Feedback required: Northern Sydney LHD Allied Health … · 2016-05-16 · Newsletter: 106/2015 Date: 8 March 2016 Distribution: Allied Health members NSLHD Contact: Your organiser

Newsletter: 106/2015 Date: 8 March 2016 Distribution: Allied Health members NSLHD Contact: Your organiser

Feedback required: Northern Sydney LHD

Allied Health Transformation Project Report Dear Member, Attached is correspondence the HSU has received from the NSLHD regarding the FGI Allied Health Transformation project report. Member feedback requested The HSU industrial team is currently reviewing the potential impacts of the proposed report upon affected employees within the NSLHD. We are now seeking feedback, views and comments from our members. Please review the attached documentation and provide comment and feedback by close of business 25 March 2016. You can submit it by email to our Health Professionals Organiser Denise O’Shaughnessy at email [email protected] with subject line NSLHD FGI report. HSU organiser visits Your HSU organisers Brendan Roberts and Denise O’Shaughnessy will be visiting your workplace shortly and convening a meeting to discuss the matter with affected employees. The most effective way to deal with these kinds of proposals is by taking into account the concerns of the group, agreeing on a way forward and presenting that united position to management. Please distribute this newsletter to your work colleagues for their information and comments and encourage them to attend the meeting. Not a member of the HSU? Now is time to join and have your say! You can join online at www.hsu.asn.au/join-hsu/ or call 1300 478 679 and join over the phone. A union’s effectiveness and negotiation power strongly depends upon the strength and density of its membership base. Join your work colleagues today by becoming a member of the Health Services Union and help us to continue to protect, build and improve your working life. In unity,

Gerard Hayes Secretary, HSU NSW/ACT.

mailto:[email protected]?subject=NSLHD FGI Report

https://www.hsu.asn.au/join-hsu/

Allied Health Transformation

Phase One

Northern Sydney Local Health District (NSLHD)

Project Report

February 2016

Francis Group International (FGI)

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TABLE OF CONTENTS

EXECUTIVE SUMMARY ................................................................................................4

1.1 KEY THEMES ................................................................................................................5 1.2 CHARACTERISTICS OF HIGH FUNCTIONING ALLIED HEALTH SERVICES ..........................................6 1.3 SUSTAINABILITY IMPROVEMENT INITIATIVES ........................................................................8 1.4 ALLIED HEALTH TRANSFORMATION PROGRAM: PHASE TWO .................................................. 14

INTRODUCTION ........................................................................................................ 15

2.1 PURPOSE OF THIS DOCUMENT ........................................................................................ 15 2.2 BACKGROUND TO THE PROJECT ...................................................................................... 15 2.3 PROJECT SCOPE AND OBJECTIVES .................................................................................... 16 2.4 PROJECT ACTIVITIES ..................................................................................................... 17

SERVICE LANDSCAPE ................................................................................................. 18

3.1 NORTHERN SYDNEY LHD .............................................................................................. 18 3.2 ALLIED HEALTH WORKFORCE ......................................................................................... 18 3.3 SUMMARY OF KEY THEMES ........................................................................................... 19 3.4 WORKFORCE PROFILES ................................................................................................. 20

CHARACTERISTICS OF HIGH FUNCTIONING ALLIED HEALTH SERVICES ......................... 35

4.1 PATIENT-CENTRIC FOCUS INFORMS MODELS OF CARE............................................................ 36 4.2 MULTIDISCIPLINARY TEAMS (MDTS) ............................................................................... 37 4.3 HIGHLY ENGAGED ALLIED HEALTH PROFESSIONAL WORKFORCE .............................................. 39 4.4 EARLY ALLIED HEALTH PROFESSIONAL INTERVENTION IN PATIENT JOURNEY ............................... 41 4.5 ALLIED HEALTH PROFESSIONALS PROVIDE FIRST POINT OF CONTACT IN EMERGENCY DEPARTMENTS 43 4.6 EXTENDED HOURS OF ALLIED HEALTH SERVICE COVERAGE ..................................................... 44 4.7 SUPPORT FOR EXTENDED SCOPES OF ALLIED HEALTH PRACTICE ............................................... 45 4.8 ALLIED HEALTH PROFESSIONALS SUPPORTED BY APPROPRIATE MODELS OF ALLIED HEALTH

ASSISTANTS (AHA) .............................................................................................................. 47 4.9 EARLY ADOPTION OF PROVEN INNOVATIONS ...................................................................... 51 4.10 SERVICES DEVELOPED IN PARTNERSHIP WITH NGOS, PRIVATE AND OTHER PUBLIC HEALTH SERVICES

53 4.11 ALLIED HEALTH SERVICES LINKED WITH ACADEMIC INSTITUTIONS ........................................... 56 4.12 BENCHMARKING ....................................................................................................... 57

GOVERNANCE MODEL ASSESSMENT .......................................................................... 59

5.1 EXECUTIVE REPRESENTATION ......................................................................................... 59 5.2 EXECUTIVE REPRESENTATION: OPTIONS FOR CONSIDERATION ................................................ 61 5.3 RECOMMENDATION: EXECUTIVE REPRESENTATION .............................................................. 64 5.4 LHD-WIDE SERVICE GOVERNANCE STRUCTURE ................................................................... 66 5.5 LHD-WIDE SERVICE GOVERNANCE: OPTIONS FOR NEAR-TERM CONSIDERATION .......................... 69 5.6 LHD-WIDE SERVICE GOVERNANCE: OPTIONS FOR FUTURE CONSIDERATION ............................... 74 5.7 RECOMMENDATION: LHD-WIDE SERVICE GOVERNANCE STRUCTURE ........................................ 77

SUSTAINABILITY PORTFOLIO ..................................................................................... 78

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6.1 ALLIED HEALTH TRANSFORMATION PROGRAM: PHASE TWO .................................................. 78 6.2 SUSTAINABILITY PORTFOLIO ........................................................................................... 78 6.3 SUSTAINABILITY IMPROVEMENT INITIATIVES ...................................................................... 80

APPENDIX A: ISSUES AND INITIATIVES MAPPING ...................................................... 86

7.1 EXERCISE PHYSIOLOGY .................................................................................................. 86 7.2 OCCUPATIONAL THERAPY .............................................................................................. 87 7.3 MENTAL HEALTH/DRUG AND ALCOHOL ............................................................................ 88 7.4 NUTRITION AND DIETETICS ............................................................................................ 89 7.5 ORTHOTICS ................................................................................................................ 90 7.6 PHYSIOTHERAPY ......................................................................................................... 91 7.7 PODIATRY ................................................................................................................. 92 7.8 PRIMARY AND COMMUNITY HEALTH ............................................................................... 93 7.9 PSYCHOLOGY ............................................................................................................. 94 7.10 SOCIAL WORK .......................................................................................................... 95 7.11 SPEECH PATHOLOGY .................................................................................................. 96

APPENDIX B: LITERATURE REVIEW ............................................................................ 97

9. APPENDIX C: STAKEHOLDERS CONSULTED 122

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Executive Summary

Allied Health (AH) workforces are integral to modern health care service provision. These professions provide a vital function in the patient care continuum, both in their own specialist clinics, or as part of multi-disciplinary care teams.

In line with other districts NSLHD employs Allied Health Professionals (AHPs) in a range of service delivery models. During 2015 NSLHD employed 1,300 (928.70 FTE) AH health staff within twenty Allied Health Disciplines, representing approximately 11% of the total clinical workforce.

Recently, a number of issues were identified as potentially impacting the provision of Allied Health Services and deserving of further exploration:

Variations in skill mix and staffing levels, models of care and ‘siloed’ delivery of services across the 5 key facilities within NSLHD.

Insufficient budgetary consideration of the requirements for cover and replacement of Allied Health Staff when on leave.

Increased demand for services in recent years, especially following the redevelopment of the Royal North Shore Hospital (RNSH) and Hornby Ku-ring-gai (HKH) campus facilities.

In response this project, the Allied Health Transformation: Phase One, was initiated in November 2015 to undertake a review of the Allied Health Service across the District with the goal of identifying and costing opportunities for improvement to achieve consistency in clinical care in the most appropriate form regardless of place of treatment or time of year.

The project had five objectives as follows:

Assess the current Models of Care against leading practice and identify opportunities to enhance same across NSLHD.

Evaluate the demand for provision and utilisation of allied health services and provide advice on the most appropriate distribution, allocation and organisation of AH resources.

Review Allied Health scope of practice and make recommendations about the opportunities for development of advanced practice allied health roles and expansion of the Allied Health Assistant (AHA) workforce.

Provide advice on future workforce needs across NSLHD – develop a tool for future workforce planning/proofing.

Explore potential governance structures for Allied Health.

The conduct of this work was intended to align with the key NSLHD strategic priorities to:

Deliver the same care, anywhere, any time of year – acknowledging that reducing clinical variation is a cornerstone in the delivery of safe, high quality patient care provision.

Optimise patient outcomes – by ensuring the ability of the LHD to deliver consistent, high quality care in a patient-centric way.

Twelve AH Disciplines were identified as being within the scope of this project:

Exercise Physiology

Neuropsychology

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Nutrition and Dietetics

Occupational Therapy

Orthotics

Podiatry

Physiotherapy

Psychology

Social Work

Speech Pathology

Mental Health/Drug and Alcohol (MHDA)

Primary and Community Care (PACH)

Staff from these Disciplines are deployed across the following areas:

All acute wards and facilities at Royal North Shore Hospital (RNSH), Hornsby Ku-ring-gai Hospital (HKH), Manly Hospital, Ryde Hospital and Mona Vale Hospital.

Sub-acute wards and facilities at Royal North Shore Hospital (RNSH), Hornsby Ku-ring-gai Hospital (HKH), Manly Hospital, Ryde Hospital and Mona Vale Hospital.

Mental Health/Drug and Alcohol Services (MHDA).

Primary and Community Health Services (Health Service and NSLHD).

It was agreed that the following areas were excluded from the scope of work:

Medical Imaging

Pharmacy

Audiology, Orthoptics and Genetic Counselling at RNSH

The new Northern Beaches Hospital and the associated impact on Allied Health Services at Northern Beaches has been excluded from the scope of work.

While these impacts will be managed through a separate process, it is acknowledged that the report recommendations should be implemented in a way that is applicable and consistent with the need to facilitate a smooth transition of Allied Health Services to the new Northern Beaches Hospital in 2018.

Two deliverables were anticipated as a result of this work:

Proposed changes to current service delivery model and governance structure documented, prioritised and costed (in detail) with risks/benefits documented.

Model for determining staffing profile for current and future service delivery.

The second deliverable (staffing profile model) was removed from the scope during Week 6 of the project. This decision was taken to ensure that the first deliverable was developed in sufficient quality and depth, in recognition that this was critical to achieving the second deliverable. Development of the second deliverable will be pursued internally by NSLHD during 2016.

1.1 Key Themes

Over 8 weeks between 2 November and 23 December2015 the project team conducted a program of desk top research and stakeholder consultation across the LHD. 285 stakeholders

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were engaged via in a series of interviews, site visits and interactive workshops. Outputs from these activities provided the two main data sources leveraged in this report

Stakeholder consultations.

Research base derived from our review of the relevant national and international literature, including NSLHD documentation.

Six key themes emerged from the stakeholder consultations as follows:

Lack of an Allied Health ‘Voice’: AH staff feel disempowered under the current governance arrangements, primarily the current routing of professional reporting lines to the Executive via another professional group. This is compounded by a sense that their ‘voice’ as a group does not carry the appropriate weight in the organisation. These factors combine to negatively impact on the current level of AHP staff engagement with the LHD and provides a potential barrier to change.

Retaining Professional identities: Each AH Discipline has a strong specialist, professional identity which is highly valued by AHPs. This is expressed in stakeholder caution when considering the potential of models of task/role substitution for example, which can be perceived as reducing standards of specialist professional practice. The diffusion of AH into Disciplines can also inhibit the ability of AHPs to represent themselves consistently as one professional group.

Value of Allied Health services not fully understood or communicated: The understanding of value of the work of Allied Health staff can provide is variable to both other clinician groups and patients alike. As a result, further opportunities exist to enhance the contribution of AHPs to the optimisation of patient care.

Resourcing levels appear stretched: stakeholders consistently report that current staffing levels are insufficient to sustain service coverage, especially around leave taking. Service design appears a root cause of this issue as AH Services have evolved over time to ‘fill a need’ and are not necessarily designed to ensure alignment of resources with demand or as linkages/extensions of existing services.

Information gaps restricting ability to access evidence for performance management: Inconsistencies in application of data policy and practice between services has led to variance in data collection practice and interpretation. Additional analytical effort is therefore required to effectively leverage the data collections as an evidence base. The effect of this is to limit the accessibility of AHPs to clinical data which could be used to inform review and improvements to practice with their Services.

Willingness to engage with the LHD to enhance services: the majority of AH stakeholders are willing to engage with a change management program focused on optimising patient care and improving service delivery. As a result there is strong potential for the LHD to engage the expert clinical knowledge of AHPs to build on current practice standards and continue to optimise patient care.

1.2 Characteristics of High Functioning Allied Health Services

The key themes above are complemented by the results of our assessment of the current Models of Care at NSLHD against leading practice. Based on our research, twelve characteristics of high functioning AH services were identified and used as the baseline for an assessment of current NSLHD practice as summarised in Figure 1 below.

The purpose of this analysis is to highlight areas of existing good practice at NSLHD and to provide an indication of areas where improvement efforts could be considered. It was clear through the

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assessment that a wide range of examples of current practice within NSLHD align with each of the 12 characteristics to some degree.

Figure 1: Characteristics of High Functioning AH Services

The results of this assessment, combined with the key themes identified above, provided the basis by which the project team has identified potential changes to the current service delivery model and governance structure.

1.3 Sustainability Improvement Initiatives

Sustainability initiatives in the table below outline the key initiatives addressing core issues raised by stakeholders during the project. The initiatives link with strategies developed in the Allied Health NSLHD clinical service plan.

1.0 Staffing

Ref. No.

Initiative Addressing stakeholder voiced issues

Implementation barriers Initiative Impact

Implementation challenge

1.1 Assess LHD wide leave requirements for each profession to inform the capacity management planning tool. • Identify need for leave across professions, teams and facilities

Assess leave patterns and work demand volumes • Historical trends of different types of leave e.g. study,

maternity, sick.

• Lack of appropriate leave relief

• Data integrity High Low

1.2 Develop capacity management planning tool to provide advice on appropriate use of additional resources (AH, AHA, admin) against demand across NSLHD.

• Lack of adequate staff resourcing and support

• Data integrity • Lack of industry staffing

number standards • Large range of patient

complexity • Service variation • Lack of national/

International data for benchmarking

High High

1.3 Assess current clinical and non-clinical activities and duties to support budget build up/cost centres and planning which will also inform the capacity management tool


Lack of industry staffing number standards • Large range of patient

complexity • Data integrity

High High

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Ref. No.




1.4 Develop discipline-specific workload measures for each profession to inform capacity management planning to support appropriate resource planning and skill mix.

• Stakeholders voiced a lack of adequate staff resourcing and support

• Large range of patient complexity

• Data integrity • No national or

international standard to determine measure

High High

1.5 Explore the benefits of extending the 7 day/week coverage for Occupational Therapy, Social work, Physiotherapy, Dietetics, Speech Pathology across the LHD to expedite discharge, reduce turnaround time, reduce length of stay, increase support, increase patient safety, improve patient outcomes.

• Delays in patient discharge due to inability to provide full service on weekend

• Resourcing • Financial Restraints • Monday- Friday Culture

for some services

High High

1.6 Review set up, skill mix, use and management of casual pools with the aim to standardise practices across the LHD to provide roster cover, to prevent service gaps and better sustain service cover during period of staff leave and recruitment.


• Financial Restraints • Resourcing

High Med

1.7 Formalise and increase the use (where appropriate) of AHPs in discharge planning in acute and sub-acute areas to enhance current participation of AH in facilitating discharge and assist reductions in LOS.

• Increased potential for involvement in discharge planning to improve patient outcomes

• Legacy practices • Resourcing

Med Med

1.8 Explore potential to change shift start and finish times to determine the benefits (staff & patient) and implications with the aim of better aligning allied health resources with service demand and enhance service delivery.


• Resourcing • 8.00 - 4.30 culture • Financial Restraints

Med Med

1.9 Establish professional reporting lines for all Allied Health staff and their specific discipline to receive discipline specific supervision as per the LHD’s AH supervision policy and to ensure appropriate recruitment.

• Lack of adequate staff support

• Minimal peer mentoring or supervision

• Resourcing • Legacy practices • Financial Restraints

Med Med

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2.0 Data

Ref. No.

Initiative Addressing issues Implementation barriers Initiative Impact


2.1 Pilot dedicated AH data manager across LHD to support data management. Key roles will be: • Implement / enforce standardised business rules for clinical

information system use across NSLHD (e.g. CHOC, eMR, turnaround time recording practice) to provide consistent basis for reporting/analysis

• Role provides additional training capacity by which to upskill clinicians on key clinical information/data collection systems (e.g. CHOC, eMR) to support enhanced, consistent data entry.

• Data systems are confusing and difficult to use; data support is low

• Service contact forms are difficult to use

• Inconsistent documentation practices for CHOC and eMR

• Data support is low; and, inconsistent documentation practices for CHOC and eMR

• Financial Constraints • Resourcing • Data Integrity

High Med

2.2 Assess the potential to invest in expanding external benchmarking of Allied Health services at all sites.

• Limited external performance benchmarking data unavailable

• Data integrity • Financial constraints

Low Med

2.3 Design and implement information reporting which better aligns with specific AH requirements, including measures of AH performance (e.g. turnaround time) and characteristics of AH service delivery (e.g. location of service delivery) and secure executive support for the AH Minimum Data Set.

• Limited meaningful reporting for AH staff of performance

• Data systems are confusing and difficult to use;



• Data integrity Med Med

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3.0 Models of care

Ref

No.



3.1 Realign AHA Coordinator role to report to Director Allied health and continue to extend processes currently underway to develop safe and appropriate models of AHA care by discipline to support AHP while exploring the potential to realign the Pharmacy educator role to Director of Allied Health.

• Lack of adequate staff resourcing and support, service structure, resistance to change

• More appropriate use of AHA

• Legacy Practice Med Low

3.2 Explore opportunity to extended- AHP scope of practice focusing on key practice areas (e.g. criteria led discharge, referrals, diagnostic ordering, prescribing etc.) and further develop training pathways, requirements, governance and credentialing to increase scope of AHPs, improve patient satisfaction and reduce cost.

• Improve opportunities for extended scope of practice

• Legacy Practice • Professional Boundaries

High High

3.3 Explore LHD wide implementation of best practice models ensuring appropriate allied health involvement (e.g. oncology, aged care, paediatrics, diabetes) across the total patient journey and services delivery models

• Need to better integrate MDT assessment and continuity of care

• Resourcing • Legacy Practice • Professional Boundaries

High High

3.4 Explore partnership opportunities in non-acute areas by determining LHD service gaps against current demand to improve; patient centric care, rates of hospital avoidance, continuity of care and integrated care.

• Lack of adequate service coverage in some areas

• More appropriate use of NGOs

• Better alignment of resourcing with service need where required

• Legacy Practices • Data integrity

Med High

3.5 Undertake a review of AH consumer perspectives of care delivery while leverage existing surveys to support service delivery improvement.

• Patient centred care • Time constraints • Consumer participation

High Med

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4.0 Innovation

Ref. No.



4.1 Develop and implement a plan to improve academic research to enhance links to district academic partner institutions to increase opportunities for AH research to enhance professional development, research funding, increased staff satisfaction, increase timely incorporation of innovation into current practice.

• Lack of capacity to undertake research for some services

• Lack of research opportunities and knowledge funding options

• Minimal professional reporting structures and lack of supervision and leave relief

• Legacy Practice • Resourcing

Med Low

4.2 Explore possibilities for the use of social media/other applications/devices to better facilitate patient/consumer engagement and support models of preventative care (e.g. cardiac rehab, PACH).

• Slow to leverage new technology

• Facilitate patient flow

• Legacy Practice Low Med

4.3 Pilot a formalised ideas’ assessment process to evaluate new ideas generated from AHPs in: • Practices (e.g. podiatry ultrasound debridement) • models of care (mobile orthotic teams) • technology (3D printing technology)

• Lack of allied health empowerment

• Value in the importance of striving for more innovation

• Facilitate patient flow • Better alignment of

services with need • Improving patient

journey and flow

• Resourcing • Time constraints

High Med

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5.0 Process

Ref. No.



5.1 Conduct LHD-wide review of internal referral process to streamline referral process to understand/validate referral duplication and inappropriate referrals to appropriately refer and prioritise referrals across all disciplines which should free up clinician time and improve patient access to care.

• Duplication and inappropriate referrals

• More appropriate and timely referrals

• Legacy practices • Multiple referral systems

not linked (e.g. ePJB and eMR)

High Med

5.2 Explore options to improve timely recruitment to mitigate staffing vacancies. This will include identifying and mitigating where recruitment delays (profession/facility/process) are occurring.

• Long delays in recruitment process


5.3 Develop and formalise a communications strategy in-line with the established governance structure and pathways for disseminating Allied Health information to ensure consistent and timely communications. This should include an escalation process for ground staff to raise issues.

• Inconsistent information received by staff

• Legacy practices High Low

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1.4 Allied Health Transformation Program: Phase Two

It is recommended that a change management program and an associated governance framework be established to take ownership of the recommendations made in this report and to oversee the subsequent phases of the Allied Health Transformation.

The recommendations in this report are further detailed as a set of 24 recommended initiatives collated in the Sustainability Portfolio. These initiatives are designed for implementation as part of a program of sustainable service transformation for Allied Health at NSLHD.

This program should be oriented to engage and facilitate the input of all relevant AH stakeholders (clinical and managerial) in service analysis and redesign processes and in this way, leverage clinical expertise and service knowledge to deliver sustainable service transformation.

The following critical dependencies to the successful implementation of this program and associated initiatives have been identified as follows:

The creation of an overarching program governance framework is necessary to own the Sustainability Portfolio and oversee implementation of its initiatives.

Realignment of the reporting arrangements for Allied Health to the LHD Executive (as outlined in section 5.3 below) actioning this recommendation will address a significant barrier to change and enhance levels of stakeholder engagement.

Establishment of the AH Steering Group (as outlined in section 5.7 below), as this new governance structure will possess the appropriate membership and a LHD-wide breadth of scope, which will enable it to facilitate and support the implementation of change initiatives.

Assignment of an appropriate resource as AH Transformation Program Manager, with appropriate Project Officer support.

Appropriate sponsorship from the Director Allied Health and an Executive report (tbc).

Considering the level of organisational and cultural change implied by the cumulative potential impact of the Sustainability Portfolio initiatives - it is anticipated that the change process will require a three year timeframe.

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Introduction

2.1 Purpose of this Document

This document details the findings of the Allied Health Transformation Project Phase One, a review of Allied Health (AH) Service Delivery across selected professions within Northern Sydney Local Health District (NSLHD) conducted between 2 November and 23 December 2015.

2.2 Background to the Project

Allied Health (AH) workforces are integral to modern health care service provision. These professions provide a vital function in the patient care continuum, both in their own specialist clinics, or as part of multi-disciplinary care teams.

AH professions are distinct from Medical and Nursing workforces notably in the broader range of entry requirements and the wider scope of tasks that they routinely perform, from the most basic to highly specialist care. Currently the NSW Ministry of Health recognises 23 separate Allied Health professions, each multi-faceted with its own array of challenges and opportunities.

In line with other districts NSLHD employs Allied Health staff in a range of service delivery models including: acute inpatient admission, ambulatory care and (outpatient) follow up, rehabilitation programs, mental health drug and alcohol inpatient units and in the respective community teams. Community services for patients with complex and ongoing chronic disease where allied health services can improve and maintain their health status are also provided.

During 2015 NSLHD employed 1,300 (928.70 FTE) AH health staff within twenty allied health disciplines, representing approximately 11% of the total clinical workforce.

A number of issues had been identified as potentially impacting the provision of Allied Health services and deserving of further exploration:

Variations in skill mix and staffing levels, models of care and ‘silo’ service delivery of services across 5 key facilities within NSLHD, the Royal North Shore (RNSH), Ryde, Manly, Mona Vale and Hornsby Ku-Ring-Gai (HKH) hospitals

Insufficient budgetary consideration of the requirements for cover and replacement of Allied Health Staff on leave including sick leave, annual leave and unpaid maternity leave. Recognition that the business case for leave cover needs to be defined and appropriately articulated

Increased demand for services in recent years, especially following the redevelopment of the RNSH and HKH campus facilities.

In response the LHD initiated the Allied Health Transformation program process. The first phase was to undertake a review of the Allied Health Service across the District with the goal of identifying and costing opportunities for improvement to achieve consistency in clinical care in the most appropriate form regardless of place of treatment or time of year. The project had five objectives as follows:

Assess the current Models of Care against leading practice and identify opportunities to enhance same across NSLHD

Evaluate the demand for provision and utilisation of allied health services across acute, sub-acute, Mental Health Drug and Alcohol and community health services and provide advice on the most appropriate distribution, allocation and organisation of allied health

16

resources to improve patient outcomes, reduce inappropriate clinical variation and improve service efficiency.

Review allied health scope of practice and make recommendations about the opportunities for development of advance practice allied health roles and expansion of the allied health assistant workforce.

Provide advice on future workforce needs across NSLHD – develop a tool for future workforce planning/proofing.

Explore potential governance structures for Allied Health to achieve the most streamlined service provision and optimise clinical workforce development and retention, ensuring all allied health staff have access to clinical supervision and clearly defined reporting lines of responsibility.

The conduct of this work was intended to align with the key NSLHD strategic priorities to:

Deliver the same care, anywhere, any time of year – acknowledging that reducing clinical variation is a cornerstone in the delivery of safe, high quality patient care provision

Optimise patient outcomes – by ensuring the ability of the LHD to deliver consistent, high quality care in a patient-centric way.

The Allied Health Transformation Project: Phase One, was initiated on 2 November 2015 for an eight week period. This report document provides the detailed findings of the investigations conducted and is the chief deliverable of the project.

2.3 Project Scope and Objectives

The following AH Disciplines were identified as being within the scope of this project:

Exercise Physiology

Neuropsychology



Orthotics

Podiatry

Physiotherapy

Psychology

Social Work

Speech Pathology

Mental Health/Drug and Alcohol (MHDA)

Primary and Community Care (PACH)

Staff from these Disciplines are deployed across the following areas:

All acute wards and facilities at Royal North Shore Hospital (RNSH), Hornsby Ku-ring-gai Hospital (HKH), Manly Hospital, Ryde Hospital and Mona Vale Hospital

Sub-acute wards and facilities at Royal North Shore Hospital (RNSH), Hornsby Ku-ring-gai Hospital (HKH), Manly Hospital, Ryde Hospital and Mona Vale Hospital

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Mental Health/Drug and Alcohol Services (MHDA)

Primary and Community Health Services (Health Service and NSLHD).

The following areas were excluded from the scope of work:

Medical Imaging

Pharmacy

Audiology, Orthoptics and Genetic Counselling at RNSH

The development of the Frenchs’ Forest Hospital is excluded from the scope of this work, however the implications for Northern Beaches’ services are acknowledged and it is understood NSLHD will address these issues separately.

Two deliverables were anticipated as a result of this work:

Proposed changes to current service delivery model and governance structure documented, prioritised and costed (in detail) with risks/benefits documented

Model for determining staffing profile for current and future service delivery.

The second deliverable (staffing model) was removed from the scope during Week 6 of the current project and will be pursued internally by NSLHD during 2016.

2.4 Project Activities

Over the eight weeks between 2 November and 23 December 2015 the project team conducted a significant program of stakeholder engagement and desk top research encompassing 285 stakeholders (a full listing is provided in section 10 below) across the LHD in four work streams as follows:

Initial interviews - a series of 1:1 discussions were held with eight senior management stakeholders across the LHD

Review of the relevant national and international literature

Allied Health Staff Workshops - 239 staff delegates attended seven half-day working sessions held between 19 and 26 November along Disciplinary lines

Site Visits and meeting with Service Managers: The Project Team has visited the five key sites conducting Service Manager interviews/group sessions with 34 service managers across the in-scope professions between 10 November and 2 December 2015.

