Commissioning Case for a Learning Disability Assessment and Treatment Unit. Adam Russell, Joint Commissioning Lead for Learning Disability

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1 TITLE OF REPORT: Commissioning Case for a Learning Disability Assessment and Treatment Unit REPORT PREPARED FOR: REPORT PREPARED BY: Wyre Forest Clinical Commissioning Board Adam Russell, Joint Commissioning Lead for Learning Disability DATE: 6 th December 2011 Introduction Lea Castle Centre, run by Coventry & Warwickshire PCT, closed in 2008, resulting in the absence of suitable local dedicated provision for people with complex learning disabilities needing treatment. As a result, people with learning disabilities requiring assessment and treatment are placed in specialist resources out of county, usually in private hospital settings. These services are generally expensive and geographically distant from the person's home and support network. The numbers of people needing such of services has increased over the last two years and the choice of external providers remains very limited within the Midlands, both within the NHS and the independent sector. Worcestershire itself only has one independent hospital registered to accept patients with a learning disability Castlebeck's Wast Hills service. The recent national problems with Castlebeck Care have exacerbated this situation, removing Worcestershire's main provider from the market for the foreseeable future. Much of the other locked unit / low secure provision regionally are block-purchased by the West Midlands Specialist Commissioning Service. Using external provision creates additional problems as the clinical responsibility for the patient transfers to the provider, rather than remaining integrated within a local patient pathway. During 2009 and 2010, commissioners within Worcestershire (NHS Worcestershire and Worcestershire County Council) identified the need for a local Assessment and Treatment Unit (ATU) to meet the needs of the minority of people with a learning disability who have severe and complex needs that require more specialised service provision. In particular, Valuing People Now (2009), the guidance that continues to frame services for people with learning disabilities, sets out the need for access to specialised support and services close to home for people with complex needs. This was reiterated within the 2009 Mansell report and more recently in a public letter to David Cameron from a range of clinicians, academics, LD organisations, parents and leading professionals, which reiterates the points made by Mansell regarding the last decade of learning disability policy in very clear terms: Page 1 of 5

2 "One element of this is that there is no place for hospitals such as Winterbourne View. Beyond a very small number of beds integrated with other local services for short-term assessment and treatment and a small number of others linked to forensic needs, the provision of learning disability hospitals is wrong." Proposal It has been intended on the basis that this is the remodelling of an existing NHS learning disability service - that the proposed assessment and treatment unit be developed and delivered through the existing partnership with Worcestershire Health and Care NHS Trust. The need for assessment and treatment services to deliver the best possible patient outcomes through being well integrated with existing local services such as social care and specialist learning disability clinical provision remains a key driver in progressing this project. The business case, jointly produced by commissioners and the Trust in August 2010, addresses the capital works required to provide a suitable building via the investment of 1.15 million capital and seeks an investment of 1.11million revenue funding from the joint commissioners for staffing, in order to progress development of a Worcestershire ATU for people with learning disabilities at Osborne Court in Malvern. Following a detailed options appraisal process, involving the joint commissioners, Trust, family carers and people with learning disabilities, the Osborne Courts site was identified as the most suitable. A similarly inclusive process was then followed to develop a detailed specification for the provision of a five-bed assessment & treatment unit, following current NHS best practice and incorporating specific local requirements. This specification forms the basis for: The detailed capital costs prepared by the Trust, although these costs will need to be revised to reflect 2011/12 prices. Page 2 of 5

3 The detailed revenue costings for staff and running costs for a unit with capacity to treat and assess up to five adults with very complex learning disabilities and associated challenging behaviours / dual diagnosis. It is expected that the majority of the patients will be detained under the Mental Health Act 1983 and that many will need to be treated within a locked environment. The rationale for the proposed assessment and treatment unit set out within the business case remains broadly current, although there are some important changes detailed under key issues below. Resources Capital: The Trust has provisionally committed to a capital investment of 1.15 million (at 2010 prices) for the remodelling and equipping of the buildings at Osborne Court to the appropriate specification. It is expected that there will need to be some revision of these costs to reflect 2011/12 prices. Revenue: This is an expensive service to staff and maintain, given the complex needs of the patients and the very small scale of the service itself at only five beds. The agreed business plan sets out the full breakdown of revenue costs, which have been reviewed by PCT finance officers. In-patient beds within a hospital setting are wholly funded via the PCT element of the learning disability aligned budget. Responsibility for managing this budget has been delegated by the joint commissioners to the learning disability Joint Commissioning Lead within the Joint Commissioning Unit. The full annual revenue cost for the service is currently calculated at 1,110,225, which equates to an annual bed rate of 222,045 ( per bed night). If the standard average bed cost of is used as the primary comparator price, it is apparent that the projected Worcestershire ATU price of per bed per night is 16% more expensive. Whilst some of this is directly attributable to lack of economies of scale, there is potential for further reductions in unit costs be negotiated if the project is approved. The average length of stay in external provision is currently 95 weeks against a proposed optimum length of stay of between 18 and 26 weeks. It can be reasonably suggested that local assessment and treatment provision, delivered in partnership with the existing learning disability clinical infrastructure commissioned from the Trust, will reduce length of stay significantly and optimise bed utilisation, leading to lower episode costs per patient. It was originally identified that the full cost of the proposed ATU would be met from re-use of the NHS Campus budget (held within the PCT element of the aligned learning disability budget as part of the S75 joint commissioning arrangements). This is now being used to fund additional expenditure in the external sector due to the increased demand for learning disability in-patient assessment and treatment beds the projected overspend for 2011/12 is 715,000 as of September 2011, leaving a residual budget of 395,727. Page 3 of 5

