NORTHUMBERLAND, TYNE AND WEAR NHS FOUNDATION TRUST BOARD OF DIRECTORS MEETING

Transcription

1 Agenda Item 10 i) NORTHUMBERLAND, TYNE AND WEAR NHS FOUNDATION TRUST Meeting Date: 23 July 2014 BOARD OF DIRECTORS MEETING Title and Author of Paper: Development of a Specialist Forensic Learning Disability Community Transition Team (Replacement of the existing Hebron services)-final Business Case Gail Bayes Group Directors Specialist Care Services Paper for Debate, Decision or Information: Decision Key Points to Note: The attached Business Case relates to the development of a Specialist Forensic Learning Disability Community Transition Team which will support the discharge of patients from the Forensic Learning Disability inpatient services at Northgate Hospital. The development will enable the replacement of the inpatient service currently provided from Hebron on the Northgate site and Hebron will close. Commissioners have now confirmed that they support the proposed development. In the context of giving their support they have however indicated their intention to review all Mental Health Community Services. The proposed development achieves an efficiency of 382K. The workforce changes result in an overall reduction of 26.75WTE. The Business Case has been agreed by all seven local CCG s. The CCG s have also requested a future review of the Trusts Community Learning Disability Services, and this will take place as part of a separate exercise. FIBD have reviewed the Case and recommend to the Board of Directors approval of this Case. The Board of Directors are asked to approve the Business Case relating to the Development of a Specialist Forensic Learning Disability Community Transition Team (Replacement of the existing Hebron services) and the closure of the Hebron unit on the Northgate Hospital site. Outcome required: Approval of Business Case

2 Business Case (BD 208) Transforming Services Development of a Specialist Forensic LD Community Transition Team (Replacement of the existing Hebron service) 2

3 Document Control Purpose of this document The purpose of this document is to present the Business Case for the development of a Specialist Forensic LD Community Transition Team which will support the discharge of patients from the Forensic Learning Disability inpatient services at Northgate Hospital and enable the replacement of the in patient service currently provided from Hebron on the Northgate Hospital site. Version Control Date Version Status Author Update Comments 19 th December 2013 V1.0 Draft H. C. McVittie Prof J Taylor Initial draft for Project Team 3 rd January 2014 V1.1 Draft H.C.McVittie Revised to include Financial Appraisal 7 th January 2014 V1.2 Draft H.C.McVittie Prof J Taylor Revised to include numbers of patients post Winterbourne Review 30th January 2014 V1.3 Draft H.C.McVittie Revised to include impact on commissioner baselines and sections relating to consultation 15 th May 2014 V 1.4 Draft H.C.McVittie Revised to include the outcome of consultation 11 th July 2014 V1.5 Final H.C.McVittie Revised to include Commissioner support 3

4 Document Approval Version Review Committee Date of Assurance/Approval 4

5 1. Introduction 2. Context 2.1 Local 2.2 Commissioners 2.3 National 3. The Case for Change 3.1 Demographics and Prevalence 3.2 The need for improved Care Pathways 3.3 Make best use of available resources 3.4 Recommendations from Transforming Care: A national response to Winterbourne View Hospital (2012) 3.5 Estate issues 4. The Proposal 4.1 Overview of Service Model 5. The Improved Service Pathway, Quality and Outcomes 6. Affordability 6.1 Revenue Impact 6.2 Impact on the Health and Social Care Economy 6.3 Estate/IMT Implications 7. Consultation 7.1 Public 7.2 Staff 7.3 Commissioners 7.4 Equality and Diversity Impact Assessment 5

6 8. Project Management Arrangements 8.1 Project Implementation Team 8.2 Timetable 9. Recommendation 10. Approvals 6

7 Appendices Appendix 1 Financial Appraisal Appendix 2 Equality and Diversity Impact Assessment 7

8 1. Introduction The purpose of this Business Case is to present the proposal for the development of a Specialist Forensic LD Community Transition Team which will support the discharge of patients from the Forensic Learning Disability inpatient services at Northgate Hospital and enable the replacement of the in patient service currently provided from Hebron on the Northgate Hospital site. This development forms an integral part of the Trust s Transformation of Specialist Services Programme. This proposal will provide an improved Service Model which better supports those who have undergone their treatment programmes within the Forensic Learning Disability inpatient services at Northgate Hospital and require support over a sustained transitional period enabling their successful discharge into the community. The proposed Service Model is in line with the national Good Practice Guidance, Commissioning Specialist Adult Learning Disability Health Services (DOH 2007) which highlights the critical components of specialist learning disability services together with the recommendations of Transforming Care: A national response to Winterbourne View Hospital (2012). The proposal has been developed in the context of the national QIPP agenda and the need to improve quality whilst reducing costs. This development forms an integral part of the Specialist Care Group s plans to improve specialist services for people with learning disabilities who have offended or display offending type behaviour, in line with national strategies and best practice and the proposals are consistent with the Trust s Transforming Services Programme and Service Model Review. 2. Context 2.1 Local The local context is viewed from the perspective of the Trust, the Service and Commissioners The Trust This Business Case has been developed in the context of the Service Model Review (SMR) which was undertaken by the Trust in 2010 and which has been broadly supported by stakeholders including Commissioners, GP s, Service Users, Carers and partner agencies including the former Strategic Health Authority, and Local Authorities. The SMR is based on a whole system service redesign approach and it shapes the strategic direction of the Trust over the next 5 years and it is integral to the Trust s Integrated Business Plan (IBP) for the period up to 2017/18. 8