Consultations were held with the Directors of Nursing (15 December) and Medical Services (14 January) to obtain an external perspective on AH Services from other professional groups.

The findings from these engagement processes and the associated recommendations have been developed and reviewed in collaboration with the NSLHD Allied Health Transformation Project Team, Working Party and Steering Committee (details of membership is provided in section 9 below) to garner further understanding of the issues impacting on Allied Health and to ensure that recommendations appropriately align with the needs and priorities of NSLHD.

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Service Landscape

This section provides an overview of the NSLHD environment and detail of each of the Allied Health workforces within the scope of this project. The common themes and issues identified across each group involved in the review process are also discussed.

3.1 Northern Sydney LHD

Northern Sydney LHD is governed by a Board of Directors and a Chief Executive. Most clinical services are provided through the three Health Services, including Hornsby Ku Ring Gai (HKH), Royal North Shore Ryde (RNSR), and Northern Beaches (NB). In 2013/14 NSLHD managed 192,000 emergency presentations: nearly 78,000 adult medical and surgical admissions, nearly 7,000 paediatric admissions and 5,500 maternity confinements. The net cost of service for the LHD was $1,132 million (Northern Sydney Local Health District, 2015).

Northern Sydney LHD has a workforce of nearly 9,000 staff (7,500 full time equivalent), three quarters of whom are female. Allied Health represents 12% of this workforce (Northern Sydney Local Health District, 2015). For further information on specific facilities and services please refer to the NSLHD Clinical Services Plan 2015-2022 (Northern Sydney Local Health District, 2015).

3.2 Allied Health Workforce

This section provides a general overview of the Allied Health workforce within NSLHD and the key themes that emerged from the consultation process, including interviews and workshops. Information and findings specific to each discipline within the scope of this project is also provided in this section.

3.2.1 General overview

The Allied Health workforce in NSLHD is deployed across inpatient, outpatient and community-based services. Allied Health departments in general hospital facilities tend to be structured around service lines with professional reporting lines managed within each professional group. Allied Health staff deployed in PACH and MHDA are structured within MDTs with individual reporting lines to team or unit managers who may or may not be an Allied Health professional. Table 1 below shows that for those Allied Health professions within the scope of this project there was a total of 710.17 FTE employed across NSLHD facilities. For specific disciplines these FTE numbers ranged from 157.06 FTE for Social Work (of which 66.41 FTE assigned to MHDA) to 4.55 for Exercise Physiology.

Workforce data indicates that across all disciplines there were 45.88 FTE Allied Health professionals deployed in PACH and 225.88 deployed in MHDA. Within MHDA there are a number of AH staff working under the Health Service Manager (HSM) award structure and these FTE numbers are not captured within this analysis. The remaining AH Professionals were deployed within inpatient, emergency department and outpatient/community facilities under the hospital health services.

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Table 1 In-scope NSLHD Allied Health workforce numbers by Discipline, November 2015.

Discipline Current FTE

Social Work 157.06

Physiotherapy 150.21

Occupational Therapy 145.98

Psychology (including neuropsychology)

132.01

Dietetics & Nutrition 54.29

Speech Pathology 50.55

Podiatry 10.47

Orthotics 5.21

Exercise Physiology 4.39

Total 710.17

3.3 Summary of Key Themes

This section provides a summary of overarching themes within the current state identified throughout the work of this project:

Lack of an Allied Health ‘Voice’

AH staff widely stated that they feel disempowered with the lack of an Allied Health ‘voice’ under the current governance arrangements, chiefly the current routing of operational reporting lines to the Executive via another professional group, i.e. through the Director Nursing and Midwifery. Staff advised that this is perceived as reflecting a lesser degree of influence for Allied Health than for the other clinical (Medical and Nursing) workforces. This is compounded by a staff sentiments that AHPs are not sufficiently consulted in service design and changes to models of care and that their ‘voice’ as a group does not carry the appropriate weight in the organisation.

Retaining Professional identities

Each of the AH disciplines has a strong specialist, professional identity which is highly valued by AHPs and which staff are concerned to see maintained through the present department-based organisational structure. Further development and expansion of the professional departments is viewed as the best mechanism by which to ensure maintenance of professional standards and develop stronger career pathways.

This pride in professional identity is also expressed by widespread enthusiasm for undertaking research activities to highlight the value of the contribution AH make to the delivery of patient care. Insecurity around potential structural changes may underpin resistance to relinquish clinical care activity to other staff groups via models of task sharing with other clinicians or through complementary staffing models, such as increasing the use of Allied Health Assistants (AHAs).

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Value of Allied Health services not fully understood or communicated

According to stakeholder feedback the understanding of the value of the work of Allied Health staff is variable among both other clinician groups and patients alike. In the absence of an AH equivalent to the Grand Round, AHPs often operate in silos and are required to orient their daily routines around the timing preference of other professions (e.g. the various timings of Medical staff ward rounds). Raising the awareness of the availability and benefits of AH services internally, with other clinicians and externally to patients has the potential to enhance the patient experience over time.

Resourcing levels appear stretched

Throughout the consultation process there were consistent reports that current staffing levels are not aligned with demand and that this provides challenges to service coverage especially around leave taking. The smaller Disciplines in particular find this most challenging, with restrictions to service a typical outcome.

While the detail of these findings require further validation, stakeholder feedback confirms the requirement for a toolkit by resourcing need can be quantified and clearly articulated (i.e. as per the second deliverable of this project, which will now be delivered internally by NSLHD).

Service design appears to be a root cause of this issue, AH services at NSLHD have evolved over time to ‘fill a need’ and were not necessarily designed to ensure alignment of resources with demand or as linkages/extensions of existing services.

Information gaps restricting ability to access evidence for performance improvement

Inconsistencies in data policy between services and the absence of business rules (or lack of enforcement of them) has led to variance in data collection practice and interpretation. The clinical information systems in use are not generally aligned with Allied Health practices, and staff report that the duplication of data entry into different clinical systems is routine. Both factors negatively impact data quality and without additional analytical effort, the ability of AHPs to leverage the data collections - as an evidential basis for service assessment and improvement – is limited. There is an opportunity to explore the benefit of providing additional analytical resource to address the issues raised through the consultation

Willingness to engage with the LHD to enhance services

The majority of AH stakeholders stated willingness to engage with a change management program focused on optimising patient care and improving service delivery. The consultation confirmed that staff have a large number of innovative ideas around potential service improvements, however they desire guidance for change processes and would engage with a structured process which facilitates the exploration of new ways of working/models of care or other improvement initiatives. However, staff workshops revealed significant amounts of scepticism and distrust among staff regarding the willingness of the LHD to engage sufficiently with Allied Health regarding potential explorations.

3.4 Workforce Profiles

This section provides a description of each of the in-scope professional groups and outlines the current configuration of the Service at NSLHD. A summary of the major issues which were raised by each Discipline during the consultation process is also provided. It should be noted that these statements reflect the reported views of AH stakeholders, which may require validation and should not be considered as the confirmed findings of the project team.

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3.4.1 Exercise Physiology

Exercise Physiologists specialise in exercise interventions for people at high-risk of developing, or with existing, chronic and complex medical conditions and injuries. An Exercise Physiologist provides exercise/physical activity programming, education and support, with a strong focus on health education, lifestyle modification and achieving behavioural change (Allied Health Professions Association, n.d.).

Configuration of service

Exercise Physiology is provided at both RNS (cardiac rehabilitation) and Macquarie (Mental Health) hospitals, providing a mix of acute inpatient and outpatient services.

Operation hours for the service are 7.30 am to 7.30 pm during week days with specific times varying across facilities.

Workforce data shows that in November 2015 there were five Exercise Physiologists (actual FTE is 4.39) employed within NSLHD.

Issues reported during consultation process

Staff advised that providing coverage between services is a challenge, partly due to lack of capacity of the small team and the increasing desire to provide more access to the service. Opportunity exists to expand clinical areas outside of cardiac rehabilitation; staff believe that this model of care would benefit patients suffering from mental health, diabetes, persistent pain and cancer.

Face-to-face client work accounts for approximately 50-60% of Exercise Physiologists’ weekly time. Provision of additional administrative support offers the potential to increase the time available for (direct and indirect) patient-related activities to clinicians and also ensure that data entry was conducted accurately and in a timely manner.

Group classes and education are a major component of the service’s activity, however these activities are not captured consistently in the data between services and locations.

Career progression pathways are ambiguous which is in part due to the relatively recent recognition of the profession itself and a lack of established pathways for Exercise Physiology Services.

Staff advised that a lack of understanding of Exercise Physiology by other Allied Health Professionals and multi-disciplinary teams contributes to inappropriate or missed referrals.

Staff report that the RNS facility does not have appropriate space for consultation and assessments. As a result, Exercise Physiologists are required to wait for the gym to be free during the Physiotherapists lunch break. This limits their access to a dedicated space to one hour per day.

3.4.2 Occupational Therapy

Occupational Therapy is a client-centred health profession concerned with promoting health and wellbeing through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational Therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better support their occupational engagement (Occupational Therapy Australia, n.d.).

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As an example, Occupational Therapists develop therapeutic activities for children that will assist them to achieve their developmental milestones, such as fine motor skills and hand-eye coordination. In acute hospital settings, Occupational Therapists provide specialist interventions to assist with functional recovery and prescribe adaptive equipment to ensure safety upon discharge from hospitals. In the community Occupational Therapists help clients regain or enhance their daily lives after specific events such as hip replacements or stroke as well as clients with chronic disabilities by assessing, providing therapy, organising equipment and modifying the client’s home and community environments to improve their safety and independence (NSLHD, 2015).


Occupational Therapy Services are provided across the district in all facilities and include inpatient, outpatient, home based and community care.

Services normally operate between 8.30 am and 5.00 pm, five days a week. RNS and Ryde provide a limited service over the weekend. There are also a number of OTs that work as part of an MDT in MHDA which operates seven days a week between 16 and 24 hours a day.

Workforce data shows that in November 2015 there were 193 Occupational Therapists (actual FTE= 145.98) employed across the district.


The most frequently-raised staff issues were that staff perceive there to be a lack of leave relief and staff resourcing.

General Hospital weekend services operate with fewer OT staff, which staff feel slows down patients’ rehabilitation progress.

General Hospital Community Services Waiting Lists can be up to six months long and are reported to be sporadic in service delivery intervals and locations.

A large proportion of Occupational Therapy time is dedicated to indirect and non-patient-related activities, reflecting the wide array of duties carried out by Occupational Therapists which should be accurately captured when measuring OT workloads.

Staff consider that the use of My Aged Care in procuring services and equipment without professional OT assessment has led to sub-optimal patient and performance outcomes and inappropriate equipment supplied to patients.

Staff and managers advised that recruitment is an issue with average time to recruit being 10 weeks from recruitment start dates, yet staff vacancy notice is only four weeks. Extensive recruitment administration requirements and need for sign-off delays the process.

Staff providing community services advised that the rationalisation in access to pool cars can be a barrier to provision of community services.

3.4.3 Psychology (including Neuro-psychology)

Psychologists study human behaviour, learning and thinking, and apply evidence-based testing and interventions to improve mental health and overcome personal issues (Health Workforce Australia, 2014). The majority of Psychologists report the bulk of their time is spent providing counselling and mental health interventions to adults on a one-to-one basis (Mathews et al., 2010). Other tasks performed by Psychologists include behavioural assessment, teaching,

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cognitive assessment, personal coaching, addictions services, research and health promotion, including mental and general health (Mathews et al., 2010).


Psychology services are provided across all facilities within the district, including associated sub-acute, outpatient/ambulatory, community health services and Mental Health Drug and Alcohol. Psychologists employed within Mental Health Drug and Alcohol work within a MDT and are usually classified as Mental Health Workers. This represents a generic classification wherein different Allied Health and nursing staff can be employed. There are also psychologists employed within Aged Care Rehab teams which are multidisciplinary. Neuropsychology services are provided in acute, sub-acute and mental health services.

Operating hours are generally between 8.30 am and 5.00 pm, five days a week, but may vary across services such as MHDA.

Workforce data shows that in November 2015 there were 169 Psychologists (actual FTE= 132.01) employed within NSLHD.


Staff perceive there to be a lack leave relief and adequate staffing resources which staff see as major concern and impact on service cover and quality of care.

The District does not currently have a Consultation Liaison Psychologist to provide consultation to patients and clinical treatment teams across the hospitals.

Staff would like to see an increase in the number of Psychologists in community teams in order to provide a full scope of service to the District.

Increasing the available opportunities to educate referrers about the roles and services provided by different Psychology disciplines (Mental Health, Clinical Psychology and Neuro-Psychology) is viewed as a key potential means by which to reduce inappropriate referrals.

Stakeholders consider that Psychology is a large Discipline which is deserving of its own Departmental structure in order to appropriately meet the professional needs of staff.

The lack of Specialist Psychologist and Psychology leadership roles in the service is seen as a career-limiting pathway with poor advancement prospects by Psychologists in the LHD.

3.4.4 Mental Health, Drug and Alcohol (MHDA)

The Mental Health, Drug and Alcohol Service offers acute, sub-acute, specialist inpatient and community services throughout six hospitals and a variety of community health centres across NSLHD. The service aims to promote collaborative client-centred care within an integrated service. The MHDA structure is significantly different to the structure of other LHD services whereby management roles can be filled by either Allied Health or nursing staff and staff are deployed within MDT structures.

Mental Health Worker positions are frontline roles within the service and are filled by the best applicants from a diverse range of allied health and nursing professionals. Selected professions are only targeted in times of specific need and/or service skill mix imbalance. The services are managed by approximately 40 managers.

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MHDA do not have operational or professional responsibility for all staff working in mental health units across NSLHD, e.g. the Specialist Mental Health Service for Older Persons within the Division of Primary Community Care and Allied Health.


The service structure is flat and includes eight main areas. Staff sit at main services and in pockets right across the LHD, with over 100 sites of operation.

Workforce data shows that in November 2015 there were 293 Allied Health staff (actual FTE= 225.44) employed within the MHDA Directorate.


Staff perceive there to be a lack of leave relief and inadequate staffing resources which staff believe is a major challenge in meeting service demand.

Professional reporting lines for Allied Health staff are unclear as a result of the MDT structure of MHDA and absence of departmental structures. This is perceived to reduce professional support and development.

Maintaining currency of practice requirements places additional burden on Allied Health Staff employed as Mental Health Workers with ongoing training requirements to maintain discipline specific credentials.

Recruitment and staff replacement is a major concern expressed by MHDA staff. The gap from resignation to a new staff member commencing was reported to be approximately four months. Time spent on recruitment-related processes was reported as significantly detracting from available clinical time and that this limits the ability for services to innovate and to implement structural change.

Staff expressed a view that the current structure of the Director Allied Health reporting into the Director Nursing and Midwifery undermines the peer relationship, presents significant conflict of interest and reduces the voice of the Allied Health professions.

Staff advised that professional accountability needs to be clearly established in order to ensure the service continues to be able to meet service needs. However, professional support is difficult due to broad reporting structures.

The configuration of the current Electronic Record (eMR) is not aligned with the clinical practice of MHDA teams. There is an opportunity to improve Electronic Records with specific MHDA Allied Health forms.

3.4.5 Nutrition and Dietetics

Dietetics contributes to the promotion of health and the prevention and treatment of illness by optimising the nutrition of communities and individuals. Dietitians must understand the biochemical, physiological and psychological factors that relate to human nutrition in health and disease and assess and advise on nutrition and diet for general good health or for special needs such as sport or medical conditions (Dieticians Association of Australia, n.d.).

Within the Healthcare System, Dietitians incorporate anthropometric, biochemical, clinical conditions, dietary intake and dietary requirements into the nutritional assessment. Dietetic nutrition assessment and intervention is conducted within all clinical specialties, as required, encompassing all body systems. For hospitalised patients, dietitians are an important member of the multidisciplinary team and contribute to patient outcomes via providing assessment and intervention to assist with reducing length of stay, preventing the development of complications and reducing mortality. Referrals are also received for malnutrition screening of admitted

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patients. These are auto generated and when completed can generate a change in DRG for the patient amounting to approximately $4,500.

Within the outpatient setting, dietitians contribute to hospital avoidance through the assessment, intervention and education on nutritional management of chronic conditions and for patients with newly diagnosed disease or conditions where modification to nutritional intake is required. Within the NSLHD community setting dietitians provide a range of nutrition services including dietary assessment and specialist dietary advice aimed towards the prevention of malnutrition, improving nutritional status and therapeutic management of many chronic diseases and conditions (NSLHD, 2015).


Nutrition and Dietetics Services are currently provided across NSLHD health facilities including inpatient, outpatient and community care settings. However, there is no eating disorder service available within NSLHD.

Services operate in RNS seven days a week and on most public holidays. Other facilities and services are provided between 8.30 am and 5.00 pm, five days a week.

Workforce data shows that in November 2015 there were 66 Dietitians (actual FTE=54.29) employed within NSLHD.


Inpatient demand is steadily increasing. Outpatient demand is also increasing but is capped by clinic capacity, resulting in increasing unmet need. Waiting lists have been greater than 10 weeks in some services.

Staff advised that technologies such as new classification systems and data entry systems are cumbersome and difficult to use.

There is a lack of administration support for the home nutrition system used in outpatients.

The Nutrition Care Policy is not consistently followed by nursing staff, at times resulting in increased length of stay for patients due to the lack of a coordinated approach to nutrition care and support from admission to transfer of care.

The changes to Community Home Support Program (CHSP) eligibility for those over 65 years of age leaves a service gap for younger patients who previously qualified for services under ADHC funding.

Dietitians have no input into food services provided within hospital facilities, and are therefore unable to ensure appropriate dietary requirements are met for all patients. This issue has been raised with HealthShare but there has been little progress to date.

3.4.6 Orthotics

Orthotists are tertiary qualified Allied Health Professionals who assess and treat the physical and functional limitations of people resulting from illnesses and disabilities. The role of an Orthotist is to assess, prescribe, design, fit, monitor, provide therapy and educate regarding the use and care of an appropriate orthosis that serves an individual’s requirements (NSLHD, 2015).

Orthotists treat a wide variety of clients and conditions such as cerebral palsy, muscular weakness after a stroke or spinal injury, and diabetic foot ulcers.

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There is currently one Orthotic department within NSLHD located at RNSH. In-patients account for over 60% of Orthotic workload. The majority of referrals are from Spinal, Orthopaedic and ICU wards. The highest percentage of outpatient referrals is from the wider NSLHD area.

Services operate between 8.30 am and 5.00 pm, five days a week.

Workforce data shows that in November 2015 there were six Orthotists (FTE=5.21) employed within NSLHD.


Referrals continue to increase but staffing levels have not kept up with demand. This impacts on staff performance against Key Performance Indicators (KPI).

Participation in research or keeping up-to-date with advances in technology is a challenge due to a lack of time and resources, for example, Functional Electronic Stimulation (FES) and digital printing which are shown to reduce casting and manufacture time providing a more responsive service.

Management advised that unpaid time in lieu is accumulated due to a lack of leave cover as staff attempt to maintain services.

Staff feel that there are delays caused by transport and coordination for patients living outside of RNS. Additional risk is posed in transporting spinal injury patients that are required to travel to RNSH.

There is no weekend Orthotic Service, which results in delays in patients being seen, a spike in referrals and unplanned activity on Mondays.

The distance from the Orthotics Department to the main clinical areas entails walking a substantial amount of time between the wards, outpatients and the workshop to make modifications to devices (estimated by the Orthotists as 0.2 FTE per week).

Staff advised that there is no Orthotic expertise in NSLHD for the management of HALO devices, resulting in a gap in services for high risk, complex spinal patients.

3.4.7 Physiotherapy

Physiotherapists assesses, diagnose, treat, and work to prevent disease and disability by providing movement and function in partnership with their patients. Physiotherapy assists recovery from injury, maximises physical function in acute and chronic disease, reduces pain and stiffness, and increases mobility for participation. Common interventions include movement assessment, gait assessment, specific exercise prescription, assisted exercise and movement, management of acute musculoskeletal injury, mobility aid assessment, respiratory management, restorative therapy for neurological deficit, postoperative therapy, casting and splinting and falls management.

Regular physiotherapy sessions are a core element of rehabilitation care pathways. Physiotherapists can impact length of stay through promoting postoperative mobility and reducing complications associated with immobility, as well as maximising physical function in disease and reducing falls-related readmissions (NSLHD, 2015) (Physiotherapy Association of Australia, n.d.). Physiotherapy in NSLHD uses value driven decision making, with a priority system used to determine which patients are seen and which patients are not seen.

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Physiotherapy Services are provided across all health facilities and the community across NSLHD, inclusive of inpatient, outpatient, home based and community services. Some Physiotherapists exist in departments, while others are structured according to funding grants. Staff and managers feel that the governance around these structures is much stronger in the departmental structure than in the funding-based structure.

Services normally operate between 8.30 am and 5.00 pm, five days a week outside of RNS and Ryde where a level of weekend cover is provided.

Workforce data shows that in November 2015 there were 211 physiotherapists (actual FTE=150.21) employed within NSLHD.


Data management is a challenge due to high input volumes and low value system outputs. NSLHD is currently testing a second version of data reporting to ensure all the necessary data fields are provided.

The use of the eMR system, while of critical importance to the LHD, was widely felt to be more time consuming to complete than a paper-based record. Reasons cited included a lack of user-friendliness, occasions which require double-handling of data and variation in clinician use of the system.

Leave and surge cover is a major challenge with limited access to casual pools (outside of RNS and Ryde), overtime or agency staff to cover absences. Lack of leave relief, slow recruitment processes and surge activity are believed to be the primary contributors to missed referrals.

Increases in Physiotherapy resources have not kept pace with demand for services.

Closer integration with primary care is required to provide more care in the community.

Further career development opportunities will allow for specialist roles such as an Acute Senior Physiotherapist.

Staff reported that the provision of paediatric Physiotherapy services varies across the District as funding provided for required levels of resource.

Staff perceived that a lack of weekend coverage in services outside of RNS and Ryde leads to delays in patients being seen and a gap in service coverage.

Staff report a need for a “step down” or “transitional” ward for patients in rehabilitation wards to be moved to that would help ensure that patients can work towards living safely in the community.

3.4.8 Podiatry

Podiatrists provide assessment, treatment and advice for the management of conditions and promotion of health related to the foot and associated lower limb (Health Workforce Australia, 2014a). Podiatrists practice in a range of settings, including hospitals, clinics, community and residential aged care settings in both the public and private sectors. (Podiatry Board of Australia, 2014b).

In the hospital setting Podiatrists are primarily focused on tissue viability, skin integrity and amputation prevention. Podiatrists play a major role in non-invasive vascular testing of the lower leg and assessment of nerve function in the feet. Podiatrists provide complex wound management services and can also prescribe and fit below knee casts, insoles, orthotics and

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footwear modifications or custom-made shoes to take pressure off the wound that is being treated. All podiatrists can prescribe and administer local anaesthetics and refer for diagnostic tests such as x-rays, ultrasounds, and pathology tests in their daily work. Podiatrists may be endorsed to prescribe and dispense schedule 2, 3, 4 and 8 medicines (NSLHD, n.d.).

In the outpatient setting Podiatrists play a role in identifying individuals at high risk of developing limb threatening foot pathology. Podiatrists work with these people to modify their risk factors and prevent ulceration, hospitalisation and amputation. High risk groups such as those with diabetes, renal disease, autoimmune disorders, spinal injury, vascular disease, and neurological diseases are commonly managed by Podiatrists (NSLHD, 2015).


Podiatry Services are provided across the district in all facilities and include inpatient, outpatient and community care.

Services normally operate between 8.30 am and 5.00 pm, five days a week.

Workforce data shows that in November 2015 there were 19 Podiatrists (actual FTE=10.47) employed within NSLHD.


There are a number of services and locations where there is no funding for the provision of podiatry services, including: mental health, burns, spinal, ICU and Graythwaite Hospital. However, consultations are provided free of charge in high risk cases which may result in limb loss. Staff feel that this highlights the need to consider referral paths and processes to mitigate service gaps.

Despite the recent addition of an inaugural inpatient podiatrist within the High Risk Foot Clinic at RNS, service gaps continue to exist. For example, there is no High Risk Foot Clinic within the Northern Beaches.

Significant scope exists for Podiatry Services to provide early intervention in Medical Assessment Units to improve outcomes.

Management suggested that a lack of senior positions has implications on supervision and upskilling of junior staff as well as the ability to share activities relating to service improvement.

There is a belief that Podiatry staff are not sufficiently engaged in service planning discussions, including service demand and available resources.

A lack of administrative support in Podiatric Services means staff are required to undertake a significant amount of non-clinical duties, taking up time which could otherwise be spent on patient care

A lack of standardised referral processes for medical staff mean services such as wound debridement carried out by Podiatrists are not billed or reimbursed fully.

3.4.9 Primary and Community Health (PaCH)

Primary and Community Health (PaCH) provides primary health/community based care to people both within their homes and in clinic environments throughout NSLHD. Allied Health Staff are a much smaller component of the PaCH Team than nursing staff and are predominately employed in the Acute Post-Acute Care Program (APAC) and the Chronic Disease Rehabilitation Service (CDRS). The APAC Service is a "Hospital in the Home" Service that provides intense, short-term, interdisciplinary acute health care and management to patients as direct substitution for

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inpatient hospital care. The CDRS is a multi-disciplinary service providing management of individuals with chronic respiratory disease and/or heart failure. Allied Health Staff report to an Allied Health Manager who undertakes a mix of managerial and clinical duties. Allied Health Professionals are usually perceived as a member of an MDT rather than as an independent Allied Health Professional.


APAC Services are provided across the LHD, including inpatient and outpatient services.

CDRS provides services across the LHD and includes: exercise rehabilitation, sputum clearance, psychological management, Pulmonary Rehabilitation Physician review, medication review, nutritional management, home modifications/aids, and disease-specific education.

Services normally operate between 8.30 am and 5.00 pm, seven days a week.

Workforce data shows that in November 2015 there were 45.88 FTE Allied Health staff employed within NSLHD (NSLHD, 2015).


Management advised that there is a lack of understanding of the contributions made by Allied Health Professionals across almost all clinical areas and that the Allied Health workforce is thus underutilised due to a lack of awareness of the workforce skills, locations, services and individual professions.

Networking ability of Allied Health is limited due to a lack of clear identification of current programs and their team members, both within the LHD and between LHDs.

Backfill practices vary between positions, teams and seasons in relation to overall service leave-related absences. Casual Pools and Agency Staff tend to not be utilised for backfill and staff replacement. This is because of case complexity, lack of supervision and setting-specific requirements of PaCH allied health roles which render the use of casual or agency staff potentially unsafe.

There are currently no AHAs in PaCH although scope for AHA input exists in rehabilitation. For example, AHAs can provide services in APAC to enable patients to stay at home e.g. through transport services, care aid delivery and basic physical assistance. Roles, responsibilities, competencies and scope of practice need to be clearly defined.

Staff suggested that there is a lack of access to complete patient records and documentation which poses challenges for an efficient service.

The service would like to participate in more regular interagency briefings and collaboration with other LHDs to ensure better integrated care solutions for patients.

3.4.10 Social Work

Social Workers liaise with individuals, families, groups and communities in the context of their physical, social and cultural environments, their past and current experiences, and their cultural and belief systems. Social Workers maintain a dual focus on both assisting with and improving human wellbeing and identifying and addressing any external issues that may impact on wellbeing or may create inequality, injustice and discrimination.

Social Workers may undertake roles in casework, counselling, advocacy, community engagement and development and social action to address issues at both the personal and social level. Social

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Workers also work in areas such as policy development, education and research, particularly around issues of social justice, disadvantage and the marginalisation of people in their communities or in society (Australian Association of Social Workers, n.d.).

Social Workers employed in NSLHD provide overall holistic care for patients leading to better patient outcomes.


Social Work Services are provided across the LHD, including in acute, sub-acute and community services.

Services normally operate between 8.30 am and 5.00 pm, five days a week, with an on-call crisis service provided Friday evening to Monday morning in Northern Beaches, HKH and RNS. MHDA has a considerable number of Social Workers working in MDTs on a 24 hours/7 day a week basis.

