Eastbourne, Hailsham and Seaford CCG Item Number: Formal Governing Body meeting Date of meeting: 13 November /13

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1 Eastbourne, Hailsham and Seaford CCG Item Number: Formal Governing Body meeting Date of meeting: 13 November /13 Title of report: Dementia: Memory Assessment Service update since October Recommendation: The Governing Body is asked to consider the recommendations included in this report, and agree on the re-commissioning of a Memory Assessment Service (MAS) in the EHS CCG locality. Summary: The attached report has been revised by Dr Joerg Bruuns to incorporate the requests of the Governing Body during its review of the previous draft during October 2013 MAS in East Sussex are currently commissioned and delivered as part of an 18 month pilot programme. The evaluation of the pilots should have enabled CCGs to now be in a position to decide which model was preferred for the long term provision of the service. However, as outlined in this paper, currently the evaluation is not considered to be robust enough to enable CCGs to make informed decisions at this stage. Additionally, the current provider of the MAS (MAC Healthcare Plc.) in EHS has given notice that it no longer wishes to provide the service from the end of March 2014 (the original pilot timescale). The Governing Body is asked to note the content of the report and support the recommendations to ensure the timely re-provision of a MAS for the EHS population, pending evaluation of all the pilots and a longer term direction agreed. Board sponsor: Dr Joerg Bruuns, GP Governing Body member and Mental Health Clinical Lead Author: Catherine Ashton, Associate Director of Strategy Date of report: 02/10/13 and Whole Systems Review by other committees: Reviewed at the Joint Commissioning Operational Group (JCOG) on 1 October Health impact: To ensure the availability of memory assessment services to support the early diagnosis of dementia. Financial implications: No direct financial implications as a result of this report. Legal or compliance implications: Safe high quality services support Care Quality Commission (CQC) compliance. Link to key objective and/or assurance framework risk: Improvement in mental health services including care of people with dementia is a key local priority. Patient and public engagement: This is an on-going pilot and engagement will be undertaken as part of the evaluation. Equality impact assessment completed: Yes; as part of original Project Initiation Document (PID) for pilots.

2 Dementia: Memory Assessment Services in East Sussex 1.0 Introduction The National Dementia Strategy Living Well with Dementia identifies three key areas for improvement: Raising awareness and understanding. Early diagnosis and support. Living well with dementia. Seventeen objectives are specified to support the achievement of these, and the provision of memory assessment and diagnostic services is specifically identified as one of the key objectives that will help ensure that the illness is diagnosed early, and that people with dementia and their carers receive the treatment and support that they need. The improvement of services for older people is a key priority for the NHS within East Sussex as population projections show that the local population, which is already older than that of most other areas nationally, is likely to continue to age. Dementia is therefore a key area of concern. The number of older people with dementia is projected to increase by 10% from 9,833 in 2010 to 10,816 by 2015 and by 24% to 13,930 by However, in line with other parts of the country, only approximately one third of people predicted to have dementia in East Sussex are recorded with this diagnosis on GP Quality and Outcomes Framework (QOF) Registers; with the result that early access to treatment and support services is compromised, and presentations often occur late in the progression of the illness and / or in crisis. The specific aims of the memory assessment and diagnostic service is to ensure: Accessibility of dementia assessment and diagnosis services. Dementia is diagnosed early. People with dementia and their carers receive appropriate treatment early in the illness. Effective referral is made to secondary & social care for those who require it. 2.0 Current Services Currently, services for the diagnosis of dementia are provided under identical service specifications by three different providers aligned to each CCG area, all of which were funded from dis-investment from Sussex Partnership Foundation Trust (SPFT) day services. Their different provider-models are being piloted and evaluated whilst in operation, with a view to determining the preferred model for procurement in the longer term. The decision to pilot different provider models was made to allow new market entrants to develop these services; including Primary Care providers doing so under Locally Enhanced Service (LES) contracts. A more traditional tendering approach was felt likely to have resulted in award to a single large provider; and less scope to encourage innovation. The pilot period was set at 18 months, with services and contracts to run from October 2012 to March 2014: High Weald Lewes Havens (HWLH) CCG SPFT. Eastbourne, Hailsham and Seaford (EHS) CCG MAC Healthcare Plc.

3 Hastings and Rother (H&R) CCG Bexhill Consortia of GP practices. The chart below outlines the value of the contract during the 18 month pilot period (which equates to 88k per annum for EHS CCG), and the number of contracted episodes. The income is based on average cost per diagnostic episode weighted for complexity which equates to an average cost of 215 per episode. Locality Value * Episodes Eastbourne Central 25, Eastbourne 64, Seaford 22, Hailsham 19, East Sussex 351,000 1,625 *In respect only of Memory Assessment Service (MAS) / Diagnostic Clinic functions i.e. excludes costs of tests such as scans, Secondary Care diagnostic referrals and prescribed drugs costs; which are in large part also met separately by MAS funding. It was anticipated that during this 18 month period the pilots would: Be set up, establish themselves and deliver a new model of service. See and diagnose a critical mass of patients. Have their relative performance quantitatively and qualitatively evaluated. This would have enabled CCGs to: Reach conclusions and have recommendations approved on preferred provider models. Commence re-procurement processes in October 2013 to allow for re-provision from April Evaluation of the pilots Quantitative information is collected on every referral, and completed diagnostic episode. In addition to basic information such as age and gender, diagnosis made, and actions taken (such as onward referral, prescribing and management planning), detailed operational information is also collected on numbers and location of patient attendances, different functions carried out by medical, nursing and administrative staff, and whether recourse was made for psychiatric or neurological opinion. The aim of collecting this data is to enable a weighted cost per diagnostic episode to be determined for each provider, for correlating with their relative performance on qualitative measures. None of the MAS have been able to operate at contracted levels of capacity, and hence have not been tested in terms of their effectiveness and efficiency in meeting demands at these levels. This has compromised the CCGs ability to quantitatively evaluate providers in terms of, for example, their skill-mix, number of patient attendances, and weighted unit costs per diagnostic episode. The absence of atypical presentations being referred has also made it impossible to evaluate their approach to these patients. It should also be noted that with a lead-in time of six weeks for CT scans, and the dip in activity associated with Christmas and the New Year, it was probably unrealistic to anticipate

