Children and Families

Project

Effects of VR on standing frame tolerance.

Leads: Bethan Villers, Paediatric Physiotherapist

What was the problem?

Standing frames are essential in children's physiotherapy, supporting posture, contracture management, strength, respiratory function, gut health and hip development. While the aim is one hour of standing daily, some children tolerate as little as 10 minutes, limiting the benefits. A solution was needed to improve standing tolerance and maximise outcomes.

Aim

To see whether the use of Virtual Reality (VR) headsets (VR games for more able children, and sensory experiences for those with profound and multiple learning disabilities) improves standing frame tolerance in primary-aged children with a neurodisability who have a prescribed standing frame programme, using each child as their own control by comparing time in the frame with and without VR. 

 

What did we do?

As students already had access to both VR and a standing frame, this began as a clinical audit looking at whether combining the two improves tolerance, in an area with no existing published research. The lead is presenting the idea at the Digital Innovation Forum and, as part of a Master's module on Creating and Applying Evidence, is writing a formal study protocol. Once this is approved, the research will be conducted with patients.

 

What are the benefits for patients and staff?

This project is still at the audit/protocol-development stage, so outcome benefits are not yet available

 

Measures used

The main outcome measure is time spent in the standing frame with and without VR, which will be compared and analysed. Patient feedback will also be collected where appropriate, unless doing so risks introducing bias, in which case it will not be collected.

Project

Targeted language groups

Leads: Vicky Caulfield and Kirsten Newman, Speech and Language Therapists

What was the problem?

A gap in targeted support for Key Stage 2 children with speech, language and communication needs (SLCN) was identified, alongside limited SaLT capacity to develop provision. Four newly appointed Speech and Language Therapy Assistants (SLTAs) were trained to deliver targeted intervention groups, increasing capacity and enabling more children to access support.

Aim

More schools will deliver targeted speech and language interventions, with staff trained to confidently support children with SLCN, leading to improved communication outcomes. Schools will be better equipped to follow the graduated approach, monitor progress, and identify children who need specialist SaLT assessment.

 

What did we do?

Four SLTAs were trained to deliver targeted intervention groups while upskilling Teaching Assistants to run them independently, increasing school capacity. Following six months of development and SLT support, 13 groups were implemented across schools.

 

What are the benefits for patients and staff?

Early feedback shows improved confidence and communication in children, increased parent engagement, and Teaching Assistants adopting new strategies and continuing the interventions independently.

 

Selection of qualitative data

Child said:

I have enjoyed it and it has made me talk more as I don't always feel able to talk in class.

Parent said:

My son feels really excited about the word that is taught in speech and language. He tries to use that word wherever he can / is applicable.

Teaching Assistant said:

I have changed the way I explain words to help the children understand better. I will use the strategies and activities in other interventions and definitely carry on running the group.

 

Measures used

Child, parent and Teaching Assistant feedback, alongside pre- and post-intervention measures, capture impact, with ongoing evaluation using the Balanced System® Prove It! tool.

 

Qi tools used

• Beyond the Balanced System ® "Prove It!" tool used to capture impact data.

Project

Universal Access Physiotherapy drop-in clinics.

Leads: Ryan Deakin, Physiotherapist

What was the problem?

Health visitors and early years workers often need a second opinion on musculoskeletal, gait or motor development concerns in young children, but physiotherapy doesn't accept referrals for normal variance. Families are instead directed to their GP, who often refers back into physiotherapy anyway, adding pressure across the system without necessarily reassuring parents.

Aim

By December 2025, to increase access to timely specialist physiotherapy advice for pre-school children with isolated musculoskeletal, gait or motor development concerns through a pilot rapid-access pathway, reducing demand on health visitors and GPs and cutting inappropriate referrals for normal developmental variation.

 

What did we do?

Ran a scoping survey with the health visiting service to understand what support staff needed, updated triage guidance and combined it with a learning resource for health visiting teams, and delivered virtual drop-in sessions and teaching from physiotherapy. The team also shadowed health visiting clinics to identify suitable presentations and visited an existing physiotherapy drop-in clinic in Worcestershire to learn about set-up and delivery.