Workforce data shows that in November 2015 there were 211 (actual FTE=157.06) Social Workers employed within NSLHD (NSLHD, 2015).


Staff felt that the challenge of managing leave cover is a significant overhead for the Service. Short-term arrangements including staff taking on extra duties to cover staff vacancies and increased patient loads tend to become permanent. This has implications for staff retention, service quality, client waiting times and length of stay. Management advised that this also results in service contact being less than service guidelines and model of care requirements.

Demand for Social Work input has increased significantly, however there has been little change in the number of FTE available except for direct service enhancement e.g. MHDA inpatient units.

Staff expressed a view that limited access to mobile devices impact on the ability for Social Work to provide appropriate models of care.

Staff suggested that the lack of support for data management is a major issue leading to 18 months of unreliable data in services outside of MHDA. This is compounded by the absence of/consistently applied Business Rules.

Management advised that recruitment is a serious difficulty due to long delays in the letter of offer being issued to new recruits. There is also a large amount of paperwork that is required for extending an existing member’s hours, even if temporary.

Staff felt that there is often a conflict in professional opinion between Social Workers and Discharge Facilitators with the perception that Social Workers obstruct the discharge process due to differences in judgements regarding appropriate discharge requirements.

Social workers report that there is a general lack of understanding by other clinicians of the role of Social Work and how they contribute to patient outcomes. Social Workers perceive themselves as not being appropriately utilised and often receive inappropriate referrals.

In order to provide broader service coverage Social Work proposed that increased resources should be provided to deliver services across greater numbers of Outpatient and Community services. There is also no designated Social Work Manager for Complex, Aged and Chronic Care.

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Speech Pathology

Speech Pathology, previously called Speech Therapy, is the diagnosis, management and treatment of individuals who are unable to communicate effectively or who have difficulty with feeding and swallowing. A broad range of clients can receive Speech Pathology Services. Clients may include children who fail to develop normal communication or people who acquire communication disabilities as a result of disease, injury or a stroke (Speech Pathology Australia, n.d.).

Speech Pathologists reduce length of stay by reducing the risk of complications associated with impaired swallowing, including chest infections, dehydration, weight-loss and aspiration pneumonia. A Speech Pathologist is an important member of the MDT covering all speciality areas within health and development.

Speech Pathologists in NSW Health will predominantly be found working within acute care facilities, rehabilitation centres, community health centres, multifunction centres and mental health facilities. They may be managed through departmental or multidisciplinary teams. They will also work closely with services within the private, non-Government and government departments (such as Education and Disability and Local Government sectors) (NSLHD, 2015).


Speech Pathology Services are provided across the LHD, including acute, sub-acute and rehabilitation services.

Services operate between 8.30 am and 4.30 pm, five days a week. There are weekend services at RNS and soon to be at HKH (end of Jan 2016).

Workforce data shows that in November 2015 there were 78 (actual FTE=50.55) speech pathologists employed within NSLHD (NSLHD, 2015).


Leave coverage is reported as a constant burden on Speech Pathology Services. Allowance for leave replacement would greatly influence the maintenance of services and interdisciplinary relationships.

Staff perceived that current staffing resources are not aligned with service demand and workloads.

Staff advised that the lack of a seven-day service outside of RNS is leading to poor out-of-hours management of patients who are unable to swallow properly, which impacts their ability to meet service KPIs.

There is a suggested lack of adequate service and professional supports at smaller sites, including full-time student educators, administration and technological support and equipment, such as teleconferencing, videoconferencing, and training. Staff feel that this impacts on innovation, professional development and service efficiency.

Management suggested that there is a lack of involvement of Speech Pathology in the early development phase of new models of care (and ensuring appropriate staffing attached), and that improved collaboration between service planners and Speech Pathology will help ensure proper service coverage.

Staff report that the amount of time they are required to spend on mandatory training that is not relevant to their roles is an inefficient use of time and places unnecessary workloads on staff.

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Staff perceive that there is a general lack of understanding by other clinicians of the role of Speech Pathology and how they contribute to patient outcomes. This can lead to service inefficiencies and compromise patient care.

3.4.11 Other Allied Health services in NSLHD

There are a number of other services which employ Allied Health professionals that participated in the review process. Details of some of the issues faced by Allied Health working in these areas was collated through manager interviews and are presented below.

Child Protection Unit

The Child Protection Unit provides Child Protection Counselling and Child Sexual Assault Services for children, young people and their families/carers where physical, emotional, sexual abuse and neglect have been substantiated by Community Services or the Joint Investigation Response Team. The Service includes a JIRT Senior Health Clinician, co-located with the Police and Community Services teams, the Out of Home Care Assessment Coordinator, the Child Protection Educator and the Child Wellbeing Coordinator. The Service also provides consultation and advice in relation to assessing risk of harm and exchange of information to NSLHD Health workers.

A number of Allied Health roles sit within Child Protection and are one-off program-specific roles unique within the LHD. Service referral occurs through a wide range of external statutory services. The service is responsible for all LHD-wide mandatory training relating to the service’s area of practice.

Issues reported during consultation process include:

The Service has a training-specific position; however all staff members have covered this position at various times due to significant recruitment delays. These delays have resulted in the position being vacant in excess of six months. This is mostly due to a shortage of appropriately-skilled candidates.

Some of the stand-alone Allied Health Professionals within the team are geographically and professionally isolated and would therefore benefit from improved networks within their discipline.

Staff suggested that frequent attendance at excessive and unnecessary meetings is a result of the uncertain nature of the service and places extra demand on staffing resources.

There are currently no designated Domestic Violence (Allied Health) Services in NSHLD. However, there is a NSLHD Policy and a Domestic Violence Resource (Nurse) within the LHD who provides training and education around the Policy which allows all staff to access/implement the Domestic Violence Screening Tool. Any clients/patients that are found to be at risk according to at least one of the four assessment questions, are referred to the police (if in the ED) or to the Social Work Department (if an inpatient).

Staff advised that there is a lack of recognition by other clinicians of the role of Allied Health professionals in the emotional support of patients which can impact on appropriate referrals.

RNS Community Aged Care

The RNSH Community Aged Care Service provides comprehensive community-based care for older people living in the Mosman, Willoughby, North Sydney, Lane Cove, Ryde and Hunters Hill Local Government Areas. The Service employs a number of Allied Health staff, including: Occupational Therapy, Social Work, Physiotherapy, Dietetics, Speech Pathology, and Psychology.

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Referrals to the service are challenged by recent aged care reforms e.g. My Aged Care, and by the broad range of referral sources. Aged Care Services and service needs are highly complex. The anticipation and coordination of service needs and access requires experience. Staff feel that the single-point-of-access My Aged Care does not facilitate these processes at the present time.

Staff advised that referral delays to the service have been as lengthy as 75 days. Complexities of cases are often not picked up until several weeks after referral due to delays in the initial consultation taking place.

Staff suggested that comprehensive Needs Assessments in the field are often overlooked due to factors such as staff inexperience and time constraints.

Opportunities exist for expansion of the integrated service model and ongoing focus on collaboration.

Aged Care and Rehabilitation services at Ryde

The goals of aged care and rehabilitation services are centred on hospital avoidance. Referrals are received across a wide mix of programs, services and community-based practitioners. The team is headed by a medical specialist. Services are provided at Graythwaite and to a lesser degree within the community. These services include a six-week post Graythwaite discharge service, a Falls Clinic and a High Risk Foot Clinic. An evidence-based Parkinson’s clinic is under development and will commence operating in 2016.


Staff proposed that timely and effective rehabilitation outpatient care requires significant staffing enhancement.

Health Contact Centre referrals represent a significant referral duplication problem, resulting in unnecessary increased workload for staff.

Staff advised that data collection practices and business rules are unclear, leading to data inaccuracies and incompleteness. Data inaccuracies also have implications for the maximisation of Activity Based Funding.

Ryde Hospital presently does not have commercial 3G or 4G mobile technology services and Wi-Fi coverage is not optimal due to service transmission barriers within the facility.

Staff reported that changes to the LHD fleet vehicle use policies have reduced access to vehicles which impacts on service delivery.

The current gym space is not large enough to enable group sessions. On occasion this can lead to a reduction in service efficiency.

Provision of coverage when staff take leave provides a challenge to the Service and the impact of leave-taking impacts service availability.

Management indicated that recruiting delays exist as a result of central processing delays and are a significant concern for service capacity.

A number of nursing specific positions are closed to AHPs which Managers believe limits career progression for AHPs in these areas.

A lack of staffing in community services is leading to an average of 4-6 week waiting times.

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It was reported that opportunities to pursue Quality Improvement and research activities are limited by a combination of long waiting lists (for spaces) as well as difficulties securing clinical coverage for the time required.

Staff feel that the service staffing levels do not align with existing benchmarks and standards, e.g. Australian Faculty of Rehabilitation Medicine staffing standards.

Child Development Unit

The Child Development Unit is a diagnostic and assessment service for young children from the Northern Sydney area who have a significant developmental delay. The service focuses on the whole family system, not just the child and their diagnosis. The team comprises Social Workers, an Occupational Therapist, Paediatricians, Psychologists and Administration Staff. All disciplines are involved in the assessment process which includes the formal assessment and diagnosis and feedback to the family. Each assessment takes a full day for three team members. The determination of who the service can best care for is a key factor in prioritising patients for assessment.


Activity measurement is made difficult by preliminary assessments which do not result in follow-up assessments as they can represent an incomplete service event.

The inability of CHOC to produce meaningful reports is a significant service challenge.

The burden of mandatory training is high, especially around training not relevant to the practice of the service.

Training the trainer and research training are unmet educational needs for the service.

Sexual Assault Service (RNS)

The sexual assault service at RNS provides forensic and counselling service for adult victims of sexual assault. The centre employs social workers and psychologists.


The service maintains its own data collection and monitoring, although this is described as “rough”. Not all service activities are captured in NAPOOS, e.g. education to other professional service providers and police collaboration. The service does not use CHOC and a move to CHOC is not planned.

A lack of VMO coverage within the service has been challenging, as has practice guideline clarity.

The long-term care needs of service clients can be significant in numbers and duration which can impact on service capacity.

Inter-service collaboration is difficult due to service demand. This in turn impacts on the efficiency of the service and optimal client outcomes.

Access age criteria can skew actual service demand and create difficulties in service access and continuity of care for clients who are not within the eligible age range.

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Characteristics of High Functioning Allied Health Services

This section was developed to meet to the first objective of this project, which was to assess current Models of Care against leading practice and identify opportunities to enhance the same across NSLHD. The outputs from this work inform the first deliverable, i.e. proposed changes to the current service delivery model and governance structure.

To achieve this the project team leveraged the research base developed during the literature review process (see section 8 below) to identify a set of 12 characteristics common to high-functioning AH services.

Findings from the stakeholder consultations and site visits with Service Managers and Allied Health professionals supported comparison between current NSLHD practice and activities and these characteristics. The purpose of this analysis is to highlight areas of existing areas of good practice at NSLHD and to provide an indication of areas where improvements efforts could be considered.

The exploration of leading practices in the delivery of clinical care is beyond the scope of this consultation. A summary of levels of evidence for each leading practice area is presented in Figure 2 below.

Figure 2: Assessment of current practice at NSLHD

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The assessment of the sites and services within NSLHD with regard to identified aspects of high-functioning Allied Health Services is based on the following definitions for levels of evidence:

Minimal evidence: Supporting staff statements and documentation were generally not identified throughout the consultation.

Some evidence: Scattered, intermittent and/or isolated staff statements and documentation were identified.

Clear evidence: Multiple supporting staff statements and documentation were identified.

Strong evidence: Consistent staff statements and documentation were identified.

The assessment was able to identify examples of current practice NSLHD that align with each of the 12 characteristics to some degree.

4.1 Patient-centric focus informs models of care

Patient-centred care and patient-directed care are founded on the principles of patient choice and patient input. Patient-centred care is focused on providing care that is respectful of and responsive to individual patient preferences and needs. This enables clinical decisions to be patient-guided and puts patients at the forefront of decision-making. Models of care which are patient centric have shown increased potential to enhance patient satisfaction and improve the appropriateness of care. Patient-Centred Care is considered an essential component of NSLHD service delivery.

Practice examples

At Bournemouth Community NHS Trust funding was re-allocated from acute care to develop intermediate care services. This included funding for a Senior Occupational Therapist and a Senior Physiotherapist for the Rapid Response Team. This created a vital link with the community rehabilitation service, provided alternatives to admissions, enhanced discharge from hospital, and enabled patients to be supported in their own homes1.

Great Western Hospitals NHS Foundation Trust found the Speech and Language Therapy (SLT) Department had challenges ensuring it met the needs of all children with speech, language and communication difficulties. In order to be as effective as possible a ‘link setting’ model was established: each educational setting now has a link SLT who represents the service and sees all children in the setting regardless of their diagnosis or difficulties. This supports equity of caseload size, reduces time and cost of travelling, prevents duplication, and ensures each setting has a named professional with whom they are able to communicate directly2.

Assessment of NSLHD practice

Clear evidence was identified, however practice was not considered highly robust due to a number of services not available that support patient through full continuum of care.

Staff advised that service gaps, service delay and need for patient transport to services present a risk to spinal patients.

1 National Health Service 2000, Meeting the Challenge: A Strategy for the Allied Health Professions 2 Great Western Hospitals NHS, 2014, Speech and Language Therapy Service Annual Report

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Management advised that decision-making around priority decisions in all Physiotherapy departments are supported by clinical guidelines, however the levels of service allowed for by the guidelines are less than ideal according to service data.

Occupational Therapy Community Services waiting lists (at Northern Beaches) can be up to six months long.

HKHS Occupational Therapy provides services from the acute wards to the rehabilitation wards or to the Rehabilitation Discharge Team OTs or community OTs

HKHS Occupational Therapy has an established equipment loan pool that assists patients to stay at, or return, home safely with convenient access to required assistive equipment.

Staff advised that scope exists for a community/home-based service to ensure ‘right service at right time’ evidence based approach for rehabilitation.

HKHS and NBs Physiotherapy provide community services to assist with hospital avoidance, provide alternate admission option and enhance discharge from hospital. This allows patients to be supported in the community and in their home. These services include: Rapid Access, Rehab & Aged Care, Rehab Discharge Team, Community Rehab Team, Outpatients, Hydrotherapy and group classes.

Scope exists for additional acute ambulatory (community) stroke teams similar to those operating at NSRHS.

Staff advised that there is an increasing need for chronic care programs such as pulmonary rehab and diabetes services across the LHD.

Patient experience activities across professional workshops revealed staff sentiments that the risk associated with missed referrals is high.

Within PACH examples of patient centred care and care delivered in partnership with the patient include CDCRS, APAC and Sexual Health/HIV.

At RNSH the burns, spinal and intensive care units do not have podiatry coverage. At NB & HKH, Podiatry does not have any dedicated cover but responds to order requests which are triaged and services provided based on level of limb-threatening risk.

Social Work operates wholly on patient centred models of care. Perinatal conferencing is one example. NBHS were pivotal to developing this model of care with Child Protection Unit, Faces and other MDT members. NBHS Social Work have 2 facilitators for the district.

Social Work operate under NSW Safe Start Maternity policy which ensures patient centred intervention for ante natal clients.

NBHS Social Work advocate through various pathways to acquire a cold cuddle cot to ensure best practice for families who have experienced a neo natal death (i.e. beyond scope of intervention).

4.2 Multidisciplinary Teams (MDTs)

Multidisciplinary Teams (MDTs) are made up of professionals from a range of disciplines who work together to deliver comprehensive care to address as many patient needs as possible. Significant scope exists for Allied Health professionals to participate in Multidisciplinary Teams to improve service delivery and patient outcomes. In many (but not all) cases, MDTs can provide more knowledge and experience than if disciplines operate in isolation, resulting in more

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comprehensive service delivery and more timely access to care. For the purposes of this review, MDT models of care are considered to be formal, structured teams including a spectrum of professions, with participation from all professions required for team activity to occur.

Practice examples

A model of professional skill-sharing, in which a range of specified tasks could be undertaken by members of a number of different professions, was implemented at the Mackay Hospital to prevent duplication in information collection and history taking. It was illustrated clinicians preferred a skill-sharing model of care, particularly when operating in the community. This resulted in decreased duplication, improved service efficiency, improved patient satisfaction, improved patient outcomes, improved team functioning and improved clinical practice3.

At the William Harvey Hospital, East Kent Hospitals NHS Trust, an Accident and Emergency Assessment Team made up of an Occupational Therapist, a Physiotherapist and a Case Manager provided a full functional and social care assessment for frail elderly patients who arrive at Accident and Emergency. This holistic care allowed patients to return home immediately to more appropriate care, with the support of an Occupational Therapist. This made 12 extra acute beds available – the equivalent of 4,500 acute bed days per year. It also meant timelier service – the Team often saw patients within 2 hours, whereas before it could often take more than 2 days. The Team aspect meant more appropriate skills to make better decisions on whether a patient can return home or should be admitted to hospital4.

A study undertaken in British Columbia, Canada, identified significant benefits to patient outcomes from a Multi-Disciplinary Team model of care in paediatric chronic kidney disease. Disease progression was markedly slower and biochemical measures of disease state demonstrably improved in patients treated by a structured MDT approach. Extensive cost savings were possible due to reduced disease progression and associated health system burden5.

Assessment of NSHLD practice

Strong Evidence was found which confirms that Clinical Services based on the use of Multidisciplinary teams are integral to AHP practice and widespread across NSLHD. This assessment differentiates by the level of formality surrounding MDT structures in different parts of the LHD. The strongest evidence is seen in PACH and MHDA, as these services operate formalised MDT programs where staff are primarily assigned along clinical pathways and the participation of all professional groups is required to support activity. While it is clearly evident that the hospital-based AH services (RNSR, HKH/NB) operate clinical MDT models, the work of the MDT continues even if AHP participation is unavailable (e.g. at Patient Journey Board meetings).

The Osteoarthritis Chronic Care Program is an example of an effective MDT, being an early multidisciplinary intervention program aimed to reduce surgical admissions. Data on earlier access to surgery and prevention/delay of surgery indicates that the program is having a positive impact. Surgical date set on initial consult is the unit of comparison.

3 Mitchell GK, Tieman JJ, Shelby-James TM 2008, 'Multidisciplinary care planning and teamwork in primary care', Med J Aust 188(8 Suppl). 4 National Health Service 2000, Meeting the Challenge: A Strategy for the Allied Health Professions 5 Ajarmeh, S., Er, L., Brin, G., Djurdjev, O. and Dionne, J.M., 2012. The effect of a multidisciplinary care clinic on the outcomes in pediatric chronic kidney disease. Pediatric Nephrology, 27(10), pp.1921-1927.

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Referrals to private community-based healthcare professionals is also a component of the program.

The Ryde and Hornsby Aged Care Services provides a coordinated multidisciplinary approach to the assessment and management of Parkinson’s disease. The service was developed in response to rising presentations.

MHDA and PACH utilise a wide range of MDT and interdisciplinary team models though the case management system.

PACH practice is founded in MDT e.g. CDCRS, APAC, ACAT and Child Protection are all examples of formal MDTs.

AH component to Rapid Access/GRACE is effective for hospital avoidance. The program includes a Registrar, Physiotherapist, Occupational Therapist and Registered Nurse.

Staff advised that all the Aged Care Services across the district are examples of a strongly-performing model of integrated care due to effective communication.

The Acute Assessment Unit (AAU) is able to provide multidisciplinary and, at times interdisciplinary patient assessment services across NSLHD

Examples of effective models of MDT across the district include:

o The RNSH Hand Surgery and Trauma Management MDT

o Strong involvement with clinical pathways e.g. stroke pathway, back pain, elective joint, criteria-led discharge and diabetes

o Multidisciplinary clinics - Amputee, Spasticity, Falls, preadmission, Parkinson’s Group

o Multidisciplinary services – including Cardiac Rehab and Diabetes.

The HKHS Spasticity Clinic is an integrated outpatient clinic providing medical, occupational therapy and physiotherapy assessment and intervention.

Safestart, Perienatal conferencing is an example of this for Social work- Ante natal care only occurs in MDT environment in the LHD

NBHS have a cognitive capacity assessment committee which is an MDT group to ensure consistent and ethical care of patients with borderline capacity (beyond scope)

4.3 Highly engaged Allied Health Professional workforce

Workforce engagement includes morale, commitment to duties and alignment with organisational values and initiatives. A highly-engaged Allied Health workforce contributes to increased service quality, increased uptake of evidence-based practice, increased workforce retention and increased acceptance of strategic change.

Practice examples

A 2011 study conducted by Hiewe et al. focused on factors impacting the uptake of evidence-based practice. Employee engagement was found to occur through promoting time efficiency and clinical relevance along with ongoing close management support6.

6 Heiwe, S., Kajermo, K.N., Tyni-Lenné, R., Guidetti, S., Samuelsson, M., Andersson, I.L. and Wengström, Y., 2011. Evidence-based practice: attitudes, knowledge and behaviour among allied health care professionals. International Journal for Quality in Health Care, p.mzq083.

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In 2011 a study by Keane et al. found that the availability of career progression possibilities and flexible employment options promoted the engagement and retention of the New South Wales Allied Health workforce, especially in rural areas7.

In 2009 Trevaglia et al. found that the engagement of Allied Health professionals in change initiatives was influenced by the degree to which the initiatives aligned with their specific work and documentation requirements. Ensuring change initiatives meet all requirements for Allied Health professionals was identified as a key factor for engagement in change8.


Some Evidence of a highly engaged workforce was seen at NSLHD overall. While the consultation identified evidence of a workforce strongly committed to patient care, consulted staff also generally reported feeling unsupported by the organisation.

Elements of current practice include:

Widespread staff sentiments were identified across most workshops that Allied Health has historically been more likely to be targeted for funding reductions than other areas and that staff work significant amounts of unpaid overtime.

Morale and trust were consistently low across all workshops.

Networking ability appears limited by inconsistent identification of current programs and their team members, both within the LHD and between LHDs.

The skilled Allied Health workforce is potentially underutilised due to suboptimal awareness of the workforce skills, locations and individuals.

The understanding of Allied Health functions and potential offerings is reportedly not widely understood by professions outside of Allied Health.

There is significant scope to build the perceptions of Allied Health across the LHD.

Staff sentiments identified through workshop sessions were that Allied Health is not perceived as being of high importance by high-level management and that Allied Health is not well represented at the higher levels of management. Staff were also of the opinion that higher levels of management are highly political in their operations and decision-making.

A significant number of staff are undertaking additional qualifications training.

RNSR management advised that all staff have exceeded minimum annual training requirements.

NBHS/HKHS AH have discipline representation on the local Access and Innovation Project group which was established to identify and complete projects to ensure hospitals meet their NEAT targets. This is indicative of a degree of staff engagement outside of routine work activities.

7 Keane, S., Smith, T., Lincoln, M. and Fisher, K., 2011. Survey of the rural allied health workforce in New South Wales to inform recruitment and retention. Australian Journal of Rural Health, 19(1), pp.38-44. 8 Travaglia, J.F., Westbrook, M.T. and Braithwaite, J., 2009. Implementation of a patient safety incident management system as viewed by doctors, nurses and allied health professionals. Health:, 13(3), pp.277-296.

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4.4 Early Allied Health Professional intervention in patient journey

The commencement of patient journeys requires a range of service needs from the outset. Early AHP involvement in patient journeys can reduce length of stay and adverse patient outcomes by reducing waiting times for AH assessment and intervention.

Practice examples

A Musculoskeletal Screening Clinic provided by Physiotherapists at the Northern Hospital in Melbourne resulted in reduced surgical consultations and improved patient flow9.

At Brisbane’s Royal Childrens’ Hospital, a Health Queensland trial of Allied Health screening and brief intervention service aimed to decrease waiting lists in general paediatrics. The trial resulted in reduced duplication of service and timely access to more targeted services, along with a reduction in surgeons’ consultation times10.

At Nambour hospital a Multidisciplinary Triage Model providing services for clients with persistent pain applied pre-appointment management tools to more accurately triage written referrals and refer directly to physiotherapy or psychology. The model resulted in reduced referrals, reduced triage time and increased non-Allied Health clinician service capability11.


Clear Evidence of early AHP intervention was noted across NSLHD. Performance measures and benchmarking processes aimed at increasing the consistency of early Allied Health intervention could potentially enable further enhancements in this aspect of service delivery. This is also done within resources which mean that follow up/ongoing therapy services are reduced.

Key examples include:


Patients admitted via the ED have a malnutrition screen conducted on admission. The malnutrition screening tool is designed to flag patients at risk of malnutrition. The screen is completed via FirstNet/Powerchart and generates an automatic electronic referral to a Dietitian if the score is greater than or equal to 2. RNSH has data to demonstrate that more than 2000 malnutrition screens are occurring each month and this represents more than 80% compliance with all adult pts admitted via ED. In addition, RNSH and Ryde Dietetics attend relevant daily board rounds and ward meetings to ensure that referral for intervention is received in a timely manner.

RNSH and Ryde Dietetics KPI is that a patient is seen by a Dietitian within 24-48hours of referral.

All the Dietetic’s Department have the KPI that a patient is seen by a Dietitian within 24-48hours of referral.

On average, 57 patients are diagnosed per month with malnutrition by the HKHS Dietitians

9 Oldmeadow, L.B., Bedi, H.S., Burch, H.T., Smith, J.S., Leahy, E.S. and Goldwasser, M., 2007. Experienced physiotherapists as gatekeepers to hospital orthopaedic outpatient care. Medical Journal of Australia, 186(12), p.625. 10 Queensland Health 2014, Ministerial taskforce on health practitioner expanded scope of practice Final Report Appendix A 11 Queensland Health 2014, Ministerial taskforce on health practitioner expanded scope of practice Final Report Appendix A

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Physiotherapy Physiotherapy Priority tool.

Clinical protocols and automatic Blanket referral systems in place for risk areas such as Orthopaedics, ICU and stroke.

Joint education sessions – aim to decrease Length of Stay by providing education prior to surgery.

Back pain pathway- patients are reviewed in ED and Physiotherapy review provides early intervention, education and discharge planning.

Stroke Pathway- patients are reviewed on Day 0.

Involved with ASET screening- early identification by the MDT of needs.

Use of Rapid Access/ APAC Physio/ community services on Discharge.

Involved with senior streamlining at Manly Emergency hospital.

Both NBs and HKH PT promote PT in ED and have a strong presence. Despite not having a “designated” ED physio, we utilise our staff resources in linking our service with ED, reviewing patients early from triage and senior streamlining, with Medical guidance.

Strong link with inpatient and outpatient/community Physiotherapy. Provide better patient journey from time of admission in ED to discharge into the community and providing continuum of care. This includes home visits, Parkinsons group, falls group, hydrotherapy.

Speech Pathology

There are two established screening programmes for dysphagia which trigger referrals on admission the stroke swallow screen and the sip/swallow algorithm.

Surgical patients are referred standardly through preadmission clinics and there are detailed triggers for early referral.

Ongoing Participation in Multidiscipline and ward based meetings triggers early referral.

Participation in the tracheostomy team (at RNSH only) triggers early referral for at risk patients admitted to the hospital.

At HKH there is a Nursing home service to manage clients early, which aims to avoid aspiration and prevent hospital admission.

At HKH Voice Care workshops are provided to screen teachers for voice impairments and providing general education to avoid these issues arising. Voice care workshop are also available for Day-care teachers and Gym staff.

NB & HKH have a clear focus on early intervention for all paediatric services. Clients under 3 years are prioritised.

Ryde Aged Care Rehab

Linkages between inpatient health professionals and outpatient community health professionals is conducive to provide early interventions. Clinicians in part time roles work in the hospital and in the outpatients and community, providing continuum of care measure and ensure early intervention.

Prioritisation of clients occurs at intake for early interventions as required.

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eMR referrals have enabled a broader cross section of staff (i.e. out of hour’s staff), to identify & refer patients via the electronic system. The Blaylock initiative by OT, in the piloted wards, has proven to increase the number of early referrals to OT. Another OT project, “Refer me to an OT” reviewed the impact of electronic referrals versus Journey Board face-to-face sources.