9 The SMR supports the Trust as it faces and responds to the Quality, Innovation, Productivity and Prevention (QIPP) challenge of continuing to improve quality whilst substantially reducing its cost base by 20% over 5 years. A key element of the SMR in the context of this Business Case is a recommendation that the Trust should have fewer but better resourced inpatient facilities as part of an integrated whole system approach to service provision with new capacity and capability in community services (both in the Trust and partner organisations) delivered and aligned with the reconfiguration of inpatient capacity. This recommendation is being taken forward as part of the Trust s Transforming Services initiative and includes the proposal covered by this Business Case. The principal driver for change is to improve the quality of the services being provided whilst meeting the QIPP challenge faced by the Trust. The Trust will broadly do this in line with recommendations for service redesign proposed in the SMR. The service redesign is also centred around Care Pathways and Packages. This approach is mandated by the Department of Health and is endorsed by the Trust. It is designed to ensure that service users consistently receive the right service, at the right time and in the right place: depending on the nature of the problem, the level of complexity, the urgency and the risk Existing Forensic Learning Disability Adult Inpatient Services The Trust currently provides the following Forensic Learning Disability (LD) Adult Inpatient Services, as a part of its Specialist Care Services portfolio. Table 1: Existing Forensic Learning Disability Adult Inpatient Services Service Inpatient Beds Description Kenneth Day Unit 30 Medium Secure Unit for men with 4 wards offering a comprehensive multi disciplinary treatment programme for offenders with a learning disability. Tweed (Villa 5) Alnwick (Villa 14) 26 Low secure unit divided into 3 flats providing assessment and treatment to men who have a learning disability and who either have offending type behaviour and pose a significant danger to themselves or the public. 18 Locked rehabilitation unit divided into 2 flats providing longer term ongoing treatment and rehabilitation services for men who have a learning disability who have either offended or displayed offending type behaviour. Tyne 24 Locked rehabilitation unit for men who typically have complex needs and a longer term care pathway.the multi disciplinary team provide rehabilitation and treatment to those whose pathways have proven difficult. 9

10 Service Inpatient Beds Description Hebron (Villa 10) Longhirst (Villa 15) 20 Locked rehabilitation unit for men with a learning disability who have received treatment within the Trust s LD Forensic Services and are deemed suitable for discharge in an agreed timescale. 18 Low secure unit for women with learning disabilities who require specialised services for offending behaviour and acute behaviour disorders. The unit consists of 2 self contained flats and provides assessment, treatment and rehabilitation. Patients admitted to these services are almost always detained under criminal and civil sections of the Mental Health Act 1983 and most have a primary diagnosis of learning disability. Under the Act people with learning disabilities cannot be detained in hospital unless they also exhibit abnormally aggressive or seriously irresponsible behaviour that risks the safety of the patient or others. A significant minority of detained patients have section 41 restriction orders applied. Over 50% of patients in this service have co-morbid mental disorders, chiefly psychoses, affective and personality disorders. A proportion of the patient population (around 10%) have pervasive developmental disorders, most notably autistic spectrum disorders. Challenging behaviour, most often in the form of violence, sexual aggression and firesetting is a pre-admission feature of the majority of admissions. Following admission approximately 50% are physically violent towards others; and almost three quarters of these violent patients have carried two or more physical assaults post-admission Existing Forensic Learning Disability Community Services The Trust provides a Community Outreach Clinic to those people living in Cumbria, Sunderland and Newcastle with a learning disability who have offended or show offending type behaviour(s) and those involved in caring for them the opportunity to seek advice and support on managing day to day forensic issues Existing Community Learning Disability Services Community Learning Disability services in Newcastle are provided by the Trust. Northumbria Healthcare NHS Foundation Trust provide Community LD services in North Tyneside and Northumberland. The Trust provides Community Learning Disability services in Sunderland (the Sunderland Community Treatment Team whilst Gateshead and South Tyneside Community Learning Disability Teams are provided by the South Tyneside NHS Foundation Trust. 10

