NHS Cumbria CCG Transforming Care Programme Learning Disabilities

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1 NHS Cumbria CCG Governing Body Agenda Item 07 December NHS Cumbria CCG Transforming Care Programme Learning Disabilities Purpose of the Report To update the Governing Body on local progress with the national agenda and development of a new service model for people with learning disabilities and / or autism. Outcome Required: Approve Ratify For Discussion X For Information X Assurance Framework Reference: - Quality Assurance - Leadership assurance Recommendation(s): The Governing Body is asked to receive the report and discuss the content. Executive Summary: Key Issues: - The need to meet the national requirements in terms of bed closures and inpatient admissions. - The development of the local workforce to support new service models. - The progress in developing new service models. Key Risks: - Funding flows in relation to dowries ( Inpatient to Community settings) - Recruitment and development of the appropriate workforce - Meeting the required targets for CNTW & targets for inpatients in relation to Cumbria Financial Impact on the CCG: - The funding of dowries as patients transfer from inpatient settings to community settings is not clear (meant to follow patients).

2 Implications/Actions for Public and Patient Engagement: - Quality of health services commissioned and any concerns related to this are always of great importance to the public and our patients. Strategic Objective(s) supported by this paper: Support quality improvement within existing services including General Practice Commission a range of health services appropriate to Cumbria s Needs Develop our system leadership role and our effectiveness as a partner Improve our organisation and support our staff to excel Impact assessment: (Including Health, Equality, Diversity and Human Rights) Please select (X) X X X X Yes Lead Director Peter Rooney, Chief Operating Officer Presented By Helen King, Director of Nursing & Quality Contact Details Helen.King@cumbriaccg.nhs.uk Date Report Written November

3 Transforming Care Learning Disabilities 7 December 2016

4 Introduction Service model vision statement Children, young people and adults with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition* have the right to the same opportunities as anyone else to live satisfying and valued lives and, to be treated with the same dignity and respect. They should have a home within their community, be able to develop and maintain relationships and get the support they need to live a healthy, safe and fulfilling life. (-Supporting people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition,oct 2015) This is the vision statement underpinning the Transforming Care Programme and the overarching purpose of the many reiterations of national strategy and policy since the 2001 Valuing People policy document. The principles of rights, independence, choice and inclusion run throughout, though unfortunately in the intervening years there have been some very high profile and unacceptable events in places like Winterbourne View and Southern Health. This report provides a summary report to provide oversight of the current situation and the local implications. Background In December 2012 the Department of Health published the Winterbourne Concordat a programme of action which outlines the commitment of organisations across health, social care, police and regulators to drive up standards of care and safeguard people with learning disabilities, autism or mental health conditions. Actions included: CCGs to maintain a register of all people with learning disabilities or autism who have mental health conditions or behaviour that challenges, and have been in NHS-funded care from 1 April 2013; All organisations to ensure people with challenging behaviour in inpatient assessment and treatment services are appropriately placed and safe, and if not make alternative arrangements for them as soon as possible; Review funding arrangements for these people and develop local action plans to deliver the best support to meet individuals needs; Review existing contracts to ensure they include an appropriate specification, clear individual outcomes and sufficient resource to meet the needs of the individual and appropriate information requirements to enable the commissioner to monitor the quality of care being provided; 2

5 Improve the general healthcare and physical health of people with learning disabilities for example, all individuals in these services should have a comprehensive health check within 6 months and a health action plan; Involve children, young people and adults with challenging behaviour and their families, carers and advocates in planning and commissioning services and seek and act on feedback about individual experience; Ensure that planning starts early with commissioners of children s services to achieve good local support and services for children and better transition planning for children with disabilities moving from children s to adult services; Ensure that health and care commissioners set out a joint strategic plan to commission the range of local health, housing and care support services to meet the needs of children, young people and adults with challenging behaviour in their area. Post Winterbourne Concordat, Norman Lamb (2013) identified five key actions for the following six months within the report, Winterbourne View: Transforming Care One Year On. They were: To meet the commitment to ensure that individuals have moved or are moving to settings closer to family by June 2014 where appropriate; To establish robust systems for service users, their supporters and clinicians to feed into and challenge the initiatives being taken forward; To drive a concerted effort to ensure that services are provided to a 21st century standard, including Positive Behaviour Support and guidance on minimising the use of restraint; To establish Key Performance Indicators using data from the Single Assessment Framework and the census; To disseminate the model service specification to both children s and adult s services so that it can be used to drive up quality. The 2014 report Winterbourne View - Time for Change; transforming the commissioning of services for people with learning disabilities and/or autism reaffirmed the direction of travel expected in relation to building community capacity. In the summer of 2015, NHS England required a number of fast track areas to develop service transformation plans. The areas were selected because they have significant NHS hospital services for learning disabilities, which are marked for closure, such as Calderstones Hospital, or for significant bed reductions. Cumbria and North East England were identified as a fast track area because of Northgate Hospital, provided by Northumberland, Tyne and Wear NHS Foundation Trust. The North East and Cumbria Regional Plan, which is now a public document, describe how localities will deliver the continued transformation, building on the recent Fast Track process. 3