AH are members of the Aged Care Assessment Team (ASET) in all ED Departments where patients are screened and issues identified on admission. This enables patients to be discharged safely or admitted with early referrals to AH staff.

AH on NBHS receive emails from pre admission clinic to flag patients who may need immediate assessment on admission.

Social work receives referrals for early intervention from Domestic, Edinburgh depression scale in ED and Maternity.

NBHS Social work is part of patient flow weekly meetings. Identify and advocate for patients to ensure strategies are in place to ensure care of patient care is optimal to ensure patients do not have increasing LoS.

NBHS AH also has patient escalation guidelines in place to ensure complex patients are identified and ensure care is optimal.

A number of priorities in SW Priority document insist on immediate intervention KPI is <2 hours e.g. - all forms of violence, sudden death and trauma.

4.5 Allied Health Professionals provide first point of contact in Emergency Departments

Emergency Departments (EDs) are frequently the first point of patient contact with the health system, however lower-acuity ED presentations can experience extended waiting times and can reduce ED capacity. Allied Health services provided as a first point of care in emergency departments can reduce treatment times, ED capacity burden and hospital admissions.

Practice examples

At Toowoomba Hospital a trial in which an Allied Health generalist clinical leader was established in ED and lower-category triage patients were assessed and managed by an Allied Health clinical lead resulted in reduced referrals to Allied Health from the ED, improved ability to meet best practice guidelines for falls and strokes, improved service integration and enhanced patient experience12.

The National Health Service (NHS) modernisation agency in the UK developed the Emergency Care Practitioner role to support ‘first contact needs’ of patients, which involved responding to 000 calls with ambulances to reduce unnecessary transports and support GPs in out of hours. This increased the capability of Emergency Departments by reducing presentations which were manageable out of the ED13.


This assessment identified Minimal Evidence overall of AH Professionals providing the first point of contact at NSLHD, Although RNSH does operate initiatives in this area across Physiotherapy,

12 Queensland Health 2014, Ministerial taskforce on health practitioner expanded scope of practice Final Report Appendix A 13 Mason, S., O’Keeffe, C., Coleman, P., Edlin, R. and Nicholl, J., 2007. Effectiveness of emergency care practitioners working within existing emergency service models of care. Emergency Medicine Journal, 24(4), pp.239-243.

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Sexual Assault Services, Social Work and Podiatry. Medical staff resistance was identified as a significant barrier. Outside of RNSH however significant scope exists to expand this model of care through the other sites and professions of the LHD.

4.6 Extended hours of Allied Health service coverage

Hospitals provide services to patients 24 hours per day, however Allied Health Service coverage can be variable over weekends and outside of routine working hours. Providing Allied Health Service coverage across all seven days can potentially promote continuity of care access and care delivery, contributing to reduced length of stay and enhanced patient outcomes as evidenced in the following examples.

Practice examples

A Central Coast LHD trial of 7 day a week Allied Health service across both Gosford and Wyong sites by providing additional Allied Health staffing for a 12 week trial period resulted in reduced LOS14.

A UK Model for a 7-day therapy service including Physiotherapy, Occupational Therapy, Speech and Dietetics resulted in streamlined patient flow, enhanced quality of care, reduced risk and appropriate skill mix balancing15.

Saturday physiotherapy service in an Australian Metropolitan Hospital decreased length of stay in patients undergoing rehabilitation in hospital and promoted favourable patient outcomes. The identity of the hospital at which the trial was undertaken was not disclosed in the research paper16.


This assessment identified Some Evidence of extending hours of AH coverage at NSLHD. A number of staff and managers identified a generalised lack of evidence of 7-day coverage to support models of care and meet KPIs, however some services provided more consistent coverage.

Weekend services were outlined for the Northern Beaches and Hornsby sites. Nutrition and Dietetics is available at Hornsby on Saturday mornings. Weekend services are available for Physiotherapy at Hornsby, Manly and Mona Vale. Social work is available on Saturdays at Hornsby, and is on-call at all NB sites. Speech Pathology weekend services will commence at Hornsby in January 2016. Other Allied Health services are not provided on weekends.

Staff report perceptions that services are devalued when KPIs are not met.

Weekend non-acute services are not provided at the same level as weekday services, with decreased staff availability reducing efficiency. Acute services operate 7 days per week.

14 The Health Roundtable 2014, Exploring Allied Health 7 day services, www.healthroundtable.org/Portals/0/memberslibrary/2014/HRT1418/SectionB-TopInnovationPesentationsAsVotedByDelegates/HRT1418-CosmosCosmos2-ExploringAH7DayServices-V17.pdf 15 The Health Roundtable 2014, Exploring Allied Health 7 day services, www.healthroundtable.org/Portals/0/memberslibrary/2014/HRT1418/SectionB-TopInnovationPesentationsAsVotedByDelegates/HRT1418-CosmosCosmos2-ExploringAH7DayServices-V17.pdf 16 Brusco, N.K., Shields, N., Taylor, N.F. and Paratz, J., 2007. A Saturday physiotherapy service may decrease length of stay in patients undergoing rehabilitation in hospital: a randomised controlled trial. Australian Journal of Physiotherapy, 53(2), pp.75-81.

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MHDA Allied Health coverage on evenings and weekends incurs penalty rates, representing a financial consideration for service coverage planning.

All Physiotherapy services across the district provide services 7 days per week including public holidays, with one fewer staff member on Sundays. RNSH includes a dedicated Physiotherapist in ED

The established weekend Speech Pathology service of 8 hours at Royal North Shore Hospital was extended to 16 hours over winter to meet the expected surge in referrals.

In OT Acute Care RNS, the Team Snr has introduced weekend cover. One shift is now available on both Saturday & Sunday to provide ongoing discharge planning and assessment. This facilitates weekend discharges and increase improvements in patient flow. At Ryde Hospital a part time OT position was redesigned to provide OT cover for the acute wards on Saturday and Sunday.

Social Work and Sexual Assault Service services provide a 24/7 crisis service at RNS Hospital. THE Sexual Assault Service is an LHD-wide program.

Nutrition and Dietetics provide a 7 day service at RNSH.

HKH provide a staggered shift service for the new STAR building (for SSU) to be able to provide services to late surgeries and promote early discharge and reductions in LoS.

HKH and NBs have been intermittently providing staggered shifts for ED (on a voluntary basis) to promote and have more presence in ED. By staggering this shift Physiotherapy are able to identify and discharge patients outside of normal hours potentially contributing to reductions in LoS.

4.7 Support for extended scopes of Allied Health practice

The range of skills and services delivered by Allied Health practitioners is expanding as health services evolve. One of the objectives of this project was to consider the current scope of AH practice at NSLHD and make recommendations about the potential for development of advance practice AHP roles and expansion of the AHA workforce. AH models which support advanced/ extended scope for AHPs often complement skill mix with increasing numbers of AHAs to provide additional AHP capacity.

Enabling extended scopes of practice can enhance service delivery, service access and service waiting times while also promoting career development, morale and job satisfaction. Scopes of practice can be extended through increasing the range of duties performed by AHPs, by enabling additional advanced/skilled AHP procedures/techniques, or both. Extended scopes of practice include any task, duty or responsibility which is not considered a basic, routine competency. Additional training and credentialing is often required. Basic and extended scopes of practice are usually defined by the profession’s regulatory body.

Practice examples

Occupational Therapists at South West London and St. George’s Mental Health NHS Trust, and NHS Beacon, extended their roles as assertive outreach workers in the Assertive Community Team. The role extension included supervising and monitoring medication treatment as well as psycho-social interventions and cognitive behavioural therapy. This helps the Teams to deliver a needs led service tailored to individual patients17.

17 National Health Service 2000, Meeting the Challenge: A Strategy for the Allied Health Professions

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In 2012-13 the Royal Brisbane and Women’s Hospital Nutrition and Dietetics Department used evidence from the UK and worked with the Gastroenterology Department to pilot a model of care involving Dieticians engaging in extended scope of practice to triage patients using a range of screening tests, and where appropriate, provide dietary and lifestyle advice prior to patients progressing to see the Gastroenterologist. A ‘dietitian-first gastroenterology clinic’ was piloted for specific referrals to the Gastroenterology Outpatient Department and treatment for patients whose presentations could be managed or resolved through dietary or lifestyle advice. The Dietician provided screening and comprehensive clinical assessment/intervention as appropriate and interpreted/requested tests under the same environment as the Gastroenterology Consultant. This resulted in reduced waiting time, improved patient satisfaction, staff satisfaction, and potential cost savings due to fewer appointments18.

At Aintree Hospitals NHS Trust in Liverpool, Senior Physiotherapists extended their role to include treating patients who were initially referred to the Orthopaedic Consultant. With the agreement of the referring GP, 1,000 patients per annum were assessed and, if appropriate, treated by the Physiotherapists. As a result, Waiting Lists for appointments with participating Consultants were reduced by up to 29 weeks. This demonstrated the valuable contribution Physiotherapists can make towards enhanced service delivery19.


Some Evidence of support for extended scopes of AHP practice was identified across NSLHD overall although the majority of evidence has been identified at RNSH and Ryde (RNSR). Many stakeholders expressed interest in taking advantage of this opportunity pending the provision of supporting resources. A number of formal competencies were identified. Training, supervision and regulatory factors will represent significant considerations in the future implementation of extended scopes of practice. Examples of current practices at NSLHD include (but are not limited to):

Podiatry

Podiatry have implemented extended scopes of practice in the following areas:

Advanced wound care and wound assessment.

NPWT.

Diabetic foot management.

Medical dressings.

Sharp wound debridement.

Ankle brachial pressure index and toe brachial pressure index.

Compression therapy.

Pressure injury prevention and management.

Rheumatoid foot – specialised interdisciplinary involvement.

Renal transplant – specialised interdisciplinary involvement.

Orthofracture – specialised interdisciplinary involvement.

18 Queensland Health 2014, Innovations in models of care for the health practitioner force in Queensland Health 19 National Health Service 2000, Meeting the Challenge: A Strategy for the Allied Health Professions

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Point of care ultrasound (enrolment in Cert Allied Health Performed Ultrasound).

Speech Pathology

Speech Pathology have implemented extended scopes of practice in the following areas:

MBS/VFSS.

Tracheostomy.

Advanced Neuro/surgery (RNSH only)

Paediatric feeding.

Neurodegenerative conditions.

Dementia.

Cancer care.

Advanced Dysphagia (includes head and neck, ventilation, spinal – at RNSH only).

Complex critical care (ICU/) communication/swallowing in Multiple medical conditions.

Nasendoscopy/fibreoptic Endoscopy instrumental and interpretation for voice and swallow.

Laryngectomy.

Burns (RNSH only).

Physiotherapy

Physiotherapy has implemented extended scopes of practice in the following areas:

ED Physiotherapy.

Triage Spinal Pain Physiotherapist.

OACCP coordinator roles.

Integrated Hand Unit Senior Physiotherapist role (RNSH only).

Physiotherapy led Orthopaedic Fracture clinic (RNSH only).

Physiotherapy Led Spasticity clinic (RNSH only).

Physiotherapy Led Osteoporosis Re-Fracture prevention coordinator (RNSH only).


At a state-wide level, Dietetics (at NSR) are investigating extended scope of practice including the potential to insert nasogastric tubes, replace gastrostomies etc.

At RNSR Dietetics support extended scopes of practice as they develop within the profession. RNSH has highly specialised senior clinicians working within complex clinical areas such as burns, spinal cord injury, critical care, allergy and GI surgery.

4.8 Allied Health Professionals supported by appropriate models of Allied Health Assistants (AHA)

Allied Health Assistants have been successful in augmenting Allied Health services both in Australia and internationally. Models of care including Allied Health Assistants (AHAs) have the ability to reduce waiting times and promote skills matching with service need by increasing

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patient access to lesser-skilled and manual tasks while also removing the burden of other tasks by Allied Health Practitioners.

Practice examples

In Queensland a model of care was proposed to provide a post-acute approach to service delivery and enable more Occupational Therapist (OT) OT time to be dedicated to those with complex needs. As part of this model an A HA was employed to complete tasks which could be delegated to allow OT to work to their full scope of practice. This resulted in improved ability for occupational therapists to work to their full scope of practice, resulting in improved service efficiency, shorter length of stay, fewer readmissions and better patient outcomes20.

An Implementation Program undertaken in Victoria to increase the uptake and utilisation of AHAs. At project commencement 29.5% AHPs regarded AHAs as not applicable to their workload. Following the project only 7.9% of AHPs reported this. 92% AHAs were highly satisfied with their jobs and 91.8% AHPs were satisfied with the use of AHAs21.

The AHP workforce in Victoria was found to be spending 17% of time undertaking tasks that could be performed by an AHA with the appropriate training and adequate supervision. The study concluded the capacity of the AHA workforce should increase to meet future demands. AHP’s reported a high level of confidence in the clinical skills and utilisation of the AHA workforce, as well as confidence in delegating tasks22.

Implementation of a Social Worker Assistant role in Queensland was achieved through a delegation model and regular clinical supervision. Outcomes included a 20% increase of new patients seen, 11% reduction in cost per occasion of service, 47% accrual of time-in-lieu, 81% increase in social worker time spent on more complex tasks, and improved social worker job satisfaction23.


Across the in-scope professions there 28 Allied Health Assistants (AHA) positions (of varying levels of FTE) were identified. AHAs are best represented in Physiotherapy (16 AHA positions) and Occupational Therapy (10 AHA positions), however scope exists for further contributions from this workforce. Other professions agreed that scope exists for AHAs in larger centres, although the type of contributions to be made was not widely agreed upon and staff expressed high levels of concern about the potential of AHA’s replacing AHPs.

Clear Evidence was identified of AHA support for AHP practice across NSLHD. In particular AHAs are well utilised in Physiotherapy, however it is also clear that scope exists for further contributions from this workforce. Other professions agreed that scope exists for AHAs in larger centres, although the type of contributions to be made was not widely agreed upon and staff expressed high levels of concern about the potential of AHA’s replacing AHPs.

There are currently no AHAs in PACH although scope for their implementation exists in rehab. There are two AHAs in a small number of areas. AHAs could provide services in APAC to enable patients to stay at home, e.g. transport services, care aid delivery, basic

20 Queensland Health 2014, Ministerial taskforce on health practitioner expanded scope of practice Final Report Appendix A 21 Victorian Department of Health, 2012. Allied Health Assistant Implementation Program Stage One. Victorian Department of Health. 22 Somerville, L., Davis, A., Elliott, A.L., Terrill, D., Austin, N. and Philip, K., 2015. Building allied health workforce capacity: a strategic approach to workforce innovation. Australian Health Review. 23 Queensland Department of Health, 2014, Social work assistant

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physical assistance. Roles, responsibilities and scope of practice are clearly defined. Competencies have not been developed as yet.

AINs have recently been introduced to MHDA. Scope exists for AHA implementation, however a scope of practice with supporting competencies would be required.

AHAs are present in rehabilitation services (e.g. Graithwaite), however staff advised sentiments that AHAs were difficult to place in acute settings due to clinical complexities.

A number of professional groups provided detailed input on AHA models of care throughout the workshop process. A summary of key inputs from Occupational Therapy, Physiotherapy, Speech Pathology and Dietetics workshops is outlined in Table 2 below.

It is also important to note that many staff have not experienced working with AHAs and therefore an education component should be assumed as part of any implementation process.

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Table 2: Stakeholder views on potential role of Allied Health Assistants at NSLHD

Profession Staff suggested activities for AHAs

Potential benefits suggested by Staff

Staff concerns


Equipment management,

Running group therapy programs

Providing session assistance to OTs

Manual handling tasks, Mobile/home/community visits

Shared workload

Increased AHP face-to-face time with patients, increased therapy frequency,

Increased workforce satisfaction

Improved patient satisfaction

Patient safety

AHP and AHA Skills maintenance

Supervision overhead

Correct staffing ratios

Uncertain career progression for AHAs

Physiotherapy

Providing exercise assistance

Running group classes,

Routine data entry

Equipment management

Providing walk assist programs

Assisting with manual handling

Misc. administration and scheduling duties

Increased PT capacity

Increased research participation

Decreased manual handling risk

Decreased staff burnout

Timely completion of administrative duties

Enhanced job satisfaction

Increased treatment time

Risk of professional replacement with AHAs

Reduced opportunity for skills maintenance

Variable treatment quality

Limited clinical judgement

High supervision needs

Delegation time demands

Speech Pathology

Development and implementation of AHA practice competencies

AHA supervision guidelines

Increased opportunities for clinical networking

Increased resource access

Clarified scope of practice definition

Alignment with AHA framework

Increased treatment time

Enhanced service consistency

Increased cost effectiveness

Reduced length of stay

Staff upskilling

Improved patient outcomes

Delegation time demands

Replacement of professional staff by AHAs

AHAs working outside of scope

Recruitment and retention difficulties

Issues with job satisfaction

An “us and them” culture

Patient refusal to receive AHA treatment

Dietetics and Nutrition

Alignment with AHA framework

Screening tool completion by AHAs

Routine charting completion

Conducting simple patient reviews

Administration task completion

CBORD/VISION activities

Patient menu choice completion

Product representative liaison duties

Improved patient outcomes

Increased screening and monitoring activities

Decreased length of stay

Increased clinical time

Increased research and quality improvement time

Improved cost effectiveness

Increased patient contact

Decreased dietitian numbers

Need to realign position description and roles

Unclear role delineation

Inadequate training or supervision of AHAs

Uncertainty regarding funding adequacy

Unclear AHA position description

Risk for AHAs working outside of cope

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4.9 Early adoption of proven innovations

The healthcare environment is rich in emerging innovations which have the potential to enhance quality of care and reduce the cost of service delivery. Services can increase reputation, effectiveness and patient-centred care delivery through being leaders in implementing evidence-based innovations.

Practice examples

In 2010 Peaco et al. found that the quality, fit and function of orthotic devices was equally as important to patient satisfaction as service-specific qualities. By adopting cost-effective advances in orthotic therapies services are able to improve patient satisfaction, thereby linking appropriate adoption of innovation with patient-centred care24.

In 2012 Reinkensmeyer et al. described the range of emerging technologies enabling enhanced therapeutic aids for use by occupational therapy, orthotists and physiotherapists. Ease, time and cost of manufacture, increased ability to meet specific patient need and reduced cost were identified as potential benefits. Initial equipment and training costs were identified as planning considerations25.

In 2011 Snowdon and Cohen published an extensive summary of innovations in healthcare, with associated benefits to clinical outcomes and organisational reputations identified. Lessons in ensuring innovations were evidence-based, cost effective and patient-centred were identified through healthcare-specific examples26.


Clear evidence of the adoption of innovative practices was identified at NSLHD overall. While there are areas of particular note, i.e. in the burns and spinal unit at RNSH, lower levels of less evidence was identified for broader NSLHD support for newer technologies such as recording patient information and staff activity with bar-codes. Suboptimal access to iPads and skype was an issue reported through stakeholder workshops for example. Staff advised during workshop sessions that current technological inefficiencies could impact on ability to provide appropriate models of care. POD - FES and additive/3D printing are examples of emerging technologies with the potential to reduce manufacture time. Earlier service access can reduce length of stay.

Areas where examples of the LHD participating in and adopting innovation are outlined below. While these are focused mostly on RNSH, it should be noted however that HKH/NB are also starting to provide some of the services:

Podiatry

RNSR is the only service in NSW to have an integrated Rheumatology Podiatry service

Employment of wound care innovations for early intervention is a common part of the management plan for patient who present at high risk.

SONOCA Low frequency Ultrasound Debridement.

SilhouetteStar wound imaging, 3D measurement and documentation system.

24 Peaco, A., Halsne, E. and Hafner, B.J., 2011. Assessing satisfaction with orthotic devices and services: A systematic literature review. JPO: Journal of Prosthetics and Orthotics, 23(2), pp.95-105. 25 Reinkensmeyer, D.J. and Boninger, M.L., 2012. Technologies and combination therapies for enhancing movement training for people with a disability. J Neuroeng Rehabil, 9, p.17. 26 Snowdon, A. and Cohen, J.A., 2011. Strengthening health systems through innovation: lessons learned. Ivey Centre for Health Innovation.

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OMRON Vascular Profiler - Automated Ankle Brachial and Toe Brachial Pressure system.

Larvae therapy.

Physiotherapy

OACCP.

ESD.

Osteoporotic Re-Fracture Prevention Program.

Low back Pain Triage Physiotherapist.

Integrated MDT Hand Surgery and Trauma management.

The use of Inspiratory Threshold training and devices has recently commenced at Manly recently. This practice is evidence based and involves inspiratory muscle training on intubated patients using the device.

Speech Pathology

AAC, and computer based apps and programmes.

Instrumental assessments including independent FEES.

Early Intervention with use of early rehab programmes for stroke, swallow screens.

Use of EMG and acoustic biofeedback (RNSH only).

NB are engaged in a research project to determine whether a psychosocial intervention model improves communication and well-being outcomes for patients post stroke.

The NB services is mirroring latest research in the provision of group therapy for delivering the Lidcombe Program for Stuttering Intervention as well as intensive service delivery for children with Childhood Apraxia of Speech

Sexual Assault

The service is currently engaged in research in conjunction with Sydney University that examines using the Short Term Intensive Psychodynamic Therapy Conversational Model as an alternative framework for working effectively with trauma clients in a shorter time frame.

Aged Care Rehabilitation

Stroke Guidelines, ACI Orthogeriatric model of care, NSW Rehabilitation models of care, LSVT models of care.

Innovation in group setting delivery in balance and falls management.

Innovation in group setting in management of aged care and rehabilitation clients with hydrotherapy model of care.

Application of innovations related to technology advancement in place, face to face contemporaneous patient recording in eMR.


Wessex Head Injury Measure development in conjunction with Speech Pathology.

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Social Work

The NBHS Social Work Department is only 1 of 2 hospitals that have explored the innovation of the cold cuddle cot for families who have experienced a neo natal death. Research indicates that this practice ensures best possible outcomes for families. Consumer feedback on discharge from hospital has been strongly supportive.

4.10 Services developed in partnership with NGOs, private and other public health services

Two aspects of this characteristic are discussed below: models of public/private partnership and partnering with other public providers (e.g. Community-based and other NGOs). An overall assessment is then provided.

4.10.1 Public/private Allied Health service models

Private Health Services and Non-public Allied Health Practitioners are widely distributed throughout public health service catchment areas. Including private Allied Health providers in public service planning and service delivery promotes service efficiency and service access.

Practice examples

In 2009 Davies et al. identified that the integration between public and private health services in Australia is extensive. Benefits included enhanced service access, reduced burden on the public system and reduced need to duplicate services. Policy, planning, effective communication and coordination of services were identified as key considerations for successful integrated care models27.

Forster et al. discussed the relationship of funding to service access in Australia in 2008. The structure of subsidies for Allied Health services was a key driver of service utilisation and service access. Consideration to the implications of changing funding models on service access and service demand was identified as a consideration in planning Allied Health Services28.

A 2011 study by McDonald et al. identified that Multidisciplinary Teams, while being recognised as highly effective, often contained a mix of public sector and private sector employees. Successful collaboration between sectors was found to attract both costs and benefits. A shared focus on patient outcomes was identified as a bridging factor with which to align service goals and outputs29.


Some Evidence supporting coordinated service delivery between the LHD and external private providers was identified as follows:

Podiatry Services at Hornsby Hospital are coordinated with private providers to arrange and deliver consultations in collaboration with the Primary Health Network.

RNSH partners with private providers through the following programs:

o PACH AH services partner with a number of external agencies e.g. CDCRS, ACAT, Transition Care.

27 Davies, G.P., Perkins, D., McDonald, J. and Williams, A., 2009. Special series: integrated primary health care: integrated primary health care in Australia. International Journal of Integrated Care, 9. 28 Foster, M.M., Mitchell, G., Haines, T., Tweedy, S., Cornwell, P. and Fleming, J., 2008. Does Enhanced Primary Care enhance primary care? Policy-induced dilemmas for allied health professionals. Medical Journal of Australia, 188(1), p.29. 29 McDonald, J., Powell Davies, G., Jayasuriya, R. and Fort Harris, M., 2011. Collaboration across private and public sector primary health care services: benefits, costs and policy implications. Journal of Interprofessional Care, 25(4), pp.258-264.

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o OACCP program, the Musculoskeletal Integrated Care Program, the “Breathe” team and follow-up neonatal care.

NB Speech Pathology attends local private practitioner meetings to coordinate services and care for local residents

Podiatry

Close liaison with local medial officers and Sydney Home Nursing Service for ongoing co-management and discharge of patients to the community.

Nutrition & Dietetics

NSLHD Dietetics has developed in conjunction with Sydney University a Northern (NSLHD) model of student training, where students complete both of their clinical placements at facilities within NSLHD in order to provide a NSLHD clinical experience, maximise the potential future benefit to the NSLHD workforce and to lessen the burden of time taken for orientation of students.

Physiotherapy

Numerous examples available through individual networks.

Musculoskeletal integrated care program with primary care including private physiotherapy practices.

‘Breathe’ team – ED, admission, APAC, Community health, primary care and private providers for patients with chronic respiratory disease.

Neonatology management and follow up.

Health lifestyle

Hydrotherapy groups- including Aboriginal and Torres Strait Islander ladies group

Stepping On program

Aged Care Rehab Ryde

RACRS currently has a partnership and shared models of care with Parkinson’s NSW, MND association, Alzheimer’s Australia, NSW Rehabilitation Network.

Hammond Care College NGO provided a day long presentation of the Day Hospital model of care and implementation of this.

OTs have developed close partnerships in the delivery care with the Home Modifications Service, Enable, Department and Housing to optimise the safety can care of patients.

SP have presented at a multitude of MND annual conferences to look at optimising patient management with Assistive Communication Devices.

Dietitian have provided community education to service providers to recognise signs and symptoms of malnourishment in the community and the benefits of early referral.


Linkages exist with local community services including NS Carer Respite, ENABLE, and Private Hospitals.

Occupational Therapy Lymphoedema Service.

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4.10.2 Services developed in partnership with external (public) providers

Hospital-based services do not represent the entirety of patient journeys and continuity of care. Partnerships with local NGOs such as aged care facilities and community providers promotes hospital avoidance and enables appropriate, timely, patient-centred care.

Practice examples

In 2006 Graff et al. found that Occupational Therapy Services, based at a hospital Geriatric Department but delivered in surrounding aged care facilities, provided long-lasting marked improvement in function and reduced carer burden. Functional improvements were associated with reduced likelihood of hospital admission for issues relating to functional ability30.

In 2007 Battersby et al. identified that a multidisciplinary, community-based chronic illness care program increased out-of-hospital Allied Health service interventions. This had benefits in enabling service delivery for patients without a need for travel while also increasing functional and quality of life outcomes without hospitalisation31.

McDonald et al. identified that coordination between public and community health is a national priority in Australia in their 2009 study. A mix of decentralised network-style and hub-and-spoke models were described as having successfully met broader patient needs. A variety of governance, and formal partnership model success factors were identified in terms of collaboration effectiveness, which has been linked to care outcomes and patient satisfaction32.


Some evidence of this characteristic was identified as follows:

Integrated links with Primary Care was identified as an ongoing challenge along with NDIS and My Aged Care.

Geriatric Outreach Teams, such as the GRACE Team at HKH and the RNS Community Aged Care program at Kirribilli, represent collaborative partnerships with local residential aged care facilities to promote hospital avoidance and streamlined patient journeys.

HKH Speech Pathology provide a very comprehensive and responsive MBS service to private clinicians, including Lady Davidson Hospital and Mount Wilga Hospital.

HKH & NB Speech Pathology have close liaison and partnership with a range of private Speech Pathologists. Frequently coordinate therapy interventions for optimal outcomes for the client.

Good relationships with NGO's. Speech Pathologists from health, ADHC, and NGO's (Lifestart, CPA, SDN, KU Services, etc.) and several meetings have taken place to discuss transition of children after ADHC disbands in 2018.