4 More recently it was planned to repatriate patients from external hospital placements to the ATU, thus redirecting to spend to the ATU budget. However, experience gained during the closure of Castlebeck's services has shown that it is extremely difficult to interrupt clinical treatment and that all but three of the current externally-placed patients have needs that would exceed the level of service provided by the ATU, e.g. need for a secure environment, access to sex offender treatment programmes or the need for a single-sex treatment environment. Currently, given that commissioners cannot achieve 60% reduction in in-patient bed purchasing due to complexity of need and sustained demand, there is no capacity within the pooled budget to resource the revenue costs of the Assessment and Treatment Unit; Commissioners cannot therefore agree the revenue costs without there being a significant financial risk for which no contingency or agreement yet exists. The lead commissioner is therefore seeking an additional 500,000 investment into the learning disability aligned health budget. Assuming that at least two existing externally-placed patients can be repatriated to the ATU and utilising the 395,000 within the current external hospital placement budget, this would enable commissioners to commit the projected 1,110,225 for the proposed project, with some limited contingencies (approx. 10%) to allow for uplift to 2011/12 prices. Background & Context Demand: Currently (November 2011) there are 10* people placed out of area, with a further 4 expected to be transferred to similar services following step-down from semi-secure provision commissioned through a regional top slicing scheme for specialist placements. The number varies slightly depending on demand but has climbed steadily over the last 18 months and now exceeds the planned budget the current low number is thought to be as a result of concentrated discharge / step-down activity linked to Castlebeck. Currently the number of admissions in each three month period usually exceeds the number of discharges. The drivers set out in the original ATU business case, i.e. that the ATU will create a saving on current expenditure and negate the need for external provision is no longer the case, with a number of market and demand changes being apparent and driving the need for additional investment to implement this project. Demand for inpatient beds is increasing, so lack of local capacity is increasing Worcestershire's log-jam and increasing Worcestershire's exposure to external providers. However, review of existing patients indicates that their clinical needs are exceedingly complex and that an ATU might not reduce the need to use external beds or provide capacity to shorten stay. Cost effectiveness: Given the lack of economies of scale in the proposed five-bed scheme, the Trust may wish to revisit the potential for a larger scheme that offers additional beds for sale to adjoining authorities. Herefordshire have expressed interest in such a scheme, given that they experience similar commissioning difficulties as Worcestershire. This would mean reconsidering the site of the ATU for one of the Page 4 of 5

5 previously discarded options such as Church View and would impact of the capital cost. Procurement: All parties involved in the development of the ATU have done so on the basis that the Trust is the preferred provider and that the project is a remodelling of an existing NHS service for this client group. However, in the absence of an open tender, there would need to be rigorous negotiation with the preferred provider regarding the revenue budget to ensure that it maintained some parity with comparable services in the external market (allowing for differences in scale). Length of stay: It is critical that the proposed unit deliver optimised length of stay targets. Early discussions have taken place regarding an incentivised or risk-sharing contract for the scheme further work needs to be done on this, including very clear service specifications and locally agreed protocols about the use of the unit and continued use of out of area placements. Alternatives to a local ATU: In the event that funding is not available for the proposed ATU, it is proposed that commissioners continue to purchase beds from external providers, with work ongoing to identify opportunities for block purchasing and a robust framework for managing risk, costs and length of stay. Recommendation The Clinical Commissioning Group Board is asked to agree a pro rata share of an additional 500,000 of recurrent funding for the Section 75 aligned learning disability health commissioning budget. The amount requested from each Clinical Commissioning Group is in accordance with the equitable share agreement already in place. This will, in addition to resources already identified within existing LD budgets and through repatriation activity, enable the Joint Commissioning Unit to progress the assessment and treatment unit during 2012/13 Page 5 of 5