11 2.1.5 The Hebron Inpatient Service Hebron is a 20 bed male locked rehabilitation ward located on the Northgate Hospital Site. The ward provides specialist treatment and rehabilitation for men with a learning disability who have offended or display offending type behaviours. The primary functions of the ward are: To habilitate/rehabilitate patients who have completed active treatment programmes within the Forensic Inpatient Services on the Northgate Hospital site (Table 1 ); To provide a step-up service for those patients who have been discharged from Hebron but whose community placements have failed and require additional support for a defined period. The services provided by Hebron were previously commissioned by the North of Tyne PCT, but are now commissioned by local CCGs. Services are partially commissioned via a block contract (71%), and the remainder via cost and volume (29%). This Business Case relates to the block contract ( 1.6m income) element of this service. 2.2 Commissioners The local strategies and commissioning intentions of the Clinical Commissioning Groups North and South of Tyne together with their relevance to this Business Case are summarised as follows: Newcastle West - Improving access, quality and outcomes for people with mental health and learning disabilities; For learning disabilities and this proposal in particular, the CCG are committed to implementing the national recommendations from Transforming Care: A national response to Winterbourne View Review Concordat (2012). Newcastle North and East - Improve prevention and wellbeing for all residents of Newcastle; For learning disabilities and this proposal in particular, the CCG are committed to implementing the national recommendations from Transforming Care: A national response to Winterbourne View Review Concordat (2012) together with a whole system transformational programme relating to adult mental health services with the aim of reducing the reliance on hospital services including reducing readmissions through supported discharge 11

12 North Tyneside - Promoting self-care and care planning; For learning disabilities and this proposal in particular, the CCG are committed to developing an action plan with the Local Authority for high quality care and support services for people who have a learning disability, autism or condition that challenges NHS funded care; incorporating key recommendations from the Winterbourne View Review Concordat. Northumberland - Ensure all commissioned services meet the needs of people with learning disabilities; For this proposal in particular, improve identification of, and support to those with learning disability and commissioned care packages appropriate to the needs of the individual. Sunderland - Achieve an integrated tiered approach to mental health across the whole healthcare system; For this proposal in particular, improve community mental health pathways for all conditions and implement the national recommendations from Transforming Care: A national response to Winterbourne View Review Concordat (2012). South Tyneside - Personalised care plans in mental health based on a stepped care approach with timely access to services; The CCG are also committed to continuing to work with NTW to realise planned efficiencies and support service development. Gateshead - Develop a fully integrated model of mental healthcare underpinned by robust whole population Emotional Health and Wellbeing Strategies; including redesigning specialist services. The CCG are also committed to continuing to work with NTW to realise planned efficiencies and support service development. 12

13 2.3 National Key points to note with regard to the National Policy and Guidance relating to the provision of specialist services for people with learning disabilities are as follows: Commissioning Specialist Adult Learning Disability Health Services-Good Practice Guidance 2007 (updated 2009) The Good Practice Guidance was issued in the light of growing concerns that some areas in the country were finding it difficult to develop commissioning strategies for specialist adult learning disability health services that reflected both current policy and best practice. This had led to outdated service models, the poor development of a community infrastructure and an over reliance on bed based services together with the following associated problems: People with learning disabilities getting stuck in the NHS system or independent health placements often for many years and sometimes many miles from their home and/or; People are often placed in increasingly expensive and inappropriate social care that fail to meet their needs; Both family carers and paid carers receiving inadequate support and training by specialist healthcare staff, resulting in an increased demand for health interventions at a later date. The Good Practice Guidance highlighted that an important component of specialist learning disability health services is that of services that support people who offend or are at risk of offending and that Commissioners have a responsibility to ensure that the principles set out in the Reed report (1992)are met. These include: Services should be designed with regard to the quality of care and proper attention to the needs of individuals; As far as possible in the community rather than institutional settings; Under conditions of no greater security than is justified by the degree of danger they present to themselves and others; In such a way as to maximise rehabilitation and their chances of sustaining an independent life; As near as possible to their homes and families, if they have them. The Guidance confirms that such services may include a specialist team, along with access to appropriate locally based services where and when necessary. 13