30 Graff, M.J., Vernooij-Dassen, M.J., Thijssen, M., Dekker, J., Hoefnagels, W.H. and Rikkert, M.G.O., 2006. Community based occupational therapy for patients with dementia and their care givers: randomised controlled trial. Bmj, 333(7580), p.1196. 31 Battersby, M., Harvey, P., Mills, P.D., Kalucy, E., Pols, R.G., Frith, P.A., McDONALD, P.E.T.E.R., Esterman, A., Tsourtos, G., Donato, R. and Pearce, R., 2007. SA HealthPlus: a controlled trial of a statewide application of a generic model of chronic illness care. Milbank Quarterly, 85(1), pp.37-67. 32 McDonald, J., Davies, G.P. and Harris, M.F., 2009. Interorganisational and interprofessional partnership approaches to achieve more coordinated and integrated primary and community health services: the Australian experience. Australian Journal of Primary Health, 15(4), pp.262-269.

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Frequent liaison with ADHC regarding adult clients to determine most appropriate services to access.

Frequent liaison with Speech Pathologists providing services to group home clients.

4.11 Allied Health services linked with academic institutions

Health Services and Academic Institutions are inherently linked through the processes of research and professional qualification attainment. Building collaborative partnerships with Academic Institutions enhances future workforce outcomes, aligns services with research activities, enhances reputation and provides opportunities for the service to participate in developing and furthering best practice.

Practice examples

Whitworth et al. identified opportunities available through partnerships between healthcare organisations and academic institutions in the UK in 2012. These included opportunities to directly contribute to the establishment of academically-validated “best practice” activities, systems and models along with increased access to emerging practices and standards33.

In 2015 Van et al. identified the employment and training benefits of partnerships between trainee and new graduate nurses and healthcare organisations in the US. Workforce outcomes were enhanced through facilitated recruitment along with increased skills and confidence amongst new graduates when first hired34.

Golenko et al. conducted a study in Australia in 2012 which explored organisation-level factors influencing research capacity. Partnerships with external organisations were identified as a key factor in promoting research activities through enabling collaboration, resource sharing and knowledge sharing35.


The overall assessment concluded that Clear Evidence was identified, however managers and staff sentiments generally indicated a lack of appreciation and support to facilitate academic links. These views may be influenced by the impending establishment of an Allied Health Professorial Position. Identifying and securing funding arrangements with Academic Institutions was widely seen as a key lever for enabling research and student supervision activities.

Key findings reflective of existing academic partnerships include:

Staff advised at workshop sessions that research is often completed in personal time due to high workloads and short staffing, limiting the capacity for participation in research projects and programs.

A number of research grants and research projects are underway which include a range of external organisations. However grants are often limited to RNSH staff only or medical and nursing. RNSR management identified professional participation in university activities including lecturing, research and undergraduate/postgraduate student supervision. Conference attendance was also stated.

33 Whitworth, A., Haining, S. and Stringer, H., 2012. Enhancing research capacity across healthcare and higher education sectors: development and evaluation of an integrated model. BMC health services research, 12(1), p.287. 34 Van, P., Berman, A., Karshmer, J., Prion, S., West, N. and Wallace, J., 2015. Academic–Practice Partnerships for Unemployed New Graduates in California. Journal of Professional Nursing. 35 Golenko, X., Pager, S. and Holden, L., 2012. A thematic analysis of the role of the organisation in building allied health research capacity: a senior managers’ perspective. BMC health services research, 12(1), p.276.

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Data quality and data availability is a limiting factor in targeting education and research activities based on service data.

Award-provided study days exist, however they are frequently not taken due to staffing shortages and inability to provide leave relief for days taken.

Managers advised that internal audit findings support the need for increased education support.

HETI operates an Allied Health Education Network. NSLHD staff advised they access this service to assist funding of training.

Award classified Student supervisors (i.e. Level 4) are intermittently located across professions and sites. These are provided through funding from universities on a non-permanent basis, while other such positions are funded by individual departments. A very small number of long-term permanent supervisors exist, however evidence of collaboration between these individuals was not identified.

Although expectations exist to participate in research and implement Evidence-Based Practice (EBP), staff sentiments were that workload significantly limits capacity for these expectations to be met.

PACH CDCRS have 2 conjoint positions with Sydney University and a number of research projects have been undertaken in CDCRS, or are currently in progress.

RNSR Speech pathology identified a program centred on increasing student capacity.

RNSH Speech Pathology, Occupational Therapy and Physiotherapy evidenced recent peer-reviewed research publications.

In 2014 an interdisciplinary orientation package was developed for NSRHS by the RNS Allied Health New Graduate & Intern Orientation Working Party.

Nutrition and Dietetics across NSLHD are linked with Sydney University for Dietetic student teaching and training. This training is for clinical placement and food services placement. RNSH also takes research project placement students which are a semester in duration. In addition RNSH is linked with the University of Sydney's Northern Clinical School for medical training and provides annual tutorials to medical students in years 1 and 2.

Involved with First Year Graduate allocation for Physiotherapy

All the Allied Health professions have associations with and accept student placements from the following tertiary academic institutions; Sydney University, Western Sydney University, Charles Sturt University, Australian Catholic University.

4.12 Benchmarking

Benchmarking practices involve the use of valid measures of service performance for the purpose of comparison. Identifying evidence-based measures of service activity and service outcomes and establishing their ongoing use in service evaluation programs enables service evaluation, comparison between services, enhanced service reputation and increased service recognition.

Practice examples

In 2015 Solomon et al. identified the importance of benchmarking in the Australian Allied Health environment. Although many gaps in available data exist, workforce

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measures were identified for benchmarking purposes along with a number of international benchmarking initiatives. The importance of data for performance measurement was established and reputational links identified36.

Nancarrow et al. described a program of Australian Allied Health service delivery, quality and outcome evaluation using established measures in 2014. This study identified that Allied Health-specific benchmarking provides visibility of service performance and enables targeted action where required. Profession-specific measures were found to be necessary given the broad spectrum of Allied Health activities37.

Duncan et al. conducted an international systematic review in 2012 which explored barriers and enablers of Allied Health service evaluation. Organisational support and engagement of practitioners at the individual level were found to be key factors in facilitating benchmarking activities38.


Some evidence of external benchmarking was identified. Some evidence of internal benchmarking against wait list targets and turnaround times was discussed, however the impact of data quality and data availability on these activities was acknowledged. NSLHD is not a member of the Australasian Allied Health Benchmarking Consortium (AALLIED HEALTHBC) and involvement of NSLHD with the Health Round Table (which includes the Allied Health Improvement Group) has been intermittent. In partnership with the Australasian Allied Health Benchmarking Consortium (AALLIED HEALTHBC) the Allied Health Improvement Group has been collecting and comparing Allied Health activity data for over 12 years.

A review of NSLHD benchmarking activities revealed that:

Key Performance Indicator (KPI) reporting requirements vary across departments in line with NSW Ministry of Health requirements.

Internal benchmarking of KPIs varies between sites and services. Some RNSH services (Physiotherapy, Speech Pathology, Nutrition and Dietetics) stated examples of extensive benchmarking activities.

Waiting lists have targets and are benchmarked by patient category.

While participation in the Allied Health Roundtable has intermittently occurred, membership has not always been continuous.

NSLHD Physiotherapy management advised the department participates in a wide range of clinical, professional and advisory groups.

NB & HKH Speech Pathology participate in benchmarking of multiple clinical areas across NSW.

36 Solomon, D., Graves, N. and Catherwood, J., 2015. Allied health growth: what we do not measure we cannot manage. Human resources for health, 13(1), p.32. 37 Nancarrow, S.A., Moran, A.M. and Boyce, R., 2014. Evaluation of a system of monitoring allied health service provision, quality and outcomes. Journal of BioSciences (JBio), 2(1). 38 Duncan, E.A. and Murray, J., 2012. The barriers and facilitators to routine outcome measurement by allied health professionals in practice: a systematic review. BMC health services research, 12(1), p.96.

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Governance Model Assessment

This section outlines potential governance structures for Allied Health with a view to optimising service provision and enhancing linkages across the key NSLHD sites. The current AH governance arrangements at NSLHD are discussed and characteristics of the present structures are highlighted.

Inputs to the assessment have been drawn from the stakeholder consultations (including interviews, staff workshops and discussions with the Working Party and Steering Group memberships) and findings from the literature review.

The assessment of the current governance model considers two key focus areas

Executive Representation: addresses the consistently expressed view of stakeholders, that the professional interests of the AH workforces are not adequately represented under the current governance arrangements.

LHD-wide Service governance structure: considers the potential of a range of governance model options to enhance AH Service provision, reduce variation in practice, optimise clinical workforce development and retention and ensure all AH staff have access to clinical supervision and clearly defined lines of reporting.

Details of the options considered and recommendations to address issues identified in these two focus areas are outlined below.

5.1 Executive Representation

The operational management function for AH services (see Figure 3 below) at NSLHD is provided through five senior managerial positions as follows:

Director Primary and Community Care and Allied Health (NSRHS): reports to the Executive Director Operations NSRHS & NSLHD and oversees AH Services across RNSH and Ryde.

Director of Primary and Community Health (PACH): reports to the Director of Nursing and Midwifery/Allied Health and provides oversight to AH staff within PACH MDTs across the LHD.

Director of Mental Health/Drug and Alcohol (MHDA): Reporting to the Executive Director Operations this position provides oversight to AH staff situated within MHDA teams across the LHD.

Allied Health Manager (HKH/NB): at 0.4 FTE this role reports through the Director Operations (NB) and provides operational oversight to the AH Disciplines across the HKH and NB sites.

Divisional Manager Women and Children’s Health (HKH/NB): this position provides operational oversight to a small number (headcount circa 10-12) of AH staff situated within the Division and who are based variously across HKH/NB.

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Figure 3: Current Operational Reporting Lines for Allied Health Services

The strategic and professional advisory function is provided via Director Allied Health NSLHD, a Tier 3 executive role until recently staffed at 0.5 FTE. The LHD has taken the decision to expand this position and has increased it to 1.0 FTE (at the HSM5 level). The LHD is currently recruiting to the role for a three year period. The AH Director reports to the NSLHD Executive via the Director Nursing and Midwifery/Allied Health and participates in the Executive Team via the Executive Leadership Team (ELT) and the Clinical Council.

Discontent with the current professional reporting arrangements (i.e. Allied Health reporting via another professional group, in this case, Nursing and Midwifery) has been clearly expressed in the stakeholder consultation process. During the interview and workshop processes the majority of Allied Health staff consulted endorsed re-orienting the Director Allied Health to report directly to the CE. Their reported view is that this would provide the AH workforces with professional representation on a level commensurate to that of the Medical and Nursing workforces. There are a number of potential ways to accomplish this.

One proposed outcome finds its origins in 2012 when, as part of NSW Health’s response to the Garling Commission Report (Recommendation 137), NSW Health provided advice to all LHDs which recommended the establishment of an Executive Director of Allied Health (Tier 2) position. This was to be a Professional Advisory role for Allied Health designed to provide:

Expert advice to the CE and other LHD Executives on strategic AH issues.

Input from an AH perspective into issues pertaining to detailed services planning, quality and safety.

A key reference point for advice on policy development with the LHD relevant to AH workforce.

Participate as a member of the Executive team in leadership of the LHD.

Update AH clinicians on health system and clinical practice improvements and to enable AH clinicians to provide feedback to the CE and LHD Executive.

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This advice was qualified however to state that the actual position configuration for undertaking these functions is at the discretion of the CE and the means by which these outcomes are achieved should occur in such a way that best meets the needs of each LHD.

As noted above these functions are currently provided at NSLHD by the Director Allied Health (Tier 3) which has recently been extended to 1.0 FTE.

In response other LHDs took a variety of approaches, (i.e. a Tier 3 position reporting directly to the CE) similar to that of NSLHD, with only one LHD known to have established the role as a Tier 2 (Nepean Blue Mountains LHD). It should also be noted that the scope of that position at NBMLHD also encompasses the function of Director Primary & Community Health.

It is the position of this review that the role functions outlined above can be satisfactorily performed by a Tier 3 Director with the appropriate reporting arrangements. There is clear evidence that the position as presently configured (and as advertised for the next 3 years) participates in the appropriate Executive Leadership fora (i.e. the Executive Leadership Team, Clinical Council) and is able to provide the intended two-way conduit between AH clinicians and the CE/Executive, by which the AH perspective can inform service planning, strategy and policy development.

The strength of stakeholder views on this subject however indicates that the LHD should address this issue as a matter of priority, as it represents a key barrier to progressing with a program of change initiatives.

In response four options were developed for consideration. Each option is assessed by benefit potential, considerations (risks and challenge for implementation) as well as its expected impact on stakeholder perceptions as addressing the key themes identified (see section 3.3 above).

5.2 Executive Representation: Options for consideration

This section provides detail and appraisal of 4 options as follows.

5.2.1 Option 1: No Change

In this option the present arrangements are not altered and the status quo persists.

Benefits:

Current arrangements offer potential to assist with patient flow resources in collaboration with Nursing and Midwifery.

Director Nursing and Midwifery has greater agility/bandwidth in portfolio than other Executives at Tier 2.

Considerations:

Continued stakeholder disengagement and lack of empowerment.

Negative stakeholder perceptions have the potential to significantly undermine any Transformation program efforts.

Lack of ability to provide relief.

Limited AH career progression options.

Making no change to the current reporting arrangements risks sustaining the current low levels of staff engagement which could negatively impact future change efforts/initiatives.

Impact on Key Themes

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5.2.2 Option 2a: Create Tier 2 Director Allied Health position

The Tier 2 role is created as originally recommended by the Garling Commission which reports directly to the CE.

Benefits:

Direct report to CE increases stakeholder perception of stronger AH voice.

Perception of stronger professional identity.

Reduced potential for perceived conflict of professional interest.

Enhanced career progression pathway.

Minimises barrier for change, i.e. would improve level of staff engagement.

Improved escalation pathway that demonstrates issues are being considered.

Considerations:

On call disaster management is a requirement/potential overhead for a Tier 2 role.

Only one of 15 LHDs have currently developed the Director Allied Health as a Tier 2 position.

NSW MoH approval would be required. The application process generates a compliance effort and time requirement to pursuing this option.

Current arrangements offer potential to assist with patient flow resources - this potential would be lost.

Removal of barrier to change (i.e. low stakeholder engagement) of reporting to Nursing and Midwifery.

The availability of Tier 2 portfolios is limited; if Allied Health is added, there is an expectation that another portfolio will have to be removed from Tier 2.

Pursuit of this option meets the specific requirement of the advice from Garling and delivers strong impact on stakeholder perceptions, however there are overheads of time and process to consider.


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5.2.3 Option 2b: Re-orient reporting lines of Director Allied Health to the CE

Under this option the current Director Allied Health Tier 3 position is retained but the reporting lines are reoriented to the CE.

Benefits:

Direct report to CE increases perception of stronger AH voice.

Perception of stronger professional identity.


Enhanced career progression pathway.

Minimises barrier for change, i.e. would improve level of staff engagement.

Improved escalation pathway that demonstrates that issues are being considered.

Removal of dual reporting requirements.

Consistent with arrangements of a number other NSW LHDs.

Consistent with other HSM position, e.g. Director Medical Workforce.

Removal of the barrier (to stakeholder engagement) of reporting to Nursing and Midwifery.

Able to implement immediately (i.e. no delay as no Ministry involvement is required).

Considerations:

Access to the Chief Executive may be more restricted than under the current arrangements.

Current arrangements offer potential to assist with patient flow resources, this potential would be lost.

Pursuit of this option delivers the same level of level of benefit as Option 2a above, but would be significantly easier to implement in a timely manner.


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5.2.4 Option 3: Re-orient reporting lines of Director Allied Health to the Executive Director Operations

Under this option the current Tier 3 role is retained but the reporting lines are reoriented to the Executive Director Operations.

Benefits:

AH do not report to another professional group.


Considerations:

Current arrangements offer potential to assist with patient flow resources - this potential would be lost.

Removal of barrier (to stakeholder engagement) of reporting to Nursing and Midwifery.

Potential conflict of reporting lines of Director Allied Health and Director PACH & AH – RNSR due to dual role of the Director Operations for RNSH and NSLHD.

Current workload associated with Operations portfolio access may be more restricted than under the current arrangements.

Pursuit of this option delivers a similar level of benefit as Option 2a above and would be relatively simple to implement in a timely manner, however the current high workload of this portfolio may restrict access.

5.3 Recommendation: Executive Representation

Following consideration of the options outlined above it is recommended to pursue Option 2b and retain the current Tier 3 Director Allied Health position, but to realign operational reporting to the Chief Executive as per Figure 4 below. This approach is similar to other positions/practices which are aligned to the Chief Executive.


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Figure 4: Proposed Realignment of AH Operational Reporting

The clearly and consistently expressed views of AH stakeholders throughout the consultation process was that of discontent with the current reporting arrangements. While not a direct impact on patient care, this issue is of sufficient salience as to provide a significant barrier to potential change efforts (through AH stakeholder disengagement) if it is not addressed.

This option was selected for its potential to:

Meet the requirements set by the Garling Commission and advice of NSW Health as regards AH representation to Executive.

Remove all potential perception of professional conflict of interest in representation to the Executive.

Enhance the level of engagement of AH staff overall and support a highly engaged AHP workforce, a key characteristic of a high functioning AH Service (see 4.3 above).

Provide appropriate levels of access (i.e. capacity of portfolio) to the Executive for reporting purposes.

This option provides the most effective solution to address the issue of AH Executive representation, at the lowest cost and at the least risk. Furthermore if adopted it will be possible to implement immediately and benefit realisation will likely occur immediately

While other options offer similar benefit potential, the high profile of the CE as a direct report for AH combined with the low implementation challenge, provides the basis for this recommendation.

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5.4 LHD-wide Service governance structure

The Allied Health workforce governance structures which are currently in place across at NSLHD fall variously within three categories common to hospital-based services in the Australian context, these models are commonly understood and are supported by a broad base in the literature, and are described in as follows:

Departmental Model: AH staff are based within departments oriented by discipline, the department provides organisation-wide professional governance39. The majority of hospital-based (i.e. Acute/sub-Acute) AH services at NSLHD (e.g. Speech Pathology, Occupational Therapy etc.) are configured in this way.

Allied Health Multidisciplinary Team (MDT) programs: where Allied Health staff are managed in AH team structures that reside within divisions. These are supported by a head of discipline for each profession who has a dual operational role for a service stream program and a governance role for their specific profession across the organisation40. At NSLHD the AH services provided by PACH and MHDA align most closely to this model. This model should not be confused with the clinical practice of working in a MDT which is common to all clinical AH practice at NSLHD.

Fully devolved or Unit Dispersement Model - where Allied Health staff are deployed across a broad range of clinical areas and are operationally managed by those areas. Professional governance is separate from line management.41 At NSLHD, Exercise Physiology - one of the smallest and most recently established of the AH disciplines - operates on this basis.

39Boyce RA 2003, “Beyond organisational design: moving from structure to service enhancement”, Australian Health Review, Vol 26, No 1, pp 175 – 183 40 Astley J 2000, “Transforming Allied”, Australian Health Review, Vol 23, No 4, pp 160 – 169 41 Boyce RA 2003, “Beyond organisational design: moving from structure to service enhancement”, Australian Health Review, Vol 26, No 1, pp 175 - 183

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Figure 5 Current NSLHD Allied Health Governance Structure

This diversity is not unusual across NSW LHDs given the variety of environments in which AH staff practice. At NSLHD however, a range of issues have been identified as arising from the current governance structure as follows:

The service and site based structure creates siloed communication which leads to difficulties coordinating between Departments and the key sites and service groups.

Structural differences between services and sites generate diversity in Clinical and Administrative practice (e.g. governance of data policy, practice and systems).

Limited ability to flex resourcing between services to meet demand, particularly at short notice, which exacerbates the challenge of mitigating gaps in service coverage.

The combination of service and site focus to AH service delivery does not always align with a LHD-wide view of service, i.e. the structure drives a natural focus on local priorities variously between the four major groupings (RNSR, HKH/NB, PACH and MHDA).

Professional groups are disaggregated i.e. split between the hospital-based services and MHDA and PACH. This separation has an impact on professional development and the collegial network connectivity of AH staff.

Current Department and Facility-based structure is valued highly by staff, supports the primary professional identity of AHPs.

AH staff working within PACH and MHDA have limited professional and supervisory links to colleagues within their Discipline.

The difference between how hospital-based AH Services (RNSR and HKH/NB) the Community and Mental Health (PACH and MHDA) Services are organised and operate is the most significant feature of the current structure. The result is that the two large, distinct groups of AH professionals exist, working under different governance structures.

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The differences between these two service blocs are also reflected in the different reporting pathways (see Figure 5 above) and the absence of consistent professional reporting lines/mechanism for the AH professionals that work within PACH and MHDA.

In addition to the two main groups there also exists a diverse collection of specialist positions in specific services and facilities across the LHD. The AH staff working within the HKH/NB Women and Children’s Health division teams (e.g. Family Care Cottage, Spilstead Service) are just one example. While AH staff in these type of positions do have formal lines of professional reporting to the relevant department, the dispersed nature of these more specialised roles inhibits visibility and communications.

Allied Health Network

One component of the governance model not depicted above is the Allied Health Network, the precise role of which is currently still developing. The Network operates under the aegis of the Director Allied Health and its membership includes representation from each of the AH Disciplines. The intention of this group is to provide leadership, support and a collaborative resource for Allied Health across NSLHD.

The Network is tasked with the timely, coordinated planning and management of relevant Allied Health issues for NSLHD, such as district-wide communication across Allied Health services, clinical efficiency, clinical governance, evidence based practice, effective clinical safety and risk management, models of care and workforce development.

At the present time however AH stakeholders report uncertainty as to the scope and nature of its activities. The potential for further development of the AH Network structure should be considered as part of the ongoing development of AH governance structures.

In summary the present Allied Health governance are simply reflective of how services have evolved. While internally coherent the hospital-based Services do not wholly align across the District. However, it is important to note that these are broadly aligned with how the other clinical professions and services are organised across NSLHD i.e. along service and facility lines. Any consideration of significant change to AH service models should not occur in isolation but rather as part of a whole of system approach.

The professional AH Department structures are highly valued by staff and provide positive benefits, especially as regards supporting the development of specialist professional expertise. Any moves to increase an emphasis District wide should be balanced by considerations of how to retain these positive aspects of the current structure.

Our assessment indicates that a new governance mechanism is required to enable the effective implementation of LHD-wide standards, i.e. an approach which retains the best of the current model, but reduces variation in practice driven by differences in service structure.

5.4.1 Options Appraisal

Five options have been developed for consideration below. The feasibility of each option is assessed against the following criteria:

Support for a High Functioning AH Service: how the proposed approach could enable NSLHD to better exhibit one or more of the relevant characteristics of a high functioning AH Service (as described in section 4 above). A subset of 3 characteristics, which governance models are most able to influence include:

o Patient-centric focus informs models of care.

o Multidisciplinary Team (MDT) models of clinical care.

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o Highly engaged AHP workforce.

The perception of stakeholders of the potential of the option to successfully address each of the key themes (see 3.3 above) identified in the consultation.

An assessment of current Organisational Readiness for implementation which considers:

o Stakeholder attitudes: the level of anticipated stakeholder support.

o Systems maturity: the ability of the organisation’s processes and systems to support the proposed solution.

o Change quotient: the ability of the organisation to absorb the quantum of change that the option would require.

The anticipated benefits, costs, risks and dependencies.

Combined assessment of these criteria forms the appraisal of each option and informs the recommendation made. The initial results of this process however made it clearly evident that a further sub-grouping of potential options was required.

Three (Options 1-3) of the five options are viable for pursuit in the near term (i.e. within the next 3-6 months). The remaining two options (Options 4 and 5) should be considered aspirational at this time. Significant organisational change and development would be required before implementation could be reasonably expected (if agreed). These two options are presented here as potential future models for based on the experience in other organisations and jurisdictions for information and consideration.

For this reason the options analysis is provided in two streams as follows below.

5.5 LHD-wide Service governance: Options for near-term consideration

This section provides discussion and appraisal of three governance options which could be practically pursued by the LHD within the next three to six months.

5.5.1 Option 1: No Change

In this option the present arrangements are not altered and the status quo persists.

Benefits

No change effort required.

Risks

The issues identified above will continue to proliferate without mitigation.

No impact on NSLHD high functioning AH service characteristics

Lack of mechanism by which to implement and/or monitor application of LHD-wide standards/practices has the potential to provide a barrier to any change program.

As noted above the current Service structures are valued highly by stakeholders; clear rationale for any change will be required and will need to be clearly articulated to stakeholders.

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5.5.2 Option 2. Establish AH Discipline leads across NSLHD

This option seeks to provide a mechanism by which to extend a consistent professional reporting structure across the full range of services while retaining the current governance structures. This to be accomplished by the establishment of a Discipline Lead for each professional group across the LHD (estimated at 0.4 FTE/role).

The Discipline Lead reports professionally to Director Allied Health, with a remit for professional development, the role scope to extend service wide including PACH and MHDA. Fixed term positions, are aligned to the 3 year tenure of the Director Allied Health and an evaluation of the performance of this model could be made at the end of that period.

Benefits

Leads provide professional linkages along Disciplinary lines across the whole of LHD Services.

Potential to alignment the tenure of these of positions to the transformation process and leverage across the LHD as network of program/change leaders.

Enhanced support for professional development for all AH staff across the LHD.

Offers potential to support a highly engaged AHP workforce, a key characteristic of a high functioning AH Service.

Career development opportunities for AH staff.

Risks

Relatively large group of Discipline Leads (20) potentially unwieldy to coordinate.

Overlap with developing role of the AH Network.

Ability to generate sufficient return for the required investment.

Resourcing challenge, especially for smaller Disciplines.

Dependencies

Significant additional investment required at 0.4 FTE per Discipline (in scope professions and others) plus the corresponding backfill requirement which would be generated.

o Additional salary costs estimated at $774,852 per annum – based on 20 Discipline Leads assuming salary costs average of mid-point on the current HSM2 award at 0.4 FTE.

o Total additional salary expenditure of $1.55 million per annum if commensurate levels of backfill provided at same resource level.

Role definition and expectations.

South Eastern Sydney LHDs’ experience with this model – that LHD is now discontinuing these positions.

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The Discipline Leads are strategic roles which lack operational responsibility therefore decisions made will still require sign off by all the operational managers in each portfolio.

Will not solve the professional day to day management in multi-disciplinary teams in MHDA and PACH.

Pursuit of this option offers delivers a relatively low level of benefit for the level of additional investment that is required. The experience of other LHDs indicates that this approach has a mixed track record, with SESLHD moving away from this model.

5.5.3 Option 3. Establish an Allied Health Structure for NSLHD

Another approach for extending the breadth of professional reporting across the full scope of services envisages the establishment of an Allied Health governance structure for NSLHD (more tightly focused than under Option 4 above).

This group to be comprised of the four Allied Health Managers representing RNSH/Ryde, HKH/NB (the two existing positions), MHDA and PACH (two new positions already scoped) as well as the AH Data manager (a new temporary position), AHA Coordinator and Pharmacy Educator positions. While not within the scope of this review it is considered essential to the viability of this approach that the membership includes representation from Pharmacy and Radiology.

This group to report along strategic and professional lines to the Director Allied Health NSLHD, and the operational reporting arrangements for those roles would be not affected. Operational reports to the Director AH under in this option would include the AHA Coordinator (current reporting lines to be re-oriented) and two anticipated roles, the AH Professorial position (approved from within current funding) and the AH Data Manager (proposed as part of this review).

The new NSLHD AH Steering Group provides a peak forum for LHD-wide decision-making and provides a linkage point to the Allied Health Network (see Figure 6 below). It should also be noted that some of these roles are envisaged as temporary/fixed term positions, subject to future review, e.g. Director Allied Health (3 year term), the Professorial position, the AH Data Manager.

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Figure 6: NSLHD Allied Health Steering Group

This arrangement will define the scope of LHD/local operational priorities and ensure that the Director of Allied Health has sufficient authority to adjudicate matters of District significance (e.g. data governance). This role provides the focal point for extension of professional linkages across the whole LHD.

Benefits

Provides a unified view of NSLHD AH services and a single point of resolution of issues of LHD significance, including AH models of care, access, professional governance, education and training.

Strengthens and simplifies decision-making processes.

All Allied Health staff will have the ability to report on professional lines to an appropriate/relevant AH Disciplines.

Improved communications (consistency and effectiveness) between the operational and strategic leaders of AH staff groups across NSLHD.