6 As part of this plan Cumbria prepared its locality plan to identify how Cumbria will implement national policy in a local context and aligned to the North East and Cumbria Fast Track. This is to ensure that there are robust services being developed underpinned by the planned trajectories showing a reduction of 50% in inpatient learning disability beds across the North East and Cumbria. The North East & Cumbria Fast Track plan was submitted to NHS England on 7 September 2015 and the transformation programme aims include: Less reliance on in-patient admissions; Developing community support and alternatives to inpatient admission; Prevention, early identification and early intervention; Avoidance of crisis and better management of crisis when it happens; Better, more fulfilled lives. The plan was structured into 5 key components: mobilising the area, understanding the current state, developing the vision, defining the model of care and planning for success. In October 2015 NHSE published the National Plan to develop community services and close inpatient facilities for people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition. Building the Right Support can be found at: This required all CCGs to form Transforming Care Partnerships (TCPs) with Local Authorities and other stakeholders to deliver the national plan. This position is reinforced by the February 2016 report by Sir Stephen Bubb, Time for Change, the Challenge Ahead which acknowledges that there has been a real step change but there is still more to do. The Main Aims Efforts are focusing on: a substantial reduction in the number of people placed in inpatient settings; reducing the length of stay for all people in inpatient settings; better quality of care for people who are in inpatient and community settings; better quality of life for people who are in inpatient and community settings. 4

7 Summary of Key Messages from Time for Change, the Challenge Ahead The key messages from the report reinforce that there has been a significant step change but the 50% reduction in inpatient learning disability beds must be met by The report also states: the need for a prevention revolution. This would see coherent and targeted early intervention preventing the need for future costly acute responses and resources. Deadline - by 2019, the Transforming Care Programme intends to reduce inpatient beds by 50% nationally. Community based services will be developed to prevent admission. Failure is not an option and cannot mean another broken promise. Success will only be recognised when the closure of hospitals is made possible by the development of community based services. Prevention has a key role to play Most forms of preventative work require up front spending key view of longer term savings. 15m made available to TCPs for capital projects. NHSE and DH to explain how this fund will be administered and how this will meet the rate of people being discharged over the next 3 years. A workforce that works - acknowledges that where commissioners drive down prices, it becomes harder to recruit good staff where there is already not enough staff in the system to provide right care in the right place. Anticipates increase needed of 10,000 staff (8% increases) both frontline and managerial across the country. This includes training and development. Initial investment is required to ensure transition can be in a safe and effective manner with savings realised in the future. Accreditation of Positive Behavioural Support (PBS). Recognition continues to gain momentum. A home not a hospital - availability of suitable housing is absolutely core. Ensure that there is a mixed availability to meet local need. Discussed use of Social Property Fund and DH s care and Support Specialised Housing Programme. Recommends the government reviews Transforming Care and a comprehensive evaluation is carried out regionally and nationally. Local Context and Current Position There is a local joint CCG and Cumbria County Council Transforming Care Partnership, which reports into the Cumbria Joint Commissioning Board. There is an Interim role across Health and Social care with key responsibilities and leadership on behalf of both health and social care. ( Anne Flanagan ) Our local Transforming Care Partnership has an ongoing extensive engagement process, implementing local strategy in Cumbria. 5

8 We are involved in a mortality audit with our local hospital providers to review deaths, which may have been avoidable, in hospital settings. We have a robust Care and Treatment (CTR) process in place and are meeting all of our trajectories, which are submitted to NHS England on a weekly basis. There is concern about the Cumbria Northumberland Tyne and Wear progress against expected trajectories (both for bed closures and numbers of inpatient admissions) and support from Cumbria is required. CTRs and pre admission CTRs are being conducted to ensure that challenge is placed into the process to check whether any other support arrangements can be considered to prevent an admission where appropriate. There are a number of challenges to overcome, workforce requirements (clinically and managerially), a lack of information and robust outcome measures, addressing health inequalities and how to develop the provider market to meet more challenging need/complexity. Inpatient population, current position and progress to date Prior to reporting in March 2014, most people from Cumbria, in inpatient settings, were placed at either Northgate Hospital, Northumberland or at Calderstones, Lancashire, and at other independent and NHS hospitals across the country. Since the commencement of reporting in March 2014, 21 people have been discharged, 18 within Cumbria and 3 placed out of county in specialist provision. Cumbria s Assessment and Treatment Unit, Edenwood is based in the Carlton Clinic, Carlisle provided by the Cumbria Partnership Foundation Trust and funded by the Cumbria Pooled Fund on a block contract.. CQC rated Edenwood inadequate in an inspection published on 23 rd March Work is progressing well to meet the requirements of the improvement action plan. Inpatient population at July 2016 Hospital Number of people Edenwood 5 Rowanwood (CPFT Mental Health 1 provision) Out of county 21 TOTAL 27 Of those who are placed out of county, 13 are in secure provision overseen by NHS England Specialised Commissioning as follows: High secure 8, Medium Secure 3 and Low secure 2. 6