14 Valuing People: a new strategy for learning disability for the 21st century-a White Paper (2001) This was the first White Paper on Learning Disability for thirty years and set out an ambitious and challenging programme of action for improving services. In terms of specific objectives the Strategy included the following objectives: Objective 5-Good Health, enabling people with learning disabilities to access a health service designed around their individual needs, with fast and convenient care delivered to a consistently high standard, and with additional support where necessary; Objective 9-Quality,ensuring all agencies commission and provide high quality, evidence based and continuously improving services which promote both good outcomes and best values; Objective 10-Workforce Training and Planning, ensuring that social and healthcare staff working with people with learning disabilities are appropriately skilled, trained and qualified, and to promote a better understanding of the needs of people with learning disabilities across the wider workforce; Objective 11-Partnership Working, promoting holistic services for people with learning disabilities through effective partnership working between all relevant local agencies in the commissioning and delivery of services. Valuing People Now: a new strategy for learning disability for the 21st century-a White Paper (2009) Valuing People Now set out the Government s strategy for people with learning disabilities for the subsequent three years following consultation, including the response to the main recommendations in Healthcare for All (2008). The strategy set out key cross-government commitments and action to set the environment to enable change to happen, and summarised local and regional actions, based on good practice to grow capacity and capability for local delivery. Transforming Care: A national response to Winterbourne View Hospital (2012) This Report presented by the Department of Health in December, 2012 sets out the steps to be taken in response to the failings identified into the inquiry into abuse at Winterbourne View, an assessment and treatment unit for people with learning disabilities managed by Castlebeck Care. As a provider of learning disability services the Trust shares the national outrage regarding the abuse and failings that took place at Winterbourne View. The Trust s learning disability services, in common with all services across England, have 14

15 subsequently been inspected by the Care Quality Commission (CQC) and the Trust was delighted by the positive reports from the CQC on the quality of the services we provide. The Report recommended that by June 2014 the way services are commissioned and delivered will be transformed to stop people being placed in hospital inappropriately, provide the right model of care, and drive up the quality of care and support for all. With regard to inpatient services the Report recommended that they: Should only admit the most complex patients; Have a short focussed admission pathway; Start discharge planning with appropriate agencies from admission; Follow a positive behaviour support model of care; Ensure that nursing staff are appropriately trained and supervised. People with learning disability and mental health, behavioural or forensic problems: the role of in-patient services (2013) This report was commissioned by the Royal College of Psychiatry as a result of the abuse scandal at Winterbourne View with the aim of informing the debate about the place of specialist inpatient care for people with learning disabilities. The report was published in July 2013 and it sets out the different types of specialist inpatient services that are currently provided together with the sort of difficult and challenging circumstances in which such services can be an appropriate intervention for a person with a learning disability. The report supports whole heartedly the enhancement of community services, particularly those with challenging behaviour and other major mental health needs, however it highlights that even if such improvements do deliver a reduction in the need for beds, a range of specialist inpatient services will still be required. The report also recognises that these specialist inpatient services must of course be of the highest quality. Guidance for Commissioners of Mental Health Services for People with Learning Disabilities (Joint Commissioning Panel for Mental Health, 2013) The Joint Commissioning Panel for Mental Health is a new collaboration co-chaired by the Royal College of General Practitioners and the Royal College of Psychiatrists which brings together leading organisations and individuals with an interest in commissioning for mental health and learning disabilities. This report describes what effective and accessible services look like based on current policy, the law and best practice. This report describes what effective and accessible services look like based on current policy, the law and best practice. Recommendations for inpatient learning disability services include: Appropriate inpatient and community services should be accessible to people with learning disabilities where possible Care pathways should span community services and the different types of inpatient beds Community services should work to reduce the numbers of people in inpatient beds and reduce stay to a minimum Inpatient services should be subject to monitoring, inspection, audit of quality including effectiveness, safety and patient experience 15

16 The skills of local provider services should be developed so that they can more effectively support people in the community, and do not need to rely on inpatient care as the only alternative. 3. The Case for Change 3.1 Demographics and Prevalence The table below shows the current working age adult population across North and South of Tyne. Table 2: Working Age Adult Population across North and South of Tyne Locality Working Age Adult Population (18-65) North of Tyne 511,382 Northumberland and North Tyneside Newcastle South of Tyne 396,364 Gateshead South Tyneside Sunderland Total 907,746 Public Health England ( advise that the various studies of Professors Eric Emerson and Chris Hatton showed that approximately twenty people in every thousand have a learning disability with 4.6 of these being likely to be known to local health and social services. But these numbers vary with age.using the most recent population estimates, Public Health England calculate the expected numbers of people in each local authority area with a learning disability in North and South of Tyne are as shown in the table below. Table 3: Number of people with a learning disability in the localities North and South of Tyne Locality Total Population Number known to services Likely true number North of Tyne Northumberland and North Tyneside 792,600 3,607 16,081 Newcastle South of Tyne Gateshead 624,800 2,841 12,638 South Tyneside Sunderland Total 1,417,400 6,448 28,719 16

