A service in transition

When you pass through the gates of the Children's Trust in the Surrey village of Tadworth, there is a feeling that you are going back in time. According to Dalton Leong, chief executive of the charity that helps rehabilitate children and young people aged naught to 19 with an acquired brain injury, many visitors refer to it as "a Tardis". It is easy to see why: the main office is a grade 1 listed 17th century manor house complete with original wooden panelling and rickety spiral staircase, while the rose gardens are immaculate with sculpted hedges and rolling lawns.

On a sunny June day, it is easy to imagine the 25-acre site playing host to aristocratic tea parties or why, when owned by Great Ormond Street Hospital for much of the 20th century, children from London were sent there to recuperate in the countryside from serious illness and injury.

It is a good metaphor to describe the process that Leong has been going through since being appointed in 2013. Under the 21-year stewardship of the previous chief executive, the Children's Trust had grown organically and cultivated a reputation for delivering gold standard care.

However, this had led to classic "mission creep", explains Leong: "You have some oddities appearing - for example, we were supporting someone in the community who was 52. It is not a criticism of the past; it's inevitable, the organisation has been going for 30 years."

Addressing such anomalies and "modernising" the charity - which was created in 1984 when the services was uncoupled from Great Ormond Street has been Leong's focus since joining, so that what it offers better reflects advancements in medical science and the changed funding climate.

Over that period, Leong has had to draw on all his 20 years of experience from the banking sector to take some "difficult decisions" about what the most economic shape of services for the charity to deliver are. Its local outreach service has been closed "because others can do it better and we were effectively losing money on it", he says, while the age limit it caters for has been reduced from 25 to 19, which will result in the "phasing out over two to three years" of its college for young adults.

A key part of this process though has been the development of a "step down" model of rehabilitation service that is seeing children referred from the NHS transferred from hospital care into the community quicker. Leong says this has resulted in the charity reducing the number of children "overstaying" their discharge date from 75 per cent to "a wholly acceptable" five per cent. "When I joined, people said 'Oh Dalton, you're going to that organisation that keeps children too long'. They were right," he says.

Cultural shift

To make this happen, the charity starts discussions about a plan for care in the community before the child has even arrived at its specialist rehabilitation facility in Tadworth. Previously, this would not have occurred until three to six months into their stay. But reshaping working practices is only part of the story - Leong has also been pushing through a "cultural shift" in staff expectations that is about "accepting we can't always be delivering a gold-plated service".

To illustrate this, he points to a chart on the wall behind his desk that shows the patient journey ending at a cliff edge. "We give them a brilliant service and then they drop off," he explains in reference to the impressive range of facilities it offers, including a hydrotherapy pool, school and college, nursing quarters and therapy rooms.

"You can give them this amazing service and then it's perceived that they're now on their own in the community or in an education setting. What we should be offering is a properly stepped-down approach allowing the child and family to adapt."

Unusually for a chief executive, he talks about developing "adequate" services rather than excellent ones as the route to doing this. "We want to be excellent and do the best we can possibly do to help the child to fulfil their potential, but there comes a point when you have to say that's adequate, otherwise the drop-off is huge when they go out (into the community)."

Delivering the best care can in fact do a "disservice" to children and parents because services in the community cannot deliver the same level of care, he adds. "If we keep them three more months, we can get them to walk five steps not three. Yes you can, but we have to accept sometimes three steps is adequate and let them develop the next two steps back out in their own setting where they will get support, even if it is not the intensive therapy we provide."

More work engaging with families at the start of the process and having "better conversations" with them early on is making this possible, says Leong, but he admits it has taken time to win staff over: "Our 525 staff have huge knowledge and expertise - a high percentage of them have been here 20 years plus - and I have huge respect for that. However, you can't be insular in your thinking because whether we like it or not, we are in a changing environment right across education, health and social care."

Leong's ambition is to do more with the same resources. He wants to raise the number of children the charity supports from 600 to 2,500 by 2017, all at a time when clinical commissioning group and local authority budgets - which account for £19m of the charity's income - are under unprecedented pressure.

In anticipation of a fall in income from the NHS, he wants to see donations grow from £7m in 2014 to £10m by 2017.

"When I joined, I said if we can sustain our position in three years time then we would have done well. I probably sounded totally unambitious, but I felt it was realistic," he adds.

Recently acquired NHS national commissioning status, which sees the charity deliver a care package for 13 children at any one time through a £3.5m annual contract, has helped boost income and "demonstrates our ability to work in partnership with the NHS truly works", Leong says. The contract has just been renewed but at a slightly lower tariff, something the charity had budgeted for: "We're scenario planning for potential further drops, but the plus side is if there is no drop, then we can support more children."

Another hangover from the past that Leong has addressed, and will be key to the Children's Trust's sustainability, is its focus on developing a national service and presence. While it has always been a national charity, its location and the fact that up until recently the word Tadworth appeared in its name gave the impression that it just served Surrey and the south east. A new strapline that brands it as "the UK's leading charity for children with brain injury" reinforces its national focus.

To that end, the big service development plan for the next three years is to expand its brain injury community service from the current two locations to 10. Staffed by brain injury specialists and funded by the Children's Trust, these services are run out of hospitals - currently in Nottingham and Sheffield - supporting about 500 children in each community. Conversations about developing a service in Wales are at an advanced stage and he hopes Scotland and Northern Ireland will follow soon after.

Leong says: "We've ventured into community services for the past five years and we know that the need is there for children with mild to moderate brain injury. It is about helping families with coping and learning strategies for children and reintegrating them back into community settings.

Minimum target

"We're saying this is what works in Yorkshire and the East Midlands and we'd like to work with you and put ourselves alongside NHS staff. A further eight is our minimum ambition, but if we don't achieve that, it's failure."

Developing regional community services will also enable the charity to elongate the relationship it has with families and develop an evidence base of progress made by children. "It's not acceptable to let children leave the rehab centre and have a cursory call four weeks later. Commissioners will ask about outcomes and that's absolutely right," he says.

Leong has also been conscious of the need to broaden the charity's profile and influence in the sector, and has been actively involved with the Every Disabled Child Matters campaign to get health and wellbeing boards signed up to its service standard charter.

The need is growing thanks to advances in medical science: there are now 40,000 children living with an acquired brain injury, of which 6,000 are severe.

The special educational needs reforms, in particular the introduction of personal budgets, are also an opportunity for the charity to expand the number of people it delivers services to, he says. "There's an opportunity there to understand how that can impact making that choice. In our opinion, parents will want continuous support through the Children's Trust. How do we bring that alive and put it into practice? That's something we want to be around the table on."

DALTON LEONG CV

1981-2002: Corporate, retail and private banking, finishing financial services career in the City

2002: Director of operations and marketing, The Shooting Star Children's Hospice, managing hospice build project

2004: Chief executive, The Shooting Star Children's Hospice - ending in jointly instigating merger with CHASE hospice care for children - now known as Shooting Star Chase

2010: Managing director, Global Radio Charities & Communities. Global is a leading commercial radio company, owning Heart, Capital, Capital XTRA, Classic FM, Smooth, LBC, Xfm and Gold, and broadcasting to 23 million listeners weekly

2013: Chief executive, the Children's Trust.