned as part of the PCT original block contract.
8.0Recommendations - Commissioning Intentions
8.1Access to children’s dysfleuncy services are reviewed with providers to ensure that children are not waiting longer than necessary as early intervention is key.
8.2That the CCG advise the PCU of their collaborative decision as to whether further challenge to NHS England is of value. PCU view is that the potential value of the contract activity might not justify the resource involved to continue the challenge.
8.3That the CCGs consider requests for tier 4 referrals on an individual (spot purchase) basis through the PCU using the range of tariff packages set out in appendix 1.
8.4Subject to agreement of 8.3, suitable pathways will be drafted to share with CCGs and providers.
Appendix 1
1