17 The Laing and Buisson Report, Mental Health and Specialist Care Services UK Market Report (2012) identifies the main factors which might lead to changes in demand for LD services in the future. These are shown in the table below: Table 4: Factors influencing the demand for learning disability services Factor tending to increase demand Factors tending to decrease in demand 1. Population change, which is projected to increase demand by 1% per annum and raise the age profile of service users, more of whom are surviving to old age. 2. Increasing inability of parents to provide informal care, which may cause latent demand to be expressed more vigorously, especially amongst older parents and single parents, the numbers of whom have increased dramatically. 1. Pre-birth screening, which may lead to a lower incidence of learning disabilities at birth. 2. Constrained public funding, which may lead to more restrictive local authority eligibility criteria and may limit the number of people with learning disabilities who can secure access to services in the future. 3. Medical interventions around birth, which may on balance increase the number and proportion of service users with lifelong severe learning and/or physical disabilities, plus higher rates of abnormalities resulting from women delaying births to a later age. During , there was a total of 27,855 admissions to NHS facilities (including high security hospitals) under the Mental Health Act 1983 (The Information Centre, October 2012). Of the 26,304 detentions under civil sections of the act during this period, just 0.8% were categorised as learning disability. However, of the 1,444 criminal detentions during the corresponding period, 5.9% were categorised as learning disability. Given that the proportion of people in the general population with learning disability (IQ scores under 70) is approximately 2.5%, it appears that more than double the expected number of people with learning disabilities are being detained in NHS facilities under MHA 1983 due to offending or offending-type behaviour. This is despite the evidence that people with learning disabilities commit more crime than people in the general population being highly equivocal. Furthermore, the median length of stay in inpatient services is five times greater for men with learning disabilities and 11 times greater for women with learning disabilities than for non-learning disabled inpatients (CQC, April 2011). In terms of the Forensic Learning Disability inpatient services at Northgate Hospital over a 4-year period ( ) there was an average of 29 admissions per year (range: 24-38) and an average of 30 discharges per year (range: 19-42). Admissions and discharges over a 5-year period (up to the end of 2013) for the local CCGs (Newcastle, Northumberland, North Tyneside, Gateshead, South Tyneside and Sunderland) and for the Newcastle Gateshead Alliance CCGs were as follows:. 17

18 5-Year Admission Data (Jan 2009-Dec 2013) Locality CCGs Total = 92 patients 5-Year Discharge Data (Jan 2009-Dec 2013) Locality CCGs Total = 94 patients Note. None of the Newcastle patients discharged during this period were discharged to the Newcastle area due to suitable services being unavailable to manage their needs/risks. 3.2 The need for improved Care Pathways The Trust, working with Commissioners, has made significant progress in terms of responding to the recommendations relating to the improvement of services for people with learning disabilities outlined in the national reports (Section 2.3 above) including: Completion of the resettlement programme enabling those living in long stay hospitals, including Northgate and Prudhoe Hospitals to move to more appropriate accommodation in the community; Progressing the transfer of all of the Trust s adult LD residential care services to alternative providers; The provision of a comprehensive programme of person centred planning and awareness for staff; The implementation of Health Checks/Health Action Plans; Investment in the Trust s specialist assessment and treatment services in particular the development of Rose Lodge, a 6m Assessment and Treatment Centre in Hebburn for those with a learning disability primarily living in Gateshead, South Tyneside and Sunderland which opened in October, 2009; Investment in a Community Outreach Clinic to those people living in Cumbria, Sunderland and Newcastle with a learning disability who have offended or show offending type behaviour(s) and those involved in caring for them the opportunity to seek advice and support on managing day to day forensic issues; Investment in the development of the Tyne Unit on the Northgate Hospital site which opened in 2013, a 24 bed purpose built locked rehabilitation unit for men who typically have complex needs and a longer term care pathway; In common with all of the Trust s services the emphasis in specialist forensic learning disability services continues to be on improving care pathways, in line with 18

19 Principal Community Pathways,including improving clinical interventions and supporting more timely and effective step down into the community thereby reducing lengths of stay and the need for inpatient rehabilitation services for those patients that have completed active treatment. This approach is consistent with CCG Strategies, the recommendations from Commissioning Specialist Adult Learning Disability Health Services-Good Practice Guidance 2007 (updated 2009) and Transforming Care: A national response to Winterbourne View Hospital (2012). The Forensic Learning Disability inpatient services at Northgate Hospital provides services for up to 135 patients in 9 ward areas in varying levels of security. Tables 5 and 6 below shows a forecast of the patients within the current population whose care is commissioned by local CCGs and who may be potentially ready for discharge into local communities within the next 2 years. Table 5: Forecast of the patients within the current population who may be potentially ready for discharge into local communities within the next 2 yearsby CCG Area CCG Number Northumberland 6 North Tyneside 5 Newcastle (Overall) 12 Gateshead 2 Sunderland 8 Total 33 Table 6: Forecast of the patients within the current population who may be potentially ready for discharge into local communities within the next 2 yearsby current ward placement Ward Number Kenneth Day Unit 1 Tweed 7 Tyne 1 Longhirst 6 Alnwick 12 Hebron 6 Total 33 19