 

What are the benefits for patients and staff?

Pre-school children with isolated musculoskeletal, growth, gait or motor concerns would gain quick access to specialist reassurance, advice or signposting, reducing the burden on health visitors and GPs seeking second opinions, while helping physiotherapy reduce referrals for children who don't need formal input.

 

Measures used

Data collected by health visiting services and early years workers on the number of children with musculoskeletal (MSK), growth or motor concerns raised, to support a proposal for wider roll-out.

 

Qi tools used

• Scoping survey and service shadowing.

Project

Prevention of body shape distortion.

Leads: Jacqui Parker, Children and Families Physiotherapy

What was the problem?

Children with complex neurodisability are at increased risk of developing body shape distortion and musculoskeletal deformities as they grow if their posture is not managed correctly. Deformity at the spine or hips, for example, can increase the likelihood of pain, pressure areas and respiratory complications, and increase the chance of the child requiring corrective surgery. In reviewing current practice and new evidence-based interventions, the children's physiotherapy service trialled an innovative approach to supine lying systems as part of its 24-hour postural management offer.

Aim

For children with complex neurodisability requiring 24-hour postural management, through effective assessment, provision of individualised lying programmes with appropriate equipment/systems, family education and monitoring to reduce scoliosis development or progression, hip dysplasia, chest infections (optimising respiratory function) and pain

 

What did we do?

We worked with the device manufacturer to learn the assessment process and upskill the wider team. We collaborated with local equipment services to improve access to the devices, secured funding for additional assessment kits, and worked with acute trusts and the community respiratory team to optimise positioning, reducing deformity while supporting respiratory health.

 

What are the benefits for patients and staff?

Early evidence shows this approach to postural care is working, with improvements seen in children's back pain and hip pain, as well as improved sleep duration and tolerance of being in bed.

 

Measures used

Data was collected at each assessment against objective markers of improvement. Wider impacts are also recorded, including pain, respiratory complications, compliance, family feedback, and the number of children needing/not needing corrective surgery.

Project

Physiotherapy in special schools: gaining consent.

Lead: Stephanie Atkinson, Physiotherapist

What was the problem?

A QI huddle raised concerns about gaining parental consent for physiotherapy interventions delivered in school without parents present, since plans can change in the moment. There was no consistent process to ensure parents understood what could take place during physiotherapy in their child's absence.

Aim

To formalise and strengthen consent practices with signed written consent forms added to the child's records, bring consistency to pre-admission conversations with parents/carers before a child starts special school, and manage expectations by clearly explaining the physiotherapy role.

 

What did we do?

Created a new consent document outlining the different interventions that could take place with a child in school in their parent's absence. This was first used in practice at Bray's School in September without issue.

 

What are the benefits for patients and staff?

Parents have a clearer understanding of what physiotherapy support their child may receive and why, supporting more consistent, transparent conversations between families and the team, and reducing the risk of interventions taking place without informed consent.

 

Measures used

Feedback collected from staff, parents and schools.

 

Qi tools used

• QI Huddle.
• Plan, Do, Study, Act (PDSA) cycle.

Project

Paediatric Physiotherapy

Leads: Carmel Kelly, Service Clinical Manager for Physiotherapy and Occupational Therapy; Christel Corbett, Paediatric Physiotherapy Team Leader; Claudette Keay, Service Manager for Therapies

What was the problem?

• Rising demand and case complexity: the service was currently managing an open caseload of approximately 3,024 patients, driven by a sustained increase in referral rates and the complexity of cases.
• Capacity constraints: limited staffing and resources had created a mismatch between demand and capacity, resulting in delays to both assessments and interventions.
• Significant backlog: there was a backlog of over 682 children awaiting initial assessment, many of whom presented with urgent needs requiring timely support.
• Extended waiting times: in addition to initial assessments, there were further delays for clinical reviews and treatment. Those long waiting times predate the COVID-19 pandemic and have been exacerbated by it.
• Urgent need for transformation: radical changes were required to ensure that children with the greatest need received timely and effective intervention, safeguarding their health and developmental outcomes.