Enhanced career development opportunities.

Provides opportunity and resource to understand and resolve a range of reported data and information issues.

Additional support for recruitment processes.

Retains benefits of current Departmental structure.

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Assist in exploration of potential AHA workforce.

Offers potential to support a highly engaged AHP workforce, a key characteristic of a high functioning AH Service

The MHDA AH Manager position is currently scoped into the MHDA Directorate restructure and will be funded from existing resources.

Dependencies

Impact on scope and FTE of the current Position Descriptions including consideration given to temporary enhancement of NB/HKH until end 2018.

Process required to clearly define the scope of what the strategic and professional priority areas of LHD significance are, and also what is in-scope as regards local operational priorities.

Requires creation of two new AH Managers for PACH and MHDA. Although scoped from existing funding there is a need to secure the requisite funding commitment. As such there is a process overhead and investment required.

The four AH Managers will provide operational professional linkages along Disciplinary lines across the whole of LHD services. The AH Managers are to have operational and budgetary control over AH positions within their Directorate and are involved in recruitment of AH staff.

Administrative (EA) support for the Director Allied Health is currently provided by Nursing. Pursuit of this option will require new resourcing arrangements to sustain this function.

Reporting arrangements if post-holders were not AH professionals (e.g. Manager Allied Health NB & HKH) clarification required re viability professional reporting lines to the Director Allied Health in this eventuality.

Pursuit of this option will establish a framework which will provide an over-arching governance mechanism which will provide sufficient leverage for the LHD to moderate and enforce standards of practice (clinical and administrative) without the need to make significant change to existing organisational structures.

The scope of professional governance will be extended to all AH staff regardless of service group, while retaining positive elements of existing departmental/service structures. The critical dependency to this option, however, is proceeding with the planned establishment of the two new Allied Health Manager positions for PACH and MHDA.

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5.6 LHD-wide Service governance: Options for future consideration

This section provides discussion and appraisal of two governance options which could be considered aspirational. Both options would require significant additional investigation and developmental work before a decision on implementation could reasonably be made.

5.6.1 Option 4: Establish Internal Matrix model across hospital-based AH Services

This option explores the potential to consolidate the current hospital-based AH Departments (RNSR and HKH/NB) on LHD-wide basis within an enhanced Allied Health Directorate for the hospital-based Services. Under this Internal Matrix model each Department holds its budget and provides AH resources to clinical services via Service Level Agreements (SLA). MHDA and PACH retain current MDT service structure and approach.

This would see the hospital-based AH Services still managed via profession-specific departments which negotiate internal SLA with clinical units. Staffing arrangements are determined based on agreements for activity.

This model creates an internal allied health matrix which (when successfully implemented) recognises both:

The importance of professionally managed services to sustaining professional identity, service management and development – via larger professional departments.

Focus on patients/consumers through allied health service delivery teams.

Examples of variations on this model are common in the New Zealand context and services which have implemented this approach include Counties-Manukau DHB, and Canterbury DHB (Burwood Hospital)42.

The Central Adelaide LHN Allied Health Directorate provides an example of how a Directorate governance model oversees district-wide AH Departments43.

Benefits

Directorate structure provides LHD-oriented AH leadership structure through which to pursue LHD-wide strategies, moderate performance variance between disciplines, and oversee SLA processes.

Provides LHD-oriented structure through which to pursue LHD-wide strategies.

Better facilitates flexible staff assignment to meet resourcing requirements as resources not “owned” by clinical services. Staff can rotate through different services for professional development.

Retains current profession-based departments.

Optimises scale, visibility and voice of Allied Health workforce.

42 Interview 5th Jan 2016, Carolyn Cooper General Manager, Canterbury DHB, NZ (2007-2013). 43Central Adelaide LHN, Nov. 2013, “Establishment of a Central Adelaide Local Health Network Allied Health Leadership Structure”, pp. 2-12.

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Offers potential to support a highly engaged AHP workforce, a key characteristic of a high functioning AH Service.

Retains current strong patient/consumer focus.

Internal re-charge model via service agreement supports ongoing realisation of cost efficiencies i.e. will highlight cost effectiveness of AH potentially increasing demand for services, demonstrating AH value.

Risks

Complexity of implementing SLA approach; if this is too formal it creates additional administrative overhead.

The role of enhanced departments not balanced by system-wide management structure increases focus on larger facilities at expense of smaller services.

SLA based model perceived negatively by AH stakeholders at NSLHD.

High quotient of change required for successful implementation.

Dependencies

Significant implications for current AH management structures.

Requires thorough and accurate understanding of cost of service provision.

Maturity of information systems and practice a pre-requisite for SLA development.

Corresponding capability and maturity required of clinical units to commission services via the internal SLA mechanism.

Accurate picture of service demand - patient flows are required.

The new AH structure would not align with the rest of the LHD service structure (i.e. Medical and Nursing).

Transition to this model would have significant implications and require a commensurate change effort on the part of NSLHD. The experience of the NZ sites indicates that a timeline of 3-5 years from initiation to full implementation is not unusual and has required strong and consistent Executive sponsorship and the current negative stakeholder perceptions of this option would need to be overcome.

The combination of the Internal Matrix model and the Directorate structure does offer the potential to facilitate a “one service/many sites” at greater cost efficiency and in a way that retains the professional departmental support valued by AH staff. However these outcomes can only be attained if the pre-requisite conditions are met and supported by a sustained (and strongly sponsored) change effort.

5.6.2 Option 5: Extend formal MDT model across NSLHD

Re-orient current staff currently within AH Departments across the LHD to a formal MDT program basis, the scope of which extends across the full range of LHD services (RNSR, HKH/NB, MHDA, PACH). AH Staff are employed by Divisions along care pathways and operationally assigned within the Clinical Divisions while professional reporting lines to Departments are retained.

Benefits

Focus on clinical service/product-line generates increased efficiency over time.

Offers potential to enhance three characteristics of a high functioning AH Services:

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o Patient-centric focus informs models of care: as MDTs provide a patient oriented structure for service delivery.

o Highly engaged AHP workforce: via enhanced team approaches to care through formalised interdisciplinary cooperation, which can increase AH input into patient care.

o Multidisciplinary Team (MDT) models of clinical care increasingly formalised under this option.

Increased potential for task sharing/generic resourcing.

Risks

Reduced visibility of AH disciplines.

Weaker professional links to the Departments for AH staff.

Complexity of dual reporting lines to Divisional team and department.

Dependencies

Further development definition of patient care division pathway/MDT.

Significant implications for current AH management positions, i.e. shift in site of operational reporting of operational reporting, need to transition.

Maturity of information systems and practice.

Commissioning of services along pathways.

Accurate picture of demand, patient flows.

Pursuit of this option also offers a similarly significant quotient of change as Option 4 albeit with a different emphasis as operational management of AH staff shifts from the professional Departments to the Clinical Divisions and more formally integrates AH clinicians into MDTs.

The experience at Hunter New England during the mid-1990s operating under this model saw a realisation of the risks highlighted above, and led the organisation to move away from this approach44. Effectively this sees the hospital-based Services transitioning towards the current MHDA and PACH model of operation and stakeholder perceptions of this option reflect a lack of enthusiasm for making that shift.

Consideration of the risk profile and current stakeholder perceptions of this approach indicates that a gradual shift over time to the formalised MDT model would have the best prospect of successful adoption.

44 Robinson M.E and Compton J.V., ”De-centralised management structures – the physiotherapy experience at John Hunter

Hospital”, Australian Physiotherapy, Vol. 42, No.4 1996

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5.7 Recommendation: LHD-wide Service governance structure

The results of the options appraisal process outlines above support the recommendation of this report to pursue Option 3 and establish a formal Allied Health governance structure for NSLHD.

This framework will provide for strategic and professional reporting to the Director Allied Health for all AH staff across NSLHD, a function which is not possible under the current governance structure. Implementation of this option provides an effective response to a number of challenges identified through the course of the project:

Consistency of communications will be enhanced as the Steering Group membership has sufficient scope and authority to approve communications and the Steering Group structure will facilitate moderation and consistency of messages, enhancing coordination LHD-wide.

Standardisation of practice will become more achievable as the AH Steering Group will provide the appropriate forum for adjudication between local and LHD practice. Diversity in Clinical and Administrative practice (e.g. governance of data policy, practice and systems) can then be moderated as the membership possess the requisite role authority.

The membership and reporting orientation of the Group will provide a LHD-wide focus which can counterbalance the natural focus on local/internal priorities, which is generated by the four major AH Service groupings (RNSR, HKH/NB, PACH and MHDA). Additional benefit will be provided by extension of links to Pharmacy and Radiology.

This model will ensure that all AHPs have access to the appropriate professional and supervisory links to colleagues within their Discipline. This approach would also work to mitigate any risk of professional isolation (which was indicated by some AHP staff) within MHDA and PACH. Additionally this new structure would align with similar governance structures (e.g. for the Nursing and Medical workforces) within the LHD.

Offers potential to support a highly engaged AHP workforce, a key characteristic of a high functioning AH Service, as it retains the current Department -based structure which is valued highly by staff, and that provides the primary professional identity of AHPs.

The governance mechanism which will be established here will also serve to support consistent communications and implementation activities which will assist future change efforts.

The key to this approach is the appointment of the 4 operational/professional heads for Allied Health at RNSH/Ryde, HKH/NBHS, MHDA and PACH and the reorientation of the AHA Coordinator position to operationally report to the Director Allied Health.

This option presents a strong benefit case for a low level of risk and required investment and our assessment of Organisational Readiness indicates a low implementation challenge. It is recommended that this option be implemented in the near future as the proposed structure has the potential to assist with the proposed change program outlined below (see section 6 below).

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Sustainability Portfolio

This section identifies a set of 23 recommended initiatives designed for implementation as part of a program of sustainable service transformation for Allied Health at NSLHD.

6.1 Allied Health Transformation Program: Phase Two

It is recommended that a change management program and associated governance framework be established to oversee the subsequent phases of the Allied Health Transformation.

This program should be oriented to engage and facilitate the input of all relevant AH stakeholders (clinical and managerial) in service analysis and redesign processes. This will leverage clinical expertise and service knowledge to deliver sustainable service transformation.

Under the Sponsorship of the Director Allied Health, the focus of this program will be to take ownership of the Sustainability Portfolio set of initiatives and provide the framework for implementation and further development over the subsequent phases of work.

Considering the level of organisational and cultural change implied by the cumulative potential impact of the Sustainability Portfolio initiatives it is anticipated that the change process will require a multi-year timeframe. The three-year tenure of the Director Allied Health position provides a natural timeline for the program.

Evaluation of Transformation progress at the conclusion of this period will provide a useful guide as to the future courses of action, provide the opportunity to determine what changes to practice are now regarded as business-as-usual, and consider those which were less successful and draw-out the lessons learned.

6.1.1 Proposed Governance

At this stage of development two levels of program governance are anticipated. At the highest level is a Program Board, which provides senior management oversight to the work of the Transformation program.

The membership of the Program Board to include:

Program Sponsors: Director Allied Health and an Executive Sponsor (tbc).

Allied Health Managers (4) and other appropriate delegates to represent AH Disciplines across PACH, MHDA, RNS/R and HKH/NB (i.e. the Allied Health Steering Group is established as recommended in 5.7 above).

AH Transformation Program Manager and appropriate level of Project Officer support.

The Program Manager has operational responsibility for the running of projects and work streams which will implement the Sustainability Portfolio initiatives. The key focus of this role is to lead, oversee and coordinate the implementation projects and work streams which will engage AHPs/staff as is required and appropriate.

This governance framework is designed to be temporary and will be charged with transitioning the work of the specific initiatives into routine practice at NSLHD.

6.2 Sustainability Portfolio

The Sustainability Portfolio framework provides a structured approach to developing and managing proposed initiatives and action plans in a way that takes account of how each initiative addresses a barrier to change, assesses the potential impact (or benefit) and considers the

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challenge required for successful implementation. Taking this approach provides a basis for further prioritisation and development of action plans for implementation.

Initiatives have been categorised into five high-level focus areas as follows:

Staffing.

Data.

Models of Care.

Innovation.

Process.

As discussed above each initiatives is assessed for potential impact (i.e. how beneficial will the recommended course of action be) and the level of implementation challenge that would be required (e.g. the number of staff groups who would need to be involved, requirements for additional cost/resource etc.).

Final prioritisation and related implementation planning of sustainability portfolio initiatives to be conducted by NSLHD at the outset of Phase Two.

6.3 Sustainability Improvement Initiatives

Sustainability initiatives in the table below outline the key initiatives addressing core issues raised by stakeholders during the project. The initiatives link with strategies developed in the Allied Health NSLHD clinical service plan (pp. 201-202).

1.0 Staffing

Ref. No.




1.1 Assess LHD wide leave requirements for each profession to inform the capacity management planning tool. • Identify need for leave across professions, teams and facilities

Assess leave patterns and work demand volumes • Historical trends of different types of leave e.g. study,

maternity, sick.

• Lack of appropriate leave relief


1.2 Develop capacity management planning tool to provide advice on appropriate use of additional resources (AH, AHA, admin) against demand across NSLHD.


• Data integrity • Lack of industry staffing

number standards • Large range of patient

complexity • Service variation • Lack of national/

International data for benchmarking

High High

1.3 Assess current clinical and non-clinical activities and duties to support budget build up/cost centres and planning which will also inform the capacity management tool


Lack of industry staffing number standards • Large range of patient

complexity • Data integrity

High High

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Ref. No.




1.4 Develop discipline-specific workload measures for each profession to inform capacity management planning to support appropriate resource planning and skill mix.

• Stakeholders voiced a lack of adequate staff resourcing and support

• Large range of patient complexity

• Data integrity • No national or

international standard to determine measure

High High

1.5 Explore the benefits of extending the 7 day/week coverage for Occupational Therapy, Social work, Physiotherapy, Dietetics, Speech Pathology across the LHD to expedite discharge, reduce turnaround time, reduce length of stay, increase support, increase patient safety, improve patient outcomes.

• Delays in patient discharge due to inability to provide full service on weekend

• Resourcing • Financial Restraints • Monday- Friday Culture

for some services

High High

1.6 Review set up, skill mix, use and management of casual pools with the aim to standardise practices across the LHD to provide roster cover, to prevent service gaps and better sustain service cover during period of staff leave and recruitment.


• Financial Restraints • Resourcing

High Med

1.7 Formalise and increase the use (where appropriate) of AHPs in discharge planning in acute and sub-acute areas to enhance current participation of AH in facilitating discharge and assist reductions in LOS.

• Increased potential for involvement in discharge planning to improve patient outcomes

• Legacy practices • Resourcing

Med Med

1.8 Explore potential to change shift start and finish times to determine the benefits (staff & patient) and implications with the aim of better aligning allied health resources with service demand and enhance service delivery.


• Resourcing • 8.00 - 4.30 culture • Financial Restraints

Med Med

1.9 Establish professional reporting lines for all Allied Health staff and their specific discipline to receive discipline specific supervision as per the LHD’s AH supervision policy and to ensure appropriate recruitment.

• Lack of adequate staff support

• Minimal peer mentoring or supervision

• Resourcing • Legacy practices • Financial Restraints

Med Med

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2.0 Data

Ref. No.



2.1 Pilot dedicated AH data manager across LHD to support data management. Key roles will be: • Implement / enforce standardised business rules for clinical

information system use across NSLHD (e.g. CHOC, eMR, turnaround time recording practice) to provide consistent basis for reporting/analysis

• Role provides additional training capacity by which to upskill clinicians on key clinical information/data collection systems (e.g. CHOC, eMR) to support enhanced, consistent data entry.

• Data systems are confusing and difficult to use; data support is low



• Data support is low; and, inconsistent documentation practices for CHOC and eMR

• Financial Constraints • Resourcing • Data Integrity

High Med

2.2 Assess the potential to invest in expanding external benchmarking of Allied Health services at all sites.

• Limited external performance benchmarking data unavailable

• Data integrity • Financial constraints

Low Med

2.3 Design and implement information reporting which better aligns with specific AH requirements, including measures of AH performance (e.g. turnaround time) and characteristics of AH service delivery (e.g. location of service delivery) and secure executive support for the AH Minimum Data Set.

• Limited meaningful reporting for AH staff of performance

• Data systems are confusing and difficult to use;



• Data integrity Med Med

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3.0 Models of care

Ref

No.



3.1 Realign AHA Coordinator role to report to Director Allied health and continue to extend processes currently underway to develop safe and appropriate models of AHA care by discipline to support AHP while exploring the potential to realign the Pharmacy educator role to Director of Allied Health.

• Lack of adequate staff resourcing and support, service structure, resistance to change

• More appropriate use of AHA

• Legacy Practice Med Low

3.2 Explore opportunity to extended- AHP scope of practice focusing on key practice areas (e.g. criteria led discharge, referrals, diagnostic ordering, prescribing etc.) and further develop training pathways, requirements, governance and credentialing to increase scope of AHPs, improve patient satisfaction and reduce cost.

• Improve opportunities for extended scope of practice

• Legacy Practice • Professional Boundaries

High High

3.3 Explore LHD wide implementation of best practice models ensuring appropriate allied health involvement (e.g. oncology, aged care, paediatrics, diabetes) across the total patient journey and services delivery models

• Need to better integrate MDT assessment and continuity of care

• Resourcing • Legacy Practice • Professional Boundaries

High High

3.4 Explore partnership opportunities in non-acute areas by determining LHD service gaps against current demand to improve; patient centric care, rates of hospital avoidance, continuity of care and integrated care.

• Lack of adequate service coverage in some areas

• More appropriate use of NGOs

• Better alignment of resourcing with service need where required

• Legacy Practices • Data integrity

Med High

3.5 Undertake a review of AH consumer perspectives of care delivery while leverage existing surveys to support service delivery improvement.

• Patient centred care • Time constraints • Consumer participation

High Med

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4.0 Innovation

Ref. No.



4.1 Develop and implement a plan to improve academic research to enhance links to district academic partner institutions to increase opportunities for AH research to enhance professional development, research funding, increased staff satisfaction, increase timely incorporation of innovation into current practice.

• Lack of capacity to undertake research for some services

• Lack of research opportunities and knowledge funding options

• Minimal professional reporting structures and lack of supervision and leave relief

• Legacy Practice • Resourcing

Med Low

4.2 Explore possibilities for the use of social media/other applications/devices to better facilitate patient/consumer engagement and support models of preventative care (e.g. cardiac rehab, PACH).

• Slow to leverage new technology

• Facilitate patient flow

• Legacy Practice Low Med

4.3 Pilot a formalised ideas’ assessment process to evaluate new ideas generated from AHPs in: • Practices (e.g. podiatry ultrasound debridement) • models of care (mobile orthotic teams) • technology (3D printing technology)

• Lack of allied health empowerment

• Value in the importance of striving for more innovation

• Facilitate patient flow • Better alignment of

services with need • Improving patient

journey and flow

• Resourcing • Time constraints

High Med

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5.0 Process

Ref. No.



5.1 Conduct LHD-wide review of internal referral process to streamline referral process to understand/validate referral duplication and inappropriate referrals to appropriately refer and prioritise referrals across all disciplines which should free up clinician time and improve patient access to care.

• Duplication and inappropriate referrals

• More appropriate and timely referrals

• Legacy practices • Multiple referral systems

not linked (e.g. ePJB and eMR)

High Med

5.2 Explore options to improve timely recruitment to mitigate staffing vacancies. This will include identifying and mitigating where recruitment delays (profession/facility/process) are occurring.

• Long delays in recruitment process


5.3 Develop and formalise a communications strategy in-line with the established governance structure and pathways for disseminating Allied Health information to ensure consistent and timely communications. This should include an escalation process for ground staff to raise issues.

• Inconsistent information received by staff

• Legacy practices High Low

Appendix A: Issues and Initiatives Mapping

This section provides summaries at discipline level of how the issues raised through the stakeholder consultation process have been responded to by the work of this project.

7.1 Exercise Physiology

Issues identified during the consultation process Initiative reference number

Providing coverage between services is a challenge, partly due to lack of capacity of the small team and the increasing desire to provide more access to the service. Opportunity exists to expand to clinical areas outside of cardiac rehabilitation; staff believe that this model of care would benefit patients suffering from mental health, diabetes, persistent pain and cancer.

1.1, 1.4, 1.6

Additional administrative support would increase the time available for direct and indirect patient related activities for clinicians, and also ensure that data entry was conducted accurately and in a timely manner.

1.3, 2.1, 2.3

Group classes and education are a major component of the service’s activity, however these activities are not captured consistently in the data between services and locations.

2.1, 2.3

Career progression pathways are ambiguous which is in part due to the relatively recent recognition of the profession itself and a lack of established pathways for Exercise Physiology Services.

Not specifically addressed in these initiatives but identified for future consideration

A lack of understanding of what Exercise Physiology is by other Allied Health Professionals and multi-disciplinary teams contributes to inappropriate or missed referrals.

5.1

Staff report that the RNS facility does not have appropriate space for consultation and assessments. As a result, Exercise Physiologists are required to wait for the gym to be free during the Physiotherapists lunch break. This limits their access to a dedicated space to one hour per day.


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7.2 Occupational Therapy


A lack of leave relief and a perceived lack of staff resourcing are seen as the biggest issues.

1.1, 1.2, 1.3, 1.4, 1.6

General hospital weekend services operate with fewer OT staff which slows down patients’ rehabilitation progress.

1.5

General hospital community service waiting lists can be up to six months long and are reported to be sporadic in service delivery intervals and locations.

1.1, 1.3, 1.4, 1.5, 5.1

A large proportion of Occupational Therapy time is dedicated to indirect and non-patient-related activities, reflecting the wide array of duties carried out by Occupational Therapists which should be accurately captured when measuring OT workloads.

1.4

The use of My Aged Care in procuring services and equipment without professional OT assessment has led to sub-optimal patient and performance outcomes and inappropriate equipment supplied to patients.

5.1

Recruitment is an issue with average time to recruit being 10 weeks from recruitment start dates, yet staff vacancy notice is only four weeks. Extensive recruitment administration and sign-off delays the process.

5.3

The rationalisation in access to pool cars can be a barrier to provision of community services.


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7.3 Mental Health/Drug and Alcohol


A lack of leave relief and inadequate staffing resources are seen as major challenges in meeting service demand.

1.1, 1.3, 1.4, 1.6

Professional reporting lines for Allied Health staff are unclear as a result of the MDT structure of MDHA and absence of departmental structures. This is perceived to reduce professional support and development.

1.9

Maintaining currency of practice requirements places additional burden on Allied Health staff employed as Mental Health workers with ongoing training requirements to maintain discipline specific credentials.


Recruitment and staff replacement is a major concern. The gap from resignation to a new staff member commencing is approximately four months. Managing recruitment-related processes significantly detracts from clinical time. The current recruitment process limits the ability for services to innovate and to implement structural change.

5.3

Staff expressed a view that the current structure of the Director Allied Health reporting into the Director of Nursing and Midwifery undermines the peer relationship, presents significant conflict of interest and reduces the voice of the Allied Health professions.

See Governance Model Assessment Section (Section 5)

Professional accountability needs to be clearly established in order to ensure the service continues to be able to meet service needs. However, professional support is difficult due to broad reporting structures.

See Governance Model Assessment Section (Section 5)

The configuration of the current Electronic Record (eMR) is not aligned with the clinical practice of MHDA teams. There is an opportunity to improve Electronic Records with specific MHDA Allied Health forms.

2.1, 2.3

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7.4 Nutrition and Dietetics

Issues identified during the consultation process Initiative reference

number

Inpatient demand is steadily increasing. Outpatient demand is also increasing but is capped by clinic capacity, resulting in increasing unmet need. Waiting lists have been greater than 10 weeks in some services.

1.1, 1.2, 1.3, 1.4, 1.6

Technologies such as new classification systems and data entry systems are cumbersome and difficult to use.

2.1, 2.3

There is a lack of administration support for the home nutrition system used in outpatients.

1.3

The Nutrition Care Policy is not consistently followed by nursing staff, at times resulting in increased length of stay for patients due to the lack of a coordinated approach to nutrition care and support from admission to transfer of care.


The changes to Community Home Support Program (CHSP) eligibility for those over 65 years of age leaves a service gap for younger patients who previously qualified for services under ADHC funding.

5.1

Dieticians have no input into food services provided within hospital facilities, and are therefore unable to ensure appropriate dietary requirements are met for all patients. This issue has been raised with HealthShare but there has been little progress to date.


90

7.5 Orthotics


number

Referrals continue to increase but staffing levels have not kept up with demand. This impacts on staff performance against Key Performance Indicators.

1.1, 1.2, 1.3, 1.4, 1.6

Participation in research or keeping up-to-date with advances in technology is a challenge due to a lack of time and resources, for example, Functional Electronic Stimulation (FES) and digital printing which are shown to reduce casting and manufacture time providing a more responsive service.

4.3

Unpaid time in lieu is accumulated due to a lack of leave cover as staff attempt to maintain services.

1.1, 1.2, 1.3, 1.4, 1.6

There are delays caused by transport and coordination for patients living outside of RNS. Additional risk is posed in transporting spinal injury patients that are required to travel to RNSH.


There is no weekend Orthotic service, which results in delays in patients being seen, a spike in referrals and unplanned activity on Mondays.

1.5

The distance of the Orthotics Department from the main clinical areas entails walking a substantial amount of time between the wards, outpatients and the workshop to make modifications to devices (estimated by the Orthotists as 0.2 FTE per week).


There is no Orthotic expertise in NSLHD for the management of HALO devices, resulting in a gap in services for high risk, complex spinal patients.


91

7.6 Physiotherapy


number

Data management is a challenge due to high input volumes and low value system outputs. NSLHD is currently testing a second version of data reporting to ensure all the necessary data fields are provided.

2.1, 2.3

The use of the eMR system is proving to be time consuming as it is now embedded into daily practice.

2.1, 2.3

Leave and surge cover is a major challenge with limited access to casual pools (outside of RNS and Ryde), overtime or agency staff to cover absences. Lack of leave relief, slow recruitment processes and surge activity are believed to be the primary contributors to missed referrals.

1.1, 1.2, 1.3, 1.4, 1.6

Increases in Physiotherapy resources have not aligned with increasing demand for services.

1.1, 1.2, 1.3, 1.4, 1.6

Closer integration with primary care is required to provide more care in the community.


Further career development opportunities will allow for specialist roles such as an Acute Senior Physiotherapist.

3.2, 3.3

Provision of paediatric Physiotherapy services varies across the District. 3.3

A lack of weekend coverage in services outside of RNS and Ryde leads to delays in patients being seen and a gap in service coverage.

1.5

Staff report a need for a “step down” or “transitional” ward for patients in rehabilitation wards to be moved to that would help ensure that patients can work towards living safely in the community.


92

7.7 Podiatry


number

There are a number of services and locations where there is no funding for the provision of podiatry services, including: mental health, burns, spinal, ICU and Graythwaite Hospital. However, consultations are provided free of charge in high risk cases which may result in limb loss. This highlights the need to consider referral paths and processes to mitigate service gaps.

3.3, 4.3, 5.1

Despite the recent addition of an inaugural inpatient podiatrist within the High Risk Foot Clinic at RNS, service gaps continue to exist. For example, there is no High Risk Foot Clinic within the Northern Beaches.

3.3, 4.3

Significant scope exists for Podiatry Services to provide early intervention in medical assessment units to improve outcomes.

3.3, 4.3

A lack of senior positions has implications on supervision and upskilling of junior staff as well as the ability to share activities relating to service improvement.


There is a belief that Podiatry staff are not sufficiently engaged in service planning discussions, including service demand and available resources.

3.3, 4.3

A lack of administrative support in Podiatric services means staff are having to undertake a large amount of non-clinical duties not under their remit.

1.3

A lack of standardised referral processes for medical staff mean services such as wound debridement carried out by Podiatrists are not billed or reimbursed fully.

5.1

93

7.8 Primary and Community Health


number

There is a lack of understanding of the contributions made by Allied Health professionals across almost all clinical areas. The Allied Health workforce is thus underutilised due to a lack of awareness of the workforce skills, locations, services and individual professions.

5.2

Networking ability of Allied Health is limited due to a lack of clear identification of current programs and their team members, both within the LHD and between LHDs.