20 Due to changes in the characteristics of patients referred and admitted to the specialist forensic Learning Disability services at Northgate over the last 4-5 years (increasing clinical complexity and higher risk profiles), along with financial pressures on all parts of the health and social care economies, and a changing legislative context (e.g. DoLS issues) it is becoming increasingly difficult to discharge these patients from hospital. At the same time the CQC and Commissioners have given guidance on reductions in the length of stay in hospital for people with learning disabilities which is being monitored nationally. The Trust s specialist learning disability forensic services have over the last two years successfully tested out a model on half of the patients within Alnwick Unit,a locked rehabilitation unit at Northgate Hospital, involving the provision of intensive support to better support individuals through the transition to achieve a timely and successful discharge. Through the application of this model 9 individuals with complex needs have been successfully discharged compared to no successful discharges in the remaining half of the patients where the model was not applied. The testing out of the above model has demonstrated that the provision of a period of intensive support to those who have completed their treatment programmes within hospital enables individuals who are detained to be discharged in a timely way back into the community, reducing lengths of stay and the need for prolonged periods of time within costly inpatient rehabilitation services. There is therefore a demonstrable need for improvements in the forensic learning disability pathway to include a period of intensive support for those who have completed their treatment as an integral part of rehabilitation services. 3.3 Make best use of available resources Activity Commissioners and the Trust have a responsibility to ensure that NHS resources are deployed to best effect. The key challenge facing the Trust over the next five years is to improve quality whilst reducing costs by as much as 20%. This requires a different way of thinking about how services are provided and, in some cases, a radically different way of providing services. As shown in the graph below occupancy rates on Hebron have fallen from 75% in April 2011 to 45% in October As at the beginning of 2014 the 20 bedded unit had only 9 patients. 20

21 Table 7: Occupancy of Hebron April 2011 to October 2013 Hebron Bed Occupancy % April Oct % 80% 70% 60% 50% 40% 30% 20% 10% 0% Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 The downward trend in occupancy can be largely attributed to the following factors: As a result of improved clinical interventions some patients are now able to be discharged directly from other units earlier in the forensic learning disability patient pathway. This has resulted in a reduced length of stay and less need for inpatient rehabilitation services for these patients. Patient clinical profiles have changed in recent years so that there are fewer lower risk and relatively higher functioning patients coming through the pathway who previously benefited from the fast-track rehabilitation service provided by Hebron. Significant resources are currently being used to support the provision of the service currently provided from Hebron which, as illustrated above, is now operating at only 45% occupancy and given the success of the intensive support model tested in Alnwick Unit the service believes that the provision of a Specialist Forensic Learning Disability Community Transition Team could not only replace the existing Hebron inpatient service but also result in significant benefits to patients and achieve efficiencies, contributing to the national QIPP agenda and the need to improve quality whilst reducing costs. 3.4 Recommendations from Transforming Care: A national response to Winterbourne View Hospital (2012) A central part of the Concordat plan of action outlined in the above Report requires health and care partners to: 21

22 Review all current placements, and support everyone inappropriately in hospital to move to community-based support; In parallel, put in place a locally agreed joint plan to ensure high quality care and support services for all people with challenging behaviour that accord with the right model of care from childhood onwards;and Give national leadership and support for local change. All current placements on the Northgate Hospital site have now been assessed and as at December 2013 one Hebron patient has been identified for post-winterbourne Review community resettlement; whilst 7 more patients have been assessed as requiring Section 117 aftercare in forensically informed community support services. Thus improved discharge pathways are required to promote more timely and effective discharge into the community thereby reducing lengths of stay for those patients who have completed active treatment. 3.5 Estate Issues Historically as a building Hebron has undergone a number of minor physical adjustments to meet the changing needs of the patient population residing there. The Trust are expected to provide forensic services of a high standard using the following security parameters (i)physical,(ii)relational, and (iii) procedural. It is not feasible or cost effective to do this without creating risks or compromising the service provided as Hebron no longer meets the needs of the patient group receiving treatment via the habilitation pathway. Currently a highly skilled staff team is able to use its skills in relational and procedural security to provide the appropriate care to patients. However, the physical state and layout of the building affects patient care in the following ways: It is a two-storey building which can make patient observation difficult; Staff do not always have clear lines of sight of patients and this can prevent the effective use of an alarm system; There are two staircases which creates risks and means some patients have to reside downstairs regardless of clinical need; The downstairs flat dayroom is too small for the number of patients, and; The clinical rooms are within the main part of the building and not in an area accessible only by staff. Taken together these issues adversely affect the delivery of high quality care and treatment to patients. 22