9 Managing interdependencies with other transformation activities There are a number of strategic developments and transformation programmes that may overlap with the work underway within the Learning Disability Transformation Programme, which is Cumbria wide in its focus, for example: West, East and North Cumbria Success Regime Better Care Together across south Cumbria and Lancashire Cumbria County Council s Commissioning Strategy for care and support delivered by Adult Social Care ( ) this will have an emphasis on delivering support close to home and optimising the use of local community assets. Mental Health Transformation Programme Draft Cumbria Autism Strategy Formation of Transforming Care Partnerships CNTW CCG 5 Year Plans Common Characteristics Better Care Fund Mencap Death by Indifference Commissioning Continuing Healthcare NICE Guidelines i) Challenging behaviour and learning disabilities: prevention and interventions for people with learning disabilities whose behaviour challenges. ii) Challenging Behaviour and Learning Disabilities Overview (Pathway) ii) Challenging Behaviour and Learning Disabilities (October 2015) iii) Proposed - Mental Health in people who have a Learning Disability (September 2015) Priorities and Risks The North East and Cumbria Transformation Board continues to have oversight of the transformation programme and is now well established due to the North East and Cumbria being a Fast Track. The concern about progress on the wider footprint of CNTW is likely to create pressure on inpatient admission numbers in Cumbria. The transfer of finance (known as dowry payment) as a result of people transferring from inpatients to community living arrangements remains unclear and continues to be discussed. In financial terms, the main challenge and risks presented by the NE & C Fast Track Transformation Programme is the timing differences that arise between: The discharge of patients from hospital to a community setting, incurring immediate additional costs for commissioners; and The reduction of commissioners inpatient costs as providers are able to close hospital wards and beds. 7

10 There is still uncertainty around how secure services currently funded by NHS England when beds are closed, how the funding will follow the patient. This includes a potential shortfall and potential step delay in funding transfer which would need to be met.these timing differences are still being understood and the detail emerging. There are other relevant financial pressures which need to be better understood and is currently being modelled to support decision making in Cumbria for example where: The cost of community provision is greater than the equivalent hospital setting a patient is leaving; and Investment in ancillary and enabling services is required to manage patients transition and avoid readmission to hospital. Cumbria County Council and the CCG have reviewed and are considering the learning disability pooled budget arrangements, which are governed by a Section 75 legal agreement, through the joint Commissioning Board. The transforming care agenda is raising concern amongst commissioners and Local Authorities across the country, primarily because of the financial impact of transferring responsibility for commissioning complex packages for people with a learning disability from NHS England Specialist Commissioning to local commissioners. The Quality Assurance is through the Contract Review Groups and the Quality Review Groups and time is limited on otherwise busy agendas. Preparation We (Health & Social Care) need to ensure that the services we have in the community are robust enough, and in the right place at the right time to support patients and provide additional support when needed to prevent future hospital admissions where possible. This will require some initial investment and frontloading of costs in development and future proofing of services. Regulation of new provision will remain the responsibility of the CQC. Resources and Capacity A "workforce that works" the February 2016 report by Sir Stephen Bubb acknowledges there may be difficulties in recruiting and retaining good staff due to the significant financial pressures on health and social care and acknowledges that there is not enough staff in the system currently. The report anticipates an increase of 10,000 staff both managerial and frontline across England by 2020 to meet the up and coming demand in the community. This includes training and development - equipping the workforce for the task and the new way of supporting people in new settings. 8

11 The health commissioning and assurance resource for this agenda in Cumbria needs to be carefully monitored and particularly as the leadership position across health and social care is on an interim basis only. 9

12 Written initially by Janice Horrocks Deputy Director of Mental Health Revised and approved by Helen King For more information contact: Helen King, Director of Nursing & Quality NHS Cumbria Clinical Commissioning Group Lonsdale Unit, Penrith Hospital Bridge Lane, Penrith CA11 8HX Tel: (reception desk)

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