Aim

To reduce the number of routine new referrals accepted to the Paediatric Physiotherapy Service by 20% by 1st December 2023

 

What did we do?

To better meet the needs of children and manage increasing demand, a new tiered service model was developed to stream patients into three levels of support:

• Specialist level: for children with identified long-term physical disabilities that significantly impact daily function and participation.  Intervention delivered primarily through 1:1 assessments, individualised treatment, and access to specialist clinical pathways.
• Targeted level: for children with specific developmental conditions, such as Down Syndrome, who require focused support.
• Universal level: suitable for all children and available pre-referral, whilst waiting or after discharge. A clinical advice line for parents and professionals. Signposting to a dedicated website with appropriate resources. Training for the wider workforce to support early intervention and consistent messaging and development of accurate, accessible information resources to empower families and carers.

 

What are the benefits for patients and staff?

• Reduced waiting times for initial assessments: families are being seen more quickly for initial assessments, resulting in a noticeable decrease in complaints about long waiting times.
• Improved access to information: parents have responded positively to being directly signposted to relevant information on the website, appreciating the ease of access rather than having to search for it themselves.
• Improved first appointment experience: families are arriving at their first appointments less frustrated due to shorter waiting times, allowing clinicians to build rapport more quickly and effectively.
• Positive feedback from physiotherapists - a physiotherapist shared:

I have found it really helpful having the webpages to refer families to when providing them with advice.

• Efficient use of online resources: clinicians have noted that having all the latest information consolidated on the website saves time. One commented:

It really saves time having all the latest information in one place on the website rather than having to spend time searching. The links are easy to use and signpost families to after seeing them in clinic. I’ve also used the specific website links while triaging, especially when waiting for the Universal Offer letters to be produced.

 

Measures used

• Measure and analyse data from waiting lists.
• Measure and analyse data from referrals.
• Measure and analyse demand, capacity, activity and backlog.
• Feedback from staff.

 

Qi tools used

• Plan, Do, Study, Act (PDSA) cycle.
• Statistical Process Control (SPC) Charts.
• Fishbone Diagram.
• Driver Diagram.
• Process Mapping.

 

Project

To refer or not to refer? Improving the quality and timing of referrals to Children's Speech and Language Therapy (SLT) Eating and Drinking Team.

Lead: Kay Jones, Clinical Expert Speech and Language Therapist – Paediatric Dysphagia

 

What was the problem?

The Children and Families (C&F) Speech and Language Therapy (SLT) Dysphagia Service had experienced steadily increasing waiting times:

• Routine need patients: waiting up to 68 weeks (target: 18 weeks)
• High need patients: waiting up to 24 weeks (target: 4–6 weeks)

A key contributing factor was the misclassification of referrals, with a high number being incorrectly prioritised as high need based on the information provided by referrers. This mis-prioritisation placed additional pressure on the service and contributed to delays for both high and routine need patients.

 

Aim

To reduce waiting time from 40 weeks to 18 weeks for routine need patients and from 17 weeks to 4 weeks for high need patients and increase appropriacy of referrals, by the  end of September 2023, by providing universal strategies and guidance for referrals.

 

What did we do?

To address the increasing waiting times and mis-prioritisation of referrals in the C&F SLT Dysphagia Service, the team implemented a series of targeted interventions:

• Pre-Referral Checklist and Universal Advice Leaflet.
• A pre-referral checklist was introduced to guide referrers in accurately identifying high need versus routine cases.
• An accompanying universal (first line) advice leaflet was developed to support families and professionals with initial management strategies.
• Both resources were made available on the service’s webpages, alongside the referral form.
• Training and Communication:
  • A training package was created to explain the purpose and use of the new resources.
  • The team actively attended referrer team meetings and forums (for example Health Visitors, Paediatricians, Children’s Nursing Teams) to launch the documents.
  • Resources were also distributed via email through the Integrated Care Board (ICB) GP circulation list.
• Consistent Triage Criteria:
  • At the point of triage, the same criteria outlined in the checklist was applied to all new referrals.
  • Referrals that met the criteria for universal support were provided with first-line advice and not added to the waiting list, helping to manage demand more effectively.