23 4. The Proposal 4.1 Overview of Service Model It is proposed to re-provide the block contract component of Hebron with a Forensic Learning Disability Community Transition Team (the Team). The Team will re-provide the Hebron service by offering a package that comprises two distinct but overlapping and interlinked components to develop, support and expedite the plans for patients who have been identified for discharge from the Forensic Learning Disability inpatient services at Northgate Hospital described in above. The components of the service would include: i. In-Reach Service. This would be a pre-discharge service that works with the locked rehabilitation villa clinical teams on the Northgate Hospital site (Tweed Unit, Tyne Unit, Alnwick and Longhirst) to develop forensically informed community service specifications, care plans and transition plans for patients on a discharge pathway. Using an established protocol the Team will convene, coordinate and administer predischarge planning meetings involving the hospital Clinical Team, Care Manager, Health Commissioner, Local Community Team/Care Coordinator, patient representatives (IMHA and Solicitor), and putative community service providers to ensure that agreed discharge plans are progressing in a timely manner. The Team will prepare and facilitate risk management workshops for stakeholder groups (e.g. Community Team members, support service providers, day service providers) as a key element of this process. ii. Outreach Service. During the initial period following discharge from hospital, this postdischarge service will provide oversight, consultancy and advice to Community Learning Disability Teams (including the designated Community Care Coordinator and local Responsible Clinician (RC)), Care Managers and service providers (support services and day services/work/education providers) on the treatment and management of offender patients. It is anticipated that most patients discharged from hospital will be subject to supervised Community Treatment Order or conditional discharge and thus liable to recall to hospital if conditions are breached or the risks to self and/or others increase to unacceptable levels. Recall is most likely to occur during the first 3-6 months following hospital discharge. Thus, depending on the patients primary needs Responsible Clinician cover will routinely be provided by the Team s Consultant Psychologist or Consultant Psychiatrist during this post-discharge transition period. Once the patient is judged to have settled in their community placement RC responsibilities will be transferred to the designated local RC. It is anticipated that the Team will be involved in each component of the process (inreach and outreach) for between 3-6 months, depending on the needs of individual patients. That is, on average the Team will be involved with each eligible patient for between 6-12 months in order to support their movement from hospital to community living in an efficient and effective manner. 23

24 4.2 The Geographical Coverage and Team Base The Team will provide services to Northgate Hospital forensic services patients who are the responsibility of the CCGs/Local Authorities covered by the Trust (Northumberland, Newcastle, North Tyneside, South Tyneside, Gateshead and Sunderland). It is proposed that the Team will be based on the Northgate Hospital site but will have a satellite office at Monkwearmouth Hospital,in Sunderland, from which it will support South of Tyne patients and the Community Teams working with them. 4.3 Caseloads Service level data indicates that in recent years around North and South of Tyne patients per annum have been admitted to forensic learning disability services at Northgate Hospital; and around the same numbers are discharged each year. On this basis it is anticipated that the Team will be actively working with between 20 and 25 patients at any time. 4.4 The Staff Team In order to maximise the opportunities for patients to be successfully discharged, rehabilitated and integrated into supported community living arrangements, a multidisciplinary team with a range of specialist skills, leadership qualities and experience of inpatient and community forensic service provision is required. Given the projected caseload and the responsibilities of Team the following skill mix is proposed: Table 8: Proposed Staff Team Post WTE AfC Band/Grade MEDICAL Consultant Psychiatrist 0.3 N/A Speciality Doctor 0.5 N/A AHP Consultant Clinical Psychologist 0.5 8c Clinical Psychologist 1.0 8a Senior Occupational Therapist Assistant Psychologist NURSING Registered Nurse (RNLD) 1.0 8a Registered Nurse (RNLD) Support Workers ADMINISTRATION Secretary/Administrator MANAGEMENT Management Total WTE 24