3.3, 5.2

Backfill practices vary between positions, teams and seasons in relation to overall service leave-related absences. Casual Pools and Agency Staff tend to not be utilised for backfill and staff replacement. This is because of case complexity, lack of supervision and setting-specific requirements of PACH allied health roles which render the use of casual or agency staff potentially unsafe.

1.1, 1.2, 1.3, 1.4, 1.6

There are currently no AHAs in PACH although scope for AHA input exists in rehabilitation. For example, AHAs can provide services in APAC to enable patients to stay at home e.g. through transport services, care aid delivery and basic physical assistance. Roles, responsibilities, competencies and scope of practice need to be clearly defined.

1.2

There is a lack of access to complete patient records and documentation which poses challenges for an efficient service.

2.1, 2.3

The service would like to participate in more regular interagency briefings and collaboration with other LHDs to ensure better integrated care solutions for patients.

5.2

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7.9 Psychology


A lack of leave relief and adequate staffing resources are seen as major concerns for service cover and quality of care.

1.1, 1.2, 1.3, 1.4, 1.6

The District does not currently have a Consultation Liaison Psychologist to provide consultation to patients and clinical treatment teams across the hospitals.


Staff would like to see more Psychologists in community teams in order to provide a full scope of service to the District.

Addressed through Governance model recommendations (see Section 5 above)

Stakeholders consider that Psychology is a large Discipline which is deserving of its own Departmental structure in order to appropriately meet the professional needs of staff.


Opportunities to educate referrers about the roles and services provided by different psychology disciplines (Mental Health, Clinical Psychology and Neuro-Psychology) to reduce inappropriate referrals.

5.1

The lack of Specialist Psychologist and Psychology leadership roles in the service is seen as a career limiting pathway for Psychologists in the LHD.

1.10

95

7.10 Social Work


number

Leave coverage is a constant burden for Social Work. Short-term arrangements involving staff adopting extra duties to cover staff vacancies and increased patient loads tend to become permanent. This has implications for burnout, service quality, service waiting times and length of stay. This also results in service contact being less than service guidelines and model of care requirements.

1.1, 1.2, 1.3, 1.4, 1.6

Patient numbers have grown considerably for Social Work, however there has been little change in the number of FTEs available to provide services except where there has been a direct service enhancement e.g. MHDA inpatient units.

1.2

Staff expressed a view that limited access to mobile devices impact on the ability for Social Work to provide appropriate models of care.


The lack of support for data management is a major issue leading to 18 months of unreliable data in services outside of MHDA. This is compounded by the absence of business rules.

2.1, 2.3

Recruitment is a serious difficulty due to long delays in the letter of offer being issued to new recruits. There is also a large amount of paperwork that is required for extending an existing member’s hours, even if temporary.

5.3

There is often a conflict in professional opinion between Social Workers and Discharge Facilitators whereby Social Workers are sometimes seen as obstructing the process because of differences in judgements about when it is appropriate to discharge a patient.


There is a general lack of understanding by other clinicians of the role of Social Work and how they contribute to patient outcomes. Social Workers perceive themselves as not being appropriately utilised and often receive inappropriate referrals.

3.3, 5.2

In order to provide better service coverage Social Work should be better resourced to provide services in more Outpatient and Community services. There is also no designated Social Work Manager for Complex, Aged and Chronic Care which impacts on service coordination and capacity.


96

7.11 Speech Pathology


number

Leave coverage is a constant burden on Speech Pathology services. Allowance for leave replacement would greatly influence the maintenance of services and interdisciplinary relationships.

1.1, 1.2, 1.3, 1.4, 1.6

Current staffing resources are insufficient to meet service demand and workloads.

1.2

The lack of a seven-day service outside of RNS is leading to poor out-of-hours management of patients who are unable to swallow properly, which impacts on patient care and devalues the service as it is unable to meet service KPIs.

1.5

There is a lack of involvement of Speech Pathology in the early development phase of new models of care (and ensuring appropriate staffing attached). Improved collaboration between service planners and Speech Pathology will help ensure proper service coverage.

5.1

Staff report that the quantity of time staff are required to spend on irrelevant mandatory training is inefficient and places unnecessary workloads on staff.


There is a general lack of understanding by other clinicians of the role of Speech Pathology and how they contribute to patient outcomes. This leads to service inefficiencies and compromises patient care.

3.3, 5.2

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Appendix B: Literature Review

Table of Contents

ALLIED HEALTH OVERVIEW........................................................................................ 98

SUMMARY OF IN-SCOPE PROFESSIONS...................................................................... 99

2.1 PHYSIOTHERAPISTS ...................................................................................................... 99 2.2 EXERCISE PHYSIOLOGISTS .............................................................................................. 99 2.3 OCCUPATIONAL THERAPISTS ........................................................................................ 100 2.4 SPEECH PATHOLOGY .................................................................................................. 100 2.5 DIETETICS / NUTRITION .............................................................................................. 100 2.6 PSYCHOLOGY & NEUROPSYCHOLOGY ............................................................................. 101 2.7 SOCIAL WORK .......................................................................................................... 101 2.8 PODIATRY ............................................................................................................... 102 2.9 ORTHOTICS .............................................................................................................. 102 2.10 ALLIED HEALTH ASSISTANTS ....................................................................................... 103

MODELS OF CARE ................................................................................................... 104

3.1 ROLES STRUCTURED ACCORDING TO PROFESSION .............................................................. 104 3.2 ROLES STRUCTURED ACCORDING TO TASK AND/OR CLINICAL STREAM ..................................... 104 3.3 MULTIDISCIPLINARY TEAMS ......................................................................................... 104 3.4 INTERDISCIPLINARY TEAMS .......................................................................................... 105

PATIENT FLOW........................................................................................................ 106

4.1 PRE-ADMISSION SCREENING ......................................................................................... 106 4.2 DISCHARGE PLANNING ................................................................................................ 106

USE OF TECHNOLOGY .............................................................................................. 108

ALLIED HEALTH ASSISTANTS .................................................................................... 109

GOVERNANCE FOR ALLIED HEALTH .......................................................................... 112

ALLIED HEALTH WORKFORCE PLANNING AND DEVELOPMENT.................................. 113

8.1 DATA ..................................................................................................................... 113 8.2 RECRUITMENT AND STAFF REPLACEMENT ........................................................................ 113 8.3 ENGAGING ALLIED HEALTH STAFF .................................................................................. 113

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Allied Health Overview

Allied Health Professionals (AHPs) are a ‘diverse group of clinicians’ who deliver care ‘across a wide range of care pathways and in a variety of different settings’ (DoH, 2008a), including hospitals, private practice, community health and home care (Mason, 2013).

A paper written by the Centre for Workforce Intelligence (2011) discusses the four main attributes of AHPs: They can be the first point of health system contact, they perform essential diagnostic and therapeutic roles, they work across a range of locations and sectors and they assess, diagnose and treat patients throughout their care journey (DoH, 2008a). Such intervention contributes to improving patient outcomes and enables improvements in functional ability both in hospitals and in the community.

Currently a progressively ageing population is juxtaposing the utilisation of workforce skills (Jessup, 2007). Therefore, as AHPs focus on ‘moving patients towards independence, rather than expensive interventions’ (Hitchcock, 2015), early intervention demand for AHPs is set to increase into the future (Dorning and Bardsley, 2014). This shift aligns with the wider trends of client-centred care and consumer-directed care.

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Summary of in-scope professions

Unless otherwise stated, the following definitions were paraphrased from HETI and are available at: http://www.heti.nsw.gov.au/allied-health/allied-health-professions-in-nsw-health

2.1 Physiotherapists

Physiotherapists provide care focused on mobility. Common duties include gait assessment, assisted exercise, mobility aid assessment and postoperative therapy. Regular physiotherapy sessions are a core element of rehabilitation care pathways. Physiotherapists can impact length of stay through promoting postoperative mobility and reducing complications associated with immobility, as well as reducing falls-related readmissions. Physiotherapists hold degree-level qualifications and are registered through AHPRA. Physiotherapists are university qualified health professionals. There are three principal degree programs: A four year Bachelor degree in Physiotherapy or Applied Science (Physiotherapy); a graduate entry Master's program; A Doctor of Physiotherapy program. These pathways to physiotherapy qualify the graduate as competent, entry-level physiotherapists eligible to apply for registration with the Physiotherapy registration Board of Australia. Physiotherapists must be registered with the Australian Health Practitioner Regulation Agency (AHPRA), Physiotherapy Board of Australia, and meet the Board's Registration Standards, in order to practice in Australia.

Physiotherapists take ‘preventative, diagnostic and therapeutic management of disorders of movement or optimisation of function, to enhance the health and well-being’ of an individual (Department of Health, Social Services and Public Safety, 2012). Physiotherapy is a health profession which addresses the prevention, assessment and treatment of human movement disorders. Physiotherapists treat patients with physical difficulties resulting from illness, injury, disability or aging. Physiotherapists treat people of all ages including children and the elderly. Physiotherapists work in a range of settings, including hospitals, health centres, industry, private practices and sports clubs. Physiotherapists assess, diagnose and treat a wide range of clinical presentations which usually involve musculoskeletal, neurological or cardio respiratory disorders.

2.2 Exercise Physiologists

Exercise physiologists hold degree-level qualifications and are accredited through ESSA; they integrate exercises and fitness principles into rehabilitation, injury treatment and injury prevention. Exercise physiologists are university-trained, health and fitness professionals that specialise in integrating exercise and physical activity principles in disease prevention, health, rehabilitation, and sports performance. Exercise physiologists work in a range of settings including hospital and community organisations, health care centres, fitness and sports clinics, aged care and rehabilitation services. In these settings exercise physiologists may be involved in the treatment and care of athletes, apparently healthy persons or those with chronic disease or illness.

The interventions performed by exercise physiologists vary considerably depending upon the specific work setting. Some examples of interventions performed include clinical exercise/fitness testing such as lung function testing and assessment of strength and aerobic capacity. Other interventions performed include exercise prescription and training, such as balance and flexibility training, strength and aerobic training. Exercise physiologists are also commonly involved in injury case management services, and occupational/workplace injury risk assessment.

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2.3 Occupational therapists

Occupational therapists are university-qualified health professionals who complete an undergraduate or graduate entry course in occupational therapy. An Occupational Therapist must be registered with AHPRA.

Occupational therapy is a profession concerned with promoting health and well-being through occupation. The primary goal of occupational therapy is to enable people to participate fully in the activities of their everyday life. It does this by using specific activities to enable people to do things that will enhance their ability to participate or by modifying the physical environment to better support participation. Occupational Therapists help their clients cope with demands, adapt to tasks and overcome challenges in their everyday lives. They do this by using a person’s usual daily activities and tasks (their occupations) in a therapeutic way.

As an example, Occupational Therapists develop therapeutic activities for children that will assist them to achieve their developmental milestones such as fine motor skills and hand-eye coordination. In acute hospital settings, Occupational Therapists provide specialist interventions to assist with functional recovery and prescribe adaptive equipment to ensure safety upon discharge from hospitals. Occupational Therapists help clients regain or enhance their daily lives after specific events such as hip replacements or stroke by assessing and modifying the clients home and community environments to improve their safety and independence.

Occupational therapists ‘asses, rehabilitate and treat’ clients using ‘purposeful activity and occupation to prevent disability and promote health and independent function’ (DoH, 2008a).

2.4 Speech Pathology

Speech pathologists complete a degree at university which encompasses all aspects of communication including speech, writing, reading, signs, symbols and gestures as well as all aspects of swallowing food and drink and the supporting science and social science aspects required. In Australia, this equates to an under-graduate Degree in Speech Pathology or Masters entry in Speech Pathology as accepted for eligibility for practising membership of Speech Pathology Australia. Overseas qualified speech pathologists need to have their qualification verified by Speech Pathology Australia.

Speech pathologists assess swallowing and prescribe texture-modified oral intake. Speech pathologists reduce length of stay by reducing the risk of complications associated with impaired swallowing including chest infections, dehydration and weight loss. Speech pathologists care for people who have communication and/or swallowing difficulties (DoH, 2008a). A speech pathologist is an important member of the multidisciplinary team covering all speciality areas within health and development. Speech Pathologists in NSW Health will predominantly be found working within acute care facilities, rehabilitation centres, community health centres, multifunction centres and mental health facilities. They may be managed through departmental or multidisciplinary teams. They will also work closely with services within the private, non-Government, government departments (such as Education and Disability and Local Government) sectors. Speech Pathologists provide speech, language and augmentative communication and swallowing assessment, therapy, management, consultation and support across the lifespan. The role of speech pathologists also includes advocacy for appropriate care and services for people with communication and/or swallowing/feeding disabilities.

2.5 Dietetics / Nutrition

Dietitians are universally qualified health professionals who complete an undergraduate or postgraduate degree in nutrition and dietetics. A dietitian must be eligible for full membership of the Dietitians Association of Australia (DAA). There are currently no registration requirements.

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Dietitians apply the science of human nutrition to help people understand the relationship between food and health and make choices to attain and maintain health, and to prevent and treat illness and disease. Dietitians work in a variety of different settings including hospitals, community, public health, food service, management, consultancy, private practice, food industry and research and training. Dietitians assist people across the lifespan.

Nutrition plays a crucial role in the management of many illnesses and diseases through the application of medical nutrition therapy. Professional interventions performed include nutritional needs assessment, prescription of individualised nutrition care plans, sorting out nutrition fact from fiction, undertaking food and nutrition research, training health care professionals and developing nutrition communications, programs and policies. Nutrition is also important for maintaining good health and is a component of health promotion and population-based programs aimed at the prevention of many chronic diseases.

Dieticians ‘translate the science of nutrition into practical information about food’ (DoH, 2008a).

2.6 Psychology & neuropsychology

Psychologists are university qualified and are registered with the Australian Health Practitioner Regulation Agency under the Psychology Board of Australia. The focus of psychologists is on human behaviour. They research and study the processes associated with how people think, feel and behave. They apply their knowledge to a wide range of situations and problems using scientifically supported intervention methods. Neuropsychologists study the structure and function of the brain as they relate to psychological processes and behaviours.

Psychologists focus upon human behaviour. They research and study the processes that are associated with how people think, feel and behave. They apply knowledge about the brain, memory, learning and human development to a broad range of situations and problems using scientifically supported intervention methods.

The practice of psychology is broad and interventions can be applied to individuals or groups. Some psychologists work with people to assist them in overcoming everyday problems such as stress and relationship difficulties; some diagnose and treat people with mental illnesses. Some psychologists work with people with chronic pain to assist them in attempting activities or movements that they have been fearful of undertaking, addressing issues of depression or anxiety, and assisting them in developing short-term and long-term goals. Other psychologists may conduct cognitive testing to determine the impact of certain neurological illnesses or injuries on a person’s cognitive functioning. Psychologists can assist children, parents and teachers by applying their knowledge of child development and learning to various problems in childhood; and other psychologists might assist people to excel in their chosen sport.

2.7 Social Work

Social workers are university qualified health professionals who complete an undergraduate or graduate entry course in social work. A social worker must be eligible for full membership with the Australian Association of Social Workers (AASW). There are currently no registration requirements.

Social workers provide a range of services to meet the non-medical needs of patients and their families. Social workers enable discharge from hospital by linking patients and their families with whichever post-discharge services and programs are required for ongoing support. Social Workers assist people to overcome a wide range of issues, including psychological, financial, health, relationship, substance abuse problems and life crises by providing counselling, support, information and referral. Social workers use a holistic approach in their assessment and intervention with clients to enhance well-being.

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The social work profession is based on the principles of human rights and social justice. The study of social work consists of theories of human behaviour, sociology, psychology and social systems. Social workers work in a variety of different settings including hospitals, community health centres, government and non-government agencies, management, private practice, research and training.

2.8 Podiatry

Podiatrists prevent, diagnose, treat and rehabilitate disorders, medical and surgical conditions of the feet and lower limbs. Podiatrists ‘diagnose and treat abnormalities of the foot’ (DoH, 2008a). Podiatrists have completed a Bachelor of Podiatry or equivalent and must be registered to practice as a Podiatrist through AHPRA.

Podiatry is the prevention, diagnosis, treatment and rehabilitation of disorders, medical and surgical conditions of the feet and the lower limbs. The Podiatrist's scope of practice includes assessment and management of lower limb problems in children, people with chronic diseases that affect the feet (such as diabetes and joint disease) and older people who commonly experience painful foot problems that affect mobility. Podiatrists also manage injuries related to postural and structural problems of the feet and sports-related foot problems. Podiatrists can work independently and as part of a group of other professions such as medical specialists, nurses and other Allied Health professionals.

In the hospital setting a Podiatrist may treat a wound of the foot to prevent an admission to hospital. As part of this treatment an assessment on the blood and nerve supply to the feet would be undertaken. Following routine care of the wound, insoles, orthotics and footwear modifications may be made to take pressure off the wound that is being treated. They may refer the patient onto other people such as nurses or the patient’s doctor for antibiotics. In the community, the podiatrist may conduct routine assessments on the feet to check the health of the feet before going onto routine treatment which may consist of cutting of abnormal or ingrown toenails or taking off painful corns and callus. The podiatrist may also have to provide education to a group of people such as those with diabetes.

2.9 Orthotics

Orthotists work in the field of Orthotics: the science that deals with the use of specialised mechanical devices that support and/or assist with the function of impaired parts of the muscular and skeletal system. Orthotists design, measure, make and fit orthosis. These ‘provide support to a part of a patient’s body, to compensate for paralysed muscles, provide relief from pain or prevent physical deformities from progressing’ (DoH, 2008a). Prosthetists provide care and advice on rehabilitation for patients who have lost or were born without a limb and fit artificial replacements (DoH, 2008a).

Orthotists are university trained Allied Health Professionals and must hold a bachelor degree in Prosthetics and Orthotics. The only Prosthetic and Orthotic training school in Australia is located at Latrobe University in Victoria. There are no requirements for registration as an orthotist. An Orthotist is a highly skilled health professional who works in the field of Orthotics which is the science that deals with the use of specialised mechanical devices that can be either dynamic or static to support, correct, and/or assist with the function of impaired parts of the muscular and skeletal system.

An orthotist's device can provide one or all of the following: protect or support an injury, assist with a patient's mobility, independence, and rehabilitation. The term 'Orthosis' is now used to encompasss a variety of devices such as braces, splints, callipers and other types of surgical appliances etc. Orthotists are the people who work in clinical and ward environments to assess patient's orthotic needs. They also design, measure, make and fit all types of custom made orthosis to patients who have disabilities, have suffered trauma injuries and/or are recovering

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from surgical procedures. Orthotists also fit a wide range of off the shelf non-custom orthosis to patients.

2.10 Allied Health Assistants

Allied Health Assistants are usually qualified at a Certificate III or IV level or have practiced as Allied Health professionals overseas. They are able to undertake routine, lesser-skilled tasks and provide administrative support. Allied Health Assistants can augment the Allied Health workforce’s ability to provide services by allowing more appropriate matching of available skill mix to service demand.

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Models of Care

Allied Health services exist under a variety of structures. Common examples include departmental organisation by profession, by clinical stream, by service type and within multidisciplinary teams. These services may be based in hospitals, in outpatient clinics or within the community; service structures are driven by resource availability, service need, service location and evidence-based best practice. York St John University undertook a study which involved 27 teams taking part in an AHP Service Improvement Project. Improvements were illustrated in quality and outcomes, productivity, access and waiting times and organisational development and learning. The researchers found the following main strategies for achieving improvements: giving patients easier and quicker access to a service, altering the mix of practitioners involved in providing a service and redesigning or developing new clinical pathways (Boak et al., 2011).

3.1 Roles structured according to profession

A widely-evident structure in healthcare, these models are based on grouping professionals by discipline and usually involve supervision by a senior member of the profession. These models have the potential to promote knowledge sharing amongst members of the same profession and profession-specific governance. Such models are more commonly seen in geographical service hubs.

3.2 Roles structured according to task and/or clinical stream

There are opportunities for models of care that structure roles according to primary tasks rather than by discipline (Nancarrow, 2003; Turnbull et al., 2009; Leathard, 2003). The NHS Confederation (2015) agrees using both the specialist and generalist skills of allied health professionals is valuable. In roles structured by task, the organisational structure is aligned with service outputs and groups of similar interventions rather than by discipline or profession. These structures can promote service delivery, however support and supervision of individual practitioners may not necessarily be provided by a senior staff member of the same profession.

3.3 Multidisciplinary teams

Multidisciplinary teams are made up of professionals from a range of disciplines who work together to deliver comprehensive care to address as many patient needs as possible (Mitchell et al, 2008). The implementation of multidisciplinary care planning requires ‘changing patterns of interaction between care providers, alignment of roles and work practices, and changes to organisational arrangements’ (Mitchell et al., 2008). Significant scope exists for Allied Health professionals to participate in multidisciplinary teams to improve service delivery and patient outcomes.

Strengths of multidisciplinary teams

Jessup (2007) discusses multidisciplinary teams provide more knowledge and experience than if disciplines operated in isolation, in turn providing more valuable care. In a study of AHPs, nurse practitioners and general practitioners in NSW. Wilson (2005) found successful quality care environments were influenced by the collaborative practices among team members.

Medical trials have illustrated the effectiveness of multidisciplinary teams in enhancing patient independence (DeCourcy, 2014). In turn, this decreases dependency on health services and length of stay in hospital, reducing clinical costs and enhancing patient satisfaction.

Mitchell et al (2008) noted multidisciplinary teams and care planning improves function planning. When conducting a project implementing Allied Health Assistants (AHAs), a

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social work department in Victoria found the use of small group forums, where social work AHPs liaised with other AHPs to brainstorm potential duties for a social work AHA, to be a success (Victorian Department of Health, 2012). The implementation of AHAs within the social work department highlighted the benefits of multidisciplinary staff involvement and open communication.

A baseline chart identified there was duplication in allied health services through information collection, history taking and collection at the Mackay Hospital and Health Service in Queensland. A model of professional skill-sharing was implemented to decrease duplication and improve service efficiency and patient satisfaction. It was illustrated clinicians preferred a skill-sharing model of care, particularly when operating in the community. They also identified benefits for patient outcomes, team functioning and clinical practice. Despite this, patients preferred care provided by one AHP (Queensland Department of Health, 2014).

Weaknesses of multidisciplinary teams

The multi-professional nature of AHP work can create challenges for consistent, high-quality data management practices (Dorning and Bardsley, 2014).

3.4 Interdisciplinary teams

Frequent interdisciplinary collaboration with doctors, nurses and other AHPs is a strong feature of Allied Health practice. Interdisciplinary teams integrate separate discipline approaches into single consultations. This means the processes of patient-history taking, assessment, diagnosis, intervention and ongoing care planning are conducted by the team simultaneously and with the patient (Jessup, 2007). This allows the patient to have more involvement in their own care and any decision-making.

Strengths of interdisciplinary teams

According to Jessup (2007), the move from multidisciplinary teams toward interdisciplinary teams is a change that will help meet the ever-growing challenges of staff satisfaction and retention rates. Such teams can also mean cost and time savings from less duplication (Jessup, 2007).

Leathard (2003) found AHPs reported having improved relationships with other health providers when working in single profession defined settings. These settings also provides the opportunity for staff to learn about other disciplines (Jessup, 2007).

They represent a patient-centred approach (Jessup, 2007).

Interdisciplinary teams may have the potential of opening up opportunities for new workforce roles, developed through identification of service system gaps not made visible through multidisciplinary teams (Jessup, 2007).

Weaknesses of interdisciplinary teams

Traditional hierarchies or dominating personalities may interfere with the ideology of interdisciplinary teams. Jessup (2007) suggests introverted or less-experienced team members feel intimidated by such personalities, and in turn are less likely to voice opinions about patient care. “Well-defined and respectful communication protocols” are required to mitigate this risk (Jessup, 2007).

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Patient flow

Pre-admission screening, discharge planning, admission prevention and community-based care are strategic areas in which the potential for Allied Health contributions to patient flow is significant.

4.1 Pre-admission screening

The early involvement of Allied Health professionals with pre-hospital and hospitalised patients can facilitate discharge needs being met, reducing the risk for these needs extending hospital length of stay. Hospital avoidance strategies and community-based services have wide scope for Allied Health involvement, especially in cases where service delivery can occur without the need for hospital admission and in ongoing management of high-risk cases to reduce risk of deterioration and subsequent hospitalisation (Low et al 2011). Partnerships with residential aged care facilities can also be considered for partnership with Allied Health services.

4.2 Discharge planning

Piggott (2015) discussed when Allied Health referrals are made AHPs have no visibility of the length of time the patient has spent in hospital, or what else the patient is waiting for in order to be discharged. This means AHPs are unable to prioritise patients based on their expected discharge date, resulting in patients staying in hospital unnecessarily whilst waiting to be assessed by an AHP. To prevent these circumstances Bendigo Health established a Patient Flow Performance sub-committee, which was a multi-disciplinary stream agreeing on patient flow, discharge planning expectations and improvement strategies. This involved developing:

Visibility of individual patient’s status towards discharge

Single source with all associated information

Ability to track, identify and prioritise patients based on special circumstances

Ability to hold staff accountable to their responsibilities and KPIs e.g. when referrals should be acted upon

Ability to measure the efficiencies of key processes

Specific information customised to the discipline that would use it

Clearly defined discharge processes consistent across the various services, and agreed upon by all stakeholders

Progress was reviewed 12 months after the process was implemented:

Readmission rates reduced by 30% from 5.5% to just under 4%

For complex patients, readmissions reduced by 50%

Length of stay decreased by 0.53 a day

Revenue per patient closer to optimum

More efficient use of beds

Another study supporting the use of MDT teams in discharge planning was conducted by Preen et al. (2005). The objective was to analyse the impact of a discharge plan, involving a MDT of tertiary, primary and community health care providers on hospital length of stay, quality of life and satisfaction with discharge processes (patient and staff) in Western Australia. The results

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found a multidisciplinary care plan improves patient quality of life, involvement, and satisfaction with discharge care – as well as staff integration and engagement.

Another study involved finding the effectiveness of Allied Health involvement in discharge planning at a Gold Coast Hospital. The aim of the project was to reduce length of stay of acute adult orthopaedic patients using an interdisciplinary model of care involving physiotherapists, occupational therapists and social workers. Data from the first six months of the project demonstrated success in improving the continuity of care provided to orthopaedic patients, with a reduction in the length of stay in target groups by 24%. This represented a saving of 3005 bed days – an estimated $1,081,800 when calculated at $360 a day. The project also saw a reduction in patients being admitted to hospital (Bandis et al., 1998).

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Use of technology

Mobile technology, clinical decision support tools and automatic referrals triggered by set entry types in electronic medical records are examples of current technological drivers of change (Miller, 2012; Reeve et al., 2008). According to Wakerman et al (2008) the use of ‘telehealth’ and ‘telemedicine’ has been increasing over the past decade. Telehealth is the ‘use of telecommunications technology to provide health across distance’ (Miller et al, 2003). These technological advances have the potential to enhance service access and delivery (Corcoran et al., 2003; Sampson & Makela, 2014) and are particularly useful in overcoming issues of access to health services, particularly in rural and remote areas.

In order to support rural and remote access to Allied Health services the increased use of telehealth has been identified as a priority for Queensland’s Department of Health. Queensland Health undertook a project to evaluate the use of telehealth. The aims of the project scoping phase were to ‘identify the workforce capacity, service redesign, and infrastructure/access resources, tools and training programs already available and those required to support telehealth implementation’ and ‘focus subsequent 2014-15 capacity building work on clinical areas and professions presenting high demand for telehealth implementation support and resources’ (Nielsen and Kirkpatrick, 2015). Two major models of telehealth services were described. The first was the dual clinician model, in which clinical staff deliver services at the hub and recipient site, and the second was the direct care model, whereby clinical staff are present at the hub site only. The main benefits of telehealth services were identified as improved timeliness and frequency of services and reduced travel for clients/clinicians to access/provide services.

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Allied Health Assistants

As stated in the National Health Workforce innovation and reform strategic framework 2011-15, there are currently skill shortages, financial pressures and rising demand, creating new thinking on how care is managed. Allied Health Assistants (AHAs) are an emerging workforce who generally hold TAFE-level certificates and/or have overseas Allied Health experience. Their scope of practice is limited in comparison with Allied Health professionals and they require the supervision of an Allied Health professional. AHAs are able to undertake a range of manual, assessment, administrative and support tasks, which can augment the capacity of the Allied Health workforce.