 

What are the benefits for patients and staff)?

• Average waiting times for routine need referrals reduced to the 18-week target by project end. High need referrals: waiting times reduced to 9 weeks.
• Improved referral quality led to a reduction in high-risk list additions during the project period.
• 30% reduction in referrals added to waiting lists, mainly for routine needs. This equates to approximately 200 fewer referrals per year 2023 to 2024 and 2024 to 2025 compared to previous years.
• The pre-referral checklist and top ten tips resource are now embedded in the clinical pathway, supporting consistent and effective triage.
• Families now receive appropriate advice earlier, avoiding unnecessary delays of up to a year for guidance that could be provided at the point of referral.
• SLT staff and colleagues across services (Early Years, School Age, Special Schools, Health Visiting, Community Nursing, Paediatrics) feel confident and supported to offer early advice as a first-line intervention.
• More appropriate and targeted referrals are being made, reducing pressure on waiting lists and ensuring children receive the right support sooner.
• Staff in schools and early years settings are better informed about when and how to refer and feel enabled to provide early advice or signpost families to relevant services.

Measures used

• Waiting list data highlighted the problem initially.
• Statistical Process Control (SPC) charts were used to show longest waits and numbers added to the waiting list and to monitor impact of project on these over time.
• Children and Families SLT patient tracker tool was also used to monitor average wait times.

 

Qi tools used

• 5W’s and 2H’s.
• Process mapping.
• Fishbone analysis.
• Driver diagram.

Project

Early years check-in calls

Lead: Deborah Berzins, Speech and Language Therapist and Early Years Co-ordinator.

 

What was the problem?

Book-ins are a huge output for the team with approximately 80 appointments offered during a week (across the city) in term time. Current base line is 27%, with an initial target to increase by 50% by March 2025. Waiting times were increasing due to the high volume of appointments being received.

 

Aim

To ensure each of the community clinics where sedation is to increase the number of families who access further targeted support following attendance at book-ins by 50% by March 2025.

 

What did we do?

Various improvement change ideas were looked at and the ‘check in call, change idea was selected to be trailed and implemented. At the book-in, families are offered the option to receive a ‘check-in’ call, 4 weeks later.
Locum staff make these calls:

• To check that families have received their report.
• To check that they understand the strategies given.
• To gather some feedback about whether it is helping.
• To problem solve any issues.
• Explain how to re-access.

 

The project also included running Early Years Online Workshops for families:

• Online group workshops hosted on MS Teams;
• On 5 different themes;
• Offered 1 to 1 with an interpreter where needed;
• Started in October 2023 to November 2024;
• Designed to enhance the f2f offer;
• Run by SLT locums making use of remote staff.

 

Early Years online workshops were run by 3 remote locum staff on MS Teams. They sent a link to each invited family and ran a pre-prepared group session on the following topics:

• Attention and Listening.
• Play and Interaction.
• Understanding of Language.
• Expressive Language.
• Higher Level Expressive Language (2 word level +).

If a family needed an interpreter, the session was run 1 to1.

 

What are the benefits for patients and staff)?

What families told us:

• Able to comment on how they will do things differently, for example, remove distractions, commenting rather than asking questions, using object cues, expanding their child’s phrases.
• Able to generate play activities or daily activities in which they will practise the strategies (which shows they have understood the content).
• Bilingualism advice helpful, especially in the interpreter sessions.
• Parents have generally been very appreciative and fed back that the advice was very clear.

 

Key Learning Points:

• Data analysis has been crucial.
• A clear starting point was needed as it wasn’t possible to test on a smaller scale before launching.
• Positive side-effects: increased access to tailored support and lots more impact data collected.
• Negative side-effect: increase on re-access demand.
• All the positives of the online workshops were adapted into the new more flexible and accessible format.

 

The check-in calls project has been a success in that we achieved our aim to increase access to follow up support from the baseline of 27% to 79%.

Measures used

• Waiting lists: data analysis.
• Staff feedback.
• Patient feedback

 

Qi tools used

• Plan, Do, Study, Act (PDSA) Cycle.
• Fishbone diagram.
• Process mapping.
• Demand and capacity modelling.