4 any diagnostic episodes being completed in the first quarter of services operation between October and December For the period October 2012 June 2013, the table below sets out referral numbers to each MAS, contracted and completed diagnostic episodes, and an indication of performance against contracted capacity, including as adjusted to reflect no episodes possibly being completed in the first quarter of operation. Memory Assessment Services: October 2012 June 2013 Provider Referral Numbers Completed Episodes % of Referrals % of 3x Quarters Contracted MAC % 43% 64% SPFT % 44% 66% Bexhill % 36% 54% % of 2x Quarters Contracted It can be seen that significantly fewer diagnostic episodes have been completed than had been contracted for, due to reasons such as non-actionable referrals and lead-in times inherent in the care pathway, and hence are not available for quantitative analysis. Qualitative measures include patient satisfaction surveys exploring information given prior to and after consultations, whether privacy and dignity was respected, and whether questions were felt able to be asked and were answered. These surveys are given to every patient (or carer) for return in pre-paid envelopes. Patient satisfaction surveys have elicited predominantly positive feedback for all MAS services, although the low return rates achieved inevitably raise issues of statistical validity. Periodic GP satisfaction surveys are the other method for qualitative evaluation, and explore the timeliness in which patients are being seen, and the quality of diagnostic and management information provided on discharge; including about repeat prescribing and ongoing management. Having agreed that GP surveys should not be conducted by MAS providers more often than every six months, the next was not scheduled to take place until October However, given the anticipated subtleties in distinguishing the source and nature of GP opinions, consideration is now being given in any case, to a more focused approach than a simple survey; potentially with external evaluation. 4.0 Update on EHS Pilot Provider MAC Healthcare In mid-september 2013, MAC Healthcare Plc. informed the Mental Health commissioning team that it would not wish to continue providing the MAS in EHS any longer than the 18 month pilot, ending March Considerations for the CCG Governing Body With no provider in place in EHS from 1 April 2014 the following decisions need to be taken. The following issues are presented to the EHS CCG Governing Body for consideration: 5.1 Decision 1:

5 Is there enough information from the evaluation for the CCG to evaluate the pilots? 5.2 Recommendation: The joint Commissioner and CCG Clinical leads do not believe that it has not been possible to reach conclusions and make recommendations on the preferred provider model for MAS services in East Sussex, due to: insufficient diagnostic activity being completed to quantitatively evaluate each pilot site; insufficient distinctions on the source and nature of GP satisfaction with MAS services in each pilot site. 5.3 Decision 2: If the Governing Body supports the recommendation that the pilots do not have sufficient evaluation to enable it to make an informed decision on the preferred provider model for MAS services in EHS, then the Governing Body must decide if it wishes to continue to commission a MAS and how this might be undertaken, before April The table below shows the options available to the Governing Body in order to support a decision about the way forward. Option Action Risk or Issue Option 1. Option 2: Option 3: Option 4: The CCG does not commission a MAS. As the current provider has served notice then this constitutes no action. Existing providers (SPFT in HWLH and Bexhill Consortia of GP practices) to be invited to offer the service in EHS for 12 months from April Re-procurement of services based on existing Service Specifications. Re-procurement of services based on new Service Specifications. This would mean no MAS being provided after March 2014 and the risk that targets for increasing diagnostic rates are not met. There would be some risk that both existing providers may not have the capacity to provide services across the whole EHS CCG area, and some risk that whichever existing provider was not selected, would object. Both of these risks could be mitigated by a robust design and pursuit of the process which has already been developed. This would involve commissioner capacity being dedicated to a six month procurement process, inviting potentially new providers to bid. It is unlikely that this would now be deliverable within the timescales available to ensure that the service is operational from April This would involve CCG Dementia leads and Commissioner capacity being dedicated to reviewing and revising the service specification before embarking on a six month procurement process, inviting potentially new providers to bid, and the risk that this could not be fully and comprehensively completed in time to allow for new services to be operational from April Recommendation: The Governing Body is recommended to approve Option 2, which provides the best opportunity for the CCG to continue to deliver MAS for its population in a timely way. The remaining pilots would then be evaluated in order to enable CCGs to make informed commissioning decisions for 2015.

6 Martin Packwood, Joint Commissioner for Mental Health, East Sussex County Council, and Catherine Ashton, Associate Director of Strategy and Whole Systems Working, EHS CCG and H&R CCG 11 October 2013