The Centre for Workforce Intelligence (2011) notes a key Allied Health workforce opportunity is the use of new and extended roles. Evidence of the use of AHAs exists nationally and internationally; support worker roles are the fastest growing tier of workers in the National Health Service (Nancarrow, 2004) and in Western Australia AHAs have been practicing in the public health system for over a decade (WA Country Health Service, 2009).

Current use of AHAs in NSW

The following disciplines currently utilise AHAs in NSW: Physiotherapists, Occupational Therapists, Diversional Therapists, Dieticians, Radiographers, Pharmacists, Speech Pathologists, Orthotists, Prosthetists, Podiatrists, Audiologists and Child Life Therapists (NSW Health, 2013).

Patient Benefits

Faster access to more focused services (Queensland DoH, 2013). An evaluation of AHA programs in Western Australia, where AHAs have been included in service models in the public health system for over a decade (WA Country Health Service, 2009) indicated increases in service provision (Moran et al., 2012).

Flexibility, allowing service provision to meet specific needs (NHS Scotland, 2005).

Higher intensity of clinical care (NSW Health, 2013).

Improved health outcomes (NHS Scotland, 2005) (NSW Health, 2013) (Health Workforce Australia, 2014), leading to increased patient satisfaction (NHS Scotland, 2005) (NSW Health, 2013) (Queensland DoH, 2013). This was evidenced in a qualitative study conducted by Nancarrow and Mackey (2005) as patients expressed satisfaction with the amount of time an occupational therapy assistant spent with them.

Potential drawbacks to patients

In a qualitative study occupational therapists raised concerns that some staff and service users may see the use of assistant practitioners as a cheap way of delivering occupational therapy services (Nancarrow and Mackey, 2005).

Arguably there is little known about the impact of AHAs on patient outcomes (Bienkowska-Gibbs et al, 2015).

Service/System Benefits

Positive impact on recruitment and retention as the service would have opportunities for career progression (NHS Scotland, 2005).

Greater utilisation of workforce skills and more appropriate skill mix within clinical teams (NHS Scotland, 2005).

Improves team working across professional groups (NHS Scotland, 2005).

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Cost effectiveness (NSW Health, 2013).

Expanded use of AHAs could reduce demand for AHPs (Duckett, 2005).

When assistants are provided with training and support they can enhance: service delivery (and allow a refocus of delivery to areas of need), workforce flexibility and team efficiencies (Health Workforce Australia, 2014).

Improved communication both within and across systems (NHS Scotland, 2005).

Potential drawbacks to the system/service

Research has highlighted the employment of AHAs can lack structure, for instance variance in the way roles are defined within services and the level of responsibility given to AHAs (NSW Health, 2013).

Uncertainty regarding the scope of AHA roles and responsibilities (NSW Health, 2013) (Health Workforce Australia, 2014).

Reluctance to implement AHAs due to confusion over clinical supervision (Farndon and Nancarrow, 2003; Health Workforce Australia, 2014), regulation and perceptions around the impact on quality and safety (Health Workforce Australia, 2014).

Hesitancy to implement AHAs due to insurance requirements (Farndon and Nancarrow, 2003).

A lack of evidence of the impact of piloting assistant roles (Health Workforce Australia, 2014).

AHP/AHA Benefits

An AHA Implementation Program took place in Victoria. The aim was to increase the uptake and utilisation of the AHA workforce in health and community services. The greatest need for AHAs was discovered in the physiotherapy, occupational therapy, orthotics, podiatry and social work disciplines (Victorian Department of Health, 2012). At Project commencement 29.5% of AHPs reported AHAs as not applicable to their workload. Following the AHA project, only 7.9% of AHPs reported this. Satisfaction levels of staff increased throughout the project - a workforce survey showed 92.2% of AHAs were highly satisfied with their jobs and 91.8% of AHPs were satisfied with the use of AHAs in their profession (Victorian Department of Health, 2012). As well as this, the Program directly influenced the professional culture of participating organisations by engaging all key stakeholders and ensuring they were an integral part of the process to develop a sustainable solution and shared vision (Victorian Department of Health, 2014).

Similarly, Somerville et al (2015) conducted a study to highlight areas where AHAs were not working to their full scope of practice, in order to improve the effectiveness of the allied health workforce in Victoria. Results illustrated Victoria’s AHP workforce spends up to 17% of time undertaking tasks that could be performed by an AHA with the appropriate training and adequate supervision. As it was AHPs reported a high level of confidence in the clinical skills (85%) and utilisation of the current AHA workforce by the AHP profession (83.5%), as well as confidence in delegating tasks to AHAs (84.5%)’. The study concluded the capacity of the workforce should increase to meet future demands.

Likewise, a number of AHP tasks which could be undertaken by AHAs were identified when implementing the Calderdale Framework in Queensland. When trialling AHAs in acute medical wards there was improved clinician satisfaction, improved confidence in

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delegating tasks to AHAs and improved capacity for AHP staff to work to their full scope of practice (Queensland Department of Health, 2014).

Potential to increase ‘knowledge, skills and competencies’ (NHS Scotland, 2005), with associated benefits to morale.

Further time for AHPs to concentrate complex tasks (NSW Health, 2013) or patients with complex needs (Lizarondo et al, 2010). This has been evidenced with the implementation of the social worker assistant role in Queensland. This was achieved through a service model that involved a delegation model and regular clinical supervision. Outcomes included: 20% increase of new patients seen, 11% reduction in cost per occasion of service, 47% accrual of time-in-lieu, 81% increase in social worker time spent on more complex tasks, and improved social worker job satisfaction (Queensland Department of Health, 2015).

Potential drawbacks to AHPs/AHAs

Research has highlighted the employment of AHAs can lack structure (NSW Health, 2013) – a study by Lizarondo et al (2010) found often roles were not clear enough.

There is potential for protectionism of AHPs (NSW Health, 2013).

Dependencies

Services must ensure there is role clarity and that the competencies of the role are mapped out (NHS Scotland, 2005). Duckett (2005) also supported this view, adding the nature of AHA supervision must be well-understood. AHPs must constantly be aware of the boundaries of their new roles to ‘ensure patient safety and maintain professional integrity’ (NHS Scotland, 2005).

Appropriate skills development and training (Health Workforce Australia, 2014).

Health Workforce Australia (2014) implies appropriate governance and supervision are pivotal. Likewise, WACHS (2009) states the successful ongoing use of AHAs is also dependent on delegation (see Appendix 1: AHA delegation decision-making for the Delegation Decision-Making Framework and Appendix 2: Delegation decision-making framework for application) and monitoring.

When implementing AHA roles it is important to have regular and transparent communication and consultation with all AHP staff (Victorian Department of Health, 2012).

Data collection is required to identify the disciplines most in need of AHA support and competency requirements (Victorian Department of Health, 2012).

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Governance for Allied Health

A clinical governance framework ‘ensures a systematic approach to delivering quality clinical care’ (Queensland Government, 2011). It is becoming progressively imperative that all AHPs operate within a clinical governance framework (Queensland Government, 2011). Appendix 3: Governance framework (Queensland Government, 2011) illustrates the Allied Health Clinical Governance Framework existent in Queensland.

The Department of Health, Social Services and Public Safety (2012) illustrates it is pivotal effective Allied Health accountability arrangements are in place, both locally and regionally. It is particularly important where the scope of Allied Health roles and responsibilities are being extended. In Northern Ireland the Department of Health, Social Services and Public Safety have actions against governance and accountability at a strategic, organisational and individual level:

Strategic

Establish a Regional Accountability Framework for AHPs

o Led by: The Lead AHP Officer in partnership with relevant stakeholders alongside peer

professional groups

Establish a mechanism that provides leadership, support and guidance for AHP governance and

accountability arrangements. Clear articulation of accountability is pivotal in any governance

framework (Queensland Government, 2011).

o Led by: The Director of Nursing and AHPs in conjunction with the Assistant Director for

AHPs

Organisational

Develop, support and monitor AHP workforce compliance with agreed accountability and

governance frameworks

o Led by: The Accountable Executive Director in conjunction with AHP Leads and Professional

Heads of Service.

Individual

The AHP workforce must be supported to use relevant standards, guidelines, protocols and procedures and to report and escalate issues of concern regarding poor practice or poor performance of others in line with organisational, professional body and regulatory guidance.

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Allied Health Workforce Planning and Development

8.1 Data

Quantitative measures of the effects of Allied Health services are less common than such measures for the nursing and medical professions. This leads to difficulties in accurate service evaluation and the use of data in service planning. A national review of allied health workforce issues illustrated that without improved data on allied health workforce requirements it would be ‘difficult to assess priorities for future action’ (Australian Health Workforce Advisory Committee, 2004).

A ‘Workforce Measures for Allied Health’ project was undertaken to explore current data sources on workload measures for AHPs. One finding was a lack of comprehensive data on activity and utilisation of AHPs, particularly in a non-hospital environment. It was recommended AHPs should complete workforce surveys. Surveys should ask AHPs about workload data, such as number of patients seen per week and the allocation of time between clinical and non-clinical duties (Scott and Cheng, 2010). However, often workforce surveys are not compulsory, meaning responses cannot be generalised.

8.2 Recruitment and staff replacement

The delivery of Allied Health services is sensitive to the availability of staff, especially in services with small numbers of staff and specialty services which require specific skills and knowledge to provide care. Service continuity is dependent upon the efficiency of recruitment services and succession planning practices. The awards under which Allied Health staff are employed generally contain allowances for various types of leave which, when taken, can have the effect of reducing service capacity. Provision for replacing staff on leave warrants consideration from a budgetary standpoint and also with regard to the availability of suitable staff to undertake replacement duties. Maternity leave is also relevant given that Allied Health workforces may have relatively high proportions of young female staff. Established ratios for Allied Health staffing are less prevalent than staffing ratios in nursing. Consideration of service hours influences service delivery and service turnaround times. Cartmill et al (2012) note using staffing ratios in workforce planning can successfully guide service planning and delivery. Despite this there is little evidence of the use of staffing ratios in an allied health setting, in comparison to the fields of nursing and medicine.

8.3 Engaging Allied Health staff

A study prepared for the Department of Health by Loughborough University (Arnold et al, 2006) involved reviewing data provided by 2051 professionals from Occupational Therapy, Physiotherapy, Radiography and Speech and Language Therapy. The following elements were found to motivate staff in the NHS:

Using professional skills and judgment and having career progression without losing patient contact (also evident in a study by Keane et al, 2012)

Job security

Enjoyable work

Flexible hours.

The study concluded the health service should:

Ensure AHPs have as much scope as possible, enabling them to exercise and have autonomy in their work

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Devise career paths that encompass promotion to senior positions (whilst still retaining patient contact)

Increase efforts to make work as flexible as possible.

Calderdale Framework

The Calderdale Framework is a workforce tool that aims to engage frontline staff to ensure safe, effective, patient-centred care (Duffy et al, 2011). It provides a systematic method for identifying new ways of working, reviewing skill mix and developing new roles by:

Identifying tasks carried out in teams

Deciding which tasks can be delegated or skill shared

Creating local clinical task instructions to standardise how tasks are completed

Providing structured training and competence assessment for professional skill sharing and delegation practice

Establishing governance processes to support clinicians

Establishing systems to sustain the model of practice in the long-term.

The seven stages to successful implementation of the Calderdale Framework are as follows:

1) Awareness Raising – to engage all involved staff at the outset

2) Service Analysis - crucial step to establish potential changes that can be made. It is an objective

process

3) Task Analysis – consensus around altered practice is gained using decision making tables. Cost

benefit considerations are integral to this stage

4) Identification/Generation of Local Clinical Task Instructions – accepted tasks are identified or

written as local clinical task instructions

5) Supporting Systems – communication networks are develop and understood. This is key to

managing delegation risks and assuring quality

6) Training – qualified staff learn to delegate effectively whilst support staff are competency

trained

7) Sustainability – becomes part of organisational induction and mandatory training.

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Appendix 1: AHA delegation decision-making

Figure 1 – AHA Delegation Decision-Making (WACHS, 2009)

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Appendix 2: Delegation decision-making framework

Figure 2 – Applying the Delegation Decision-Making Framework (WACHS, 2009)

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Appendix 3: Governance framework

Figure 3 – Allied Health Clinical Governance Framework (Queensland Government, 2011)

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9. Appendix C: Stakeholders Consulted

This section provides the names and titles of the membership of the Working Party and Steering Committee. This section also includes the names of the stakeholders consulted throughout the work of the project either through 1:1 interviews, site visits or stakeholder workshops

9.1 Steering Committee

Name Title

Anthony Dombkins Director, Nursing and Midwifery, NSLHD

Julie Wright Acting Director, AH, NSLHD

Maree Hynes Director, Planning and Innovation, NSLHD

Kim Field Director Primary and Community Health NSLHD

Andrea Taylor Director, MHDA

Jane Street Director Workforce & Culture, NSLHD

Rosemary Cullen Director Operations, NBHA

Martin Freeman Project Lead, FGI

9.2 Working Party

Name Title

Anthony Dombkins Director, Nursing and Midwifery, NSLHD

Julie Wright Acting Director, AH, NSLHD

Kerry Griffiths Project Officer, AH Transformation Project

Bronwyn Nolan Manager, AH, NBHS & HKHS, NSLHD

Fran Tolliday Manager, Primary and Community Care and AH, NSLHD

Pauline Kemp Representative for Primary and Community Health NSLHD

Andrea Taylor Manager, MDHA, NSLHD

Jane Street Director Workforce & Culture, NSLHD

Martin Freeman Project lead, FGI

Cathy Baker Project Manager, FGI

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9.3 Stakeholder consultations

Name Position

Diane Saddler Manger, Occupational Therapist, RNS

James Hui Manager, Orthotics, RNS

Thomas Paine Orthotics, RNS

Gary Rolls Manager, Physiotherapy, RNS

Barbara Lucas Manager, Physiotherapy, RNS

Ian Reid Manager, Podiatry, RNS

Kareen Doyle Manager, RNSH Community Aged Care

Louise Clarke Manager, Occupational Therapist, NB

Anastasia Scott Manager, Speech Pathologist, NB

Katie Lee Manager, Physiotherapist, NB

Carol Whitehead Manager, Child Protection Services, RNS

Steph Kaffara Manager, Child Protection Services, RNS

Jayne Roberts Exercise Physiology – RNS Cardiac Rehab

Christine Bruntsch Exercise Physiology – RNS Cardiac Rehab

Frank Bazik General Manager, NB

Andrew Montague Director Operations, RNS/Ryde

Beverly White Manager, Child Development, RNS

Christine Hoggard Child Development, RNS

Con Pappadopoulos Child Development, RNS

Philippa Greathead Manager, Speech Pathology, Primary and Community Care

Hassan Kadous Manager, Ryde Aged Care and Rehab Services

Andrea Taylor MHDA Director, CYMHS Service Director

Kathi Boorman MHDA Director, CYMHS Service Director

Anne Harsanyi Manager, Sexual Assault RNS

Bronwyn Nolan Allied Health Manager, Hornsby/NB

Christine Tait Lees Manager Talent Development

Rebecca Day Manager Talent Development

Fran Tolliday Director Primary and Community Care, RNS/Ryde Health Service

Jane Street Director Workforce and Culture

Julie Wright Acting Director Allied Health

Kim Field Director Primary and Community Health

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Mary-Ellen Tarrant Manager, Speech Pathology, RNS Ryde

Emma Inglis Manager, Speech Pathology, RNS Ryde

Diana Wolfram Manager, Speech Pathology, RNS Ryde

Ray Araullo Manager, Social Work, Ryde

Eileen Van Dijk Manager, Social Work, Ryde

Stephen Spennati Manager, Physiotherapy, Ryde

Gwen Hickey Manager, Dietetics, Ryde

Radah Murthi Manager, Dietetics, Ryde

Melinda Hunt Manager, OT, HKH

Lisa Francis Manager, Speech Pathology, HKH

Susan Armour Manager, Social Work Hornsby, HKH

Lisa Eldridge Manager, Dietetics, HKH

Cathy Stephens Manager, Podiatry, HKH

Tersha Van Antwerpen MHDA Manager

Jan Plain MHDA Manager

Melissa Feek MHDA Manager

Maureen Fechter MHDA Manager

Jenny Kemp MHDA Manager

Brooke Richards MHDA Manager

Jenna Frost MHDA Manager

Andrew Clement MHDA Manager

Gloria Room MHDA Manager

Deborah Stewart Manager Health Services Clinical Redesign

Kerry Griffiths Manager Social Work NB

Kathleen Thorpe Director of Nursing and Midwifery HKH

Brian Bonham Director of Nursing Ryde Hospital

Jacqueline Edgeley DON Mona Vale Hospital

Philip Hoyle Director of Medical Services, RNSH

Kevin Luong Director of Medical Services, NBHS

Darlene Mather Director of Medical Services, Ryde

Samuel Ah Kit Director of Medical Services, Hornsby

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9.4 Stakeholder Workshops

Staff listed below were noted as having accepted a Workshop invitation, however in some cases nominated delegates may have attended workshops in place of some stakeholders named below.

MHDA

Name Position

Lee Meredith Occupational Therapist Level 4 Year 1

Loren Catherine Social Worker Level 1 Year 2

Matt Symond Clinical Psychologist Year 5

Shirley Till Clinical Psychologist Year 5

Sharon Mak Dietician Level 3 Year 2

Jenny Smith Clinical Psychologist Year 5

Di Simes Social Worker Level 5 Year 1

Angela Clancy Psychologist Year 5

Mark McIntyre Social Worker Level 3 Year 2

Angela Hayne Senior Clinical Psychologist Year 3

Jenni Blieden Social Worker Level 4 Year 2

Holly Murphy Social Worker Level 2 Year 1

Tamara Robinson-Macleod Provisional Psychologist Year 1

Bev Moss OT Grade 5 / HSM 3

Roisin Browne Occupational Therapist Level 4

Karen Barfoot OT Level 7

Andrew Clement Senior Psychologist Team Leader

Alison Waite S W Level 3

Anna Metcalf OT level 5

Brooke Richards SW Level 6

Kirralee Hall OT Level 2

Vida Istenic SW Level 3

Rosie Boardman Psychologist

Sabrina Symonds Occupational Therapist Level 2

Miroslav Milenkovic, Clinical Psychologist

Dominica Andersen Occupational Therapist Level 4

Ricky Koster Social Worker Level 3

Velencia Taljaard Occupational Therapist Level 3

Janice Plain Dietitian 4

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Tertia van Antwerpen OT L4

Janet Edmond OT L5

Unny Sankaran OT L

Melissa Fick Psych

Katherine Edmunds Psych

Louise Ingram SW

John Kennedy Gould SW

Kristine Grainger EP 3

Podiatry

Name Position

Thomas Paine Podiatrist

Derek Lee Podiatrist

Phlilip Ho Podiatrist

Ian Reid Podiatrist

Phillip Corne Podiatrist

Robert Tompsett Podiatrist

Mischa Kronenberg Podiatrist

Orthotics

Name Position

James Hui Orthotist

Thomas Paine Orthotist

Derek Lee Orthotist

Neuro-psychology

Name Position

Diane Winsor Neuro-psychologist

Michael Perdices Neuro-psychologist

Helen Pechlivanidis Neuro-psychologist

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Name Position

Helen McGrath Nutrition & Dietetics NBHS

Jennifer McDonnell Nutrition & Dietetics NBHS

Karen Humphreys Nutrition & Dietetics NBHS

Kate Unicomb Nutrition & Dietetics NBHS

Irene Rulli Nutrition & Dietetics NBHS

Katrina Tran Nutrition & Dietetics NBHS

Lisa Eldridge Nutrition & Dietetics HKHS

Deborah Andersson Nutrition & Dietetics HKHS

Caroline Hull Nutrition & Dietetics HKHS

Amanda Carter Nutrition & Dietetics HKHS

Caryn Kneale Ryde Aged Care Nutrition

Radha Murthi Nutrition & Dietetics

Caryn Kneale Nutrition & Dietetics

Cathryn Herden Nutrition & Dietetics

Natalia (Natasha) Davis Nutrition & Dietetics

Gwen Hickey Nutrition & Dietetics

Jennifer Smith Nutrition & Dietetics

Rebecca Prior Nutrition & Dietetics

Fiona Simpson Nutrition & Dietetics

Sharon Youde Nutrition & Dietetics

Speech Pathology

Name Position

Anastasia Scott Speech Pathology NBHS

Kerrie Condon Speech Pathology NBHS

Valerie Parrott Speech Pathology NBHS

Lauren van Rees Speech Pathology NBHS

Natalie Albores Speech Pathology NBHS

Lisa Francis Speech Pathology HKHS

Deanna Rolfe Speech Pathology HKHS

Erin Carpenter Speech Pathology HKHS

Annmarie Triplone Speech Pathology HKHS

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Peta Tonkin Speech Pathology HKHS

Caleb Heng RNSH Speech

Philippa Greathead Community RNSH-speech

Natalie Albores RNS Aged Care- Speech

Emma Inglis Ryde Aged Care Speech


Name Position

Helen Lapin RNSH Occupational Therapist

Carlien Badenhorst RNSH Occupational Therapist

Laura Fairjones Occupational Therapist

Linda Stone Occupational Therapist

Cathy Carlton Occupational Therapist

Joshua Innes Occupational Therapist

Lorna Hutchinson Occupational Therapist

Fiona Li Occupational Therapist

Fiona Penrose Occupational Therapist

Sarah Reade Occupational Therapist

Megan Hamilton Occupational Therapist

Melinda Hunt HKHS Occupational Therapist

Lois Clarke Occupational Therapist NBHS

Kate Luscombe Occupational Therapist NBHS

Jacqui Degan Occupational Therapist NBHS

Alex Cehak Occupational Therapist NBHS

Rachelle Foxton Occupational Therapist NBHS

Kylie Williams Occupational Therapist NBHS

Renee Gearin Occupational Therapist NBHS

Jo Hallett Occupational Therapist NBHS

Vanessa Rapkins Occupational Therapist NBHS

Sarah Fox Occupational Therapist NBHS

Di Sadler Occupational Therapist

Megan Yeo Occupational Therapist

Katrina Travassaros Occupational Therapist

Lisa Benad Occupational Therapist

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Jo Flannnery Occupational Therapist

Ian Cappleman Occupational Therapist

Amanda Maunder Occupational Therapist

Claudia Cross OT Occupational Therapist

Megan Petterson, Occupational Therapist

Michelle Williams Occupational Therapist

Laura De Vries Occupational Therapist

Belinda Caruso Occupational Therapist

Katie Grattan Smith Occupational Therapist

Marielle Sprangers Occupational Therapist

Tarryn Arthur Occupational Therapist

Rosemary Franzsen Occupational Therapist

Rachael Marlow Occupational Therapist

Christopher Jones Occupational Therapist

Kris Lewis Occupational Therapist

Adrian Jones Occupational Therapist

Megan Petterson Occupational Therapist Aged Care RN

Kareene Doyle Occupational Therapist Aged Care RN

Rosemary Franzsen Occupational Therapist Ryde Aged care

Rachael Marlow Occupational Therapist Ryde Aged care

Jayne Roberts Occupational Therapist

Physiotherapy / Exercise Physiology

Name Position

Michelle Appleby Physiotherapist

Janet Pickering Physiotherapist

Katie Lee NB/HK Physiotherapist

Sam West NBHS Physiotherapist

Kathryn Holloway NBHS Physiotherapist

Jane Woolgar NBHS Physiotherapist

Elizabeth Grigg NBHS Physiotherapist

Imogen Birch NBHS Physiotherapist

Christopher Mahoney NB Physiotherapist

Cathy Molloy NBHS Physiotherapist

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Susan Lambert NBHS Physiotherapist

Salpi Sevagian NBHS Physiotherapist

Ian Jordan HKHS Physiotherapist

James Wighton HKHS Physiotherapist

Elizabeth Parker HK Physiotherapist

Jennifer White HK Physiotherapist

Lyndall Windsor HK Physiotherapist

James Crossie HK Physiotherapist

Peter Cheng HK Physiotherapist

Christine Potter HK Physiotherapist

Daniel Ng HK Physiotherapist

Gary Rolls RNS Physiotherapist

Deborah Taylor rns Physiotherapist

Stephen Spennati Physiotherapist

Barbara Lucas Physiotherapist

Lydia Chen Physiotherapist

Jill Westaway Physiotherapist

Nadine Mesite Physiotherapist

Charlotte Strong Physiotherapist

Ashlea Hills Physiotherapist

Kirsty Lawrensen Physiotherapist

Renee Fine Physiotherapist

Trish Evans Physiotherapist

Nicola Kertangara Physiotherapist

Sarah Giaccari Physiotherapist

Elisabeth Lawson Physiotherapist

Leisl Davis Physiotherapist

Cayley Smith Physiotherapist

Julia Scott Physiotherapist

Rachel Edmondson Physiotherapist

Karen Thomas Physiotherapist

Tracey Cragg Physiotherapist

Christine Collins Physiotherapist

Lois Tonkin Physiotherapist

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Ray Jongs Physiotherapist

Kahli Mason Physiotherapist

Davide DeSousa Physiotherapist

Katie Fairhurst Physiotherapist

Rosemary Baecher Physiotherapist

Hassan Kadous Ryde aged care Physiotherapist

Sandy Tuch RNS Aged care Physiotherapist

Christine Bruntsch Physiotherapist

PACH

Name Position

Ana Peiretti Occupational Therapist Level 3

Peter Hawkins Social Worker

Wendy Siddall Physiotherapist

Ros Carroll Physiotherapist

Chris Jones Occupational Therapist Level

Kim Hien Physiotherapist

Sarah Hobson Occupational Therapist

Carol Whitehead Child Protection

Psychology / Social Work

Name Position

Alisa Green Clinical Psychologist

Jane McAuliffe Clinical Psychologist

Ann Wignall Principal Psychologist

Melissa Pigot Clinical Psychologist

Dr Helen Pechlivanidis Clinical Psychologist

Robert Pringle Snr Clinical Psychologist Head of Psychology NB

Angela Hayne Clinical Psychologist Head of Psychology HK

Melissa Fick Snr Clinical Psychologist 1

Kerry Griffiths Social Worker

Michelle Watson Social Worker

Brooke Du Ross Social Worker

Alison Innes Social Worker

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Annette Walker Social Worker

Angela Lohmann Social Worker

Sally Christmas Social Worker

Hayley Keeling Social Worker

Violin Wong Social Worker

Fiona Meicklejohn Social Worker

Ray Araullo Social Worker

Sandra Barr-Lynch Social Worker

Eileen Van Dijk Social Worker

Kate Lindberg Social Worker

Emily Mahony Social Worker

Louise Finn Social Worker

Anthea Murray Social Worker

Victoria Whitfield Social Worker

Jenny Havyatt Social Worker

Kathy Leader Social Worker

Mai Peedo Social Worker

Helen Tonkin Social Worker

Andrea Duffy Social Worker

Rebecca Sainsbury Social Worker

Kathy Taylor Social Worker

Bev White, Social Worker

Elizabeth Sharratt, CDS

Wendy Longman Social Worker

Maria Macek Snr Psychologist Yr 3

Marina Veddovi Snr Psychologist Yr 3

Grahame Colditz Social Worker

Jo Wigan Social Worker

Sarina Browne Social Worker

Anne Harsanyi Social Worker

Elisabeth Awad Psychologist

Joanne Jorgensen-Casey Social Worker

Bernice Moran Social Worker

Maurice Finn Psychologist

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Sarah Overton Clinical Psychologist

Mayumi Oguchi Clinical Psychologist

Susan Armour Social Worker

Cathy Marshall Social Worker

Vivienne Peters Social Worker

Lauren Quirk Social Worker

Sarah-Jane Brewer Social Worker

Natalie Wu Social Worker

Vanessa Zeleny Neuropsychologist

Feedback required: Northern Sydney LHD Allied Health … · 2016-05-16 · Newsletter: 106/2015 Date: 8 March 2016 Distribution: Allied Health members NSLHD Contact: Your organiser

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