25 5. The improved Service Pathway, Quality and Outcomes The table below shows a summary of the overall positive quality impacts of the proposal. Table 9: Positive quality impacts of the proposal Positive Quality Impact Higher quality services with patients being pulled through the system resulting in shorter periods of detention in hospital (consistent with Commissioner targets, CQC standards, Winterbourne review recommendations and the Mental Health Act Code of Practice least restriction principle). Patients receiving care and treatment closer to their homes and families. The forensic learning disability pathway would be more closely aligned to patient s needs and consistent with the Principal Community Pathway model. Community Teams and services will receive specialist consultancy, support and advice that will result in those Teams/services increasing their knowledge, skills and confidence in managing these and similar patients in future. More timely/shorter discharge process reducing the cost of double payments by the responsible Local Authorities and CCGs during the transition period-to the benefit of the health and social care community. Closure of the Hebron inpatient unit Measures Reduced length of stay Improved Outcomes-more effective discharges Reduction in number of readmissions Patient/Carer Satisfaction Positive feedback from Commissioners and CQC Improved Outcomes Patient/Carer Satisfaction Improved Outcomes Patient/Carer Satisfaction Positive feedback from Commissioners and CQC Improved Outcomes Patient/Carer Satisfaction Positive feedback from Commissioners and CQC Reduced length of stay Improved Outcomes-more effective discharges Reduction in number of readmissions Patient/Carer Satisfaction Positive feedback from Commissioners and CQC Positive benefits to the health and social care community Vacation of a building that is increasingly becoming not fit for purpose 25

26 The table below shows a summary the potential risks associated with the proposal. Table 10: Potential risks Potential risks Agreement required with all affected CCGs regarding the proposal and recurrent funding Difficulties recruiting staff to key posts with the relevant skills Measures Approval of Business Case by all CCGs Appointment to key posts Management/Mitigation Effective consultation and engagement process Promotion of the new service as development opportunity/good service to work in. 6. Affordability 6.1 Revenue Impact The table below summarises the revenue implications of the proposal. A detailed finance schedule can be found in Appendix 2. Table 11: Revenue Implications of the proposal - Revenue Existing Proposal Efficiencies Consequences WTE 000 WTE 000 WTE 000 Income -2,315-1, * Direct Costs , Indirect Costs Overheads Surplus *Adjustment made for financial delivery to income position The proposal achieves an efficiency of 382K 26

27 The workforce implications of the proposal have been modelled and these are shown in the table below. Table 12: Implications for the Workforce - Staff Existing Services WTE Proposed Service WTE Difference WTE Medical Nursing AHP Day Services 7.34 nil Administration Management Total Staff The workforce changes result in an overall reduction of WTE and this reduction will be managed by the Trust through the Transitional Employment and Development Approach (TED) which has been established to support staff redeployment. The TED Approach aims to provide training and development where required to assist an individual in moving to a new job, provide additional employment experiences and opportunities to develop new skills and keep people in meaningful employment. 6.2 The impact on the Health and Social Care economy 6.2.1Impact on Commissioner Baselines The current income level for Hebron Unit is shown in the table below. Table 13:Existing SLAs Existing SLAs CCG Plan Activity Newcastle N&E CCG Block OBD ,774 Newcastle West CCG Block OBD ,199 North Tyneside CCG Block OBD ,575 Northumberland CCG Block OBD 1, ,450 Gateshead CCG Block OBD ,017 South Tyneside CCG Block OBD ,941 Sunderland CCG Block OBD ,747 Sub total SLA Hebron North & South CCGs 4,689 1,653,703 27

28 Durham Dales Easington & Sedgefield CCG Block OBD 78 27,671 North Durham CCG Block OBD ,118 Non ed Activity Target Block OBD 1, ,304 Total SLA Hebron 6,570 2,314,796 The Trust as part of the national QIPP agenda has an implied efficiency expectation within the annual contract adjustment. The service change proposed in this Business case affects all North, South and 2 Durham CCGs. The expected QIPP savings for Newcastle North & East CCG are 705,463, for Newcastle West CCG are 733,710 for North Tyneside CCG are 549,485, for Northumberland CCG are 1,672,007, for Gateshead CCG are 756,701, for South Tyneside CCG are 842,963, for Sunderland CCG are 2,012,291, for Durham Dales, Easington & Sedgefield (DDES) CCG are 62,857 and for North Durham are 37,737. The proposed change would deliver a contribution of 31,159 towards Newcastle North & East CCG s target, 32,382 towards Newcastle West CCG s target, 43,149 towards North Tyneside CCG s target, 132,629 towards Northumberland CCG s target, 12,480 towards Gateshead CCG s target, 55,874 towards South Tyneside CCG s target, 74,798 towards Sunderland CCG s target, 27,671 towards DDES CCG s target and would exceed North Durham CCG s target. This is based on total efficiency savings of 382,471 for North and South CCGs and disinvestment of 70,789 for Durham CCGs. The following tables show the total existing SLAs and the proposed SLAs. Table 14:Existing SLAs and Proposed SLAs Existing SLAs Newcastle N&E CCG Plan Activity Hebron Villa 10 Block OBD ,774 All other services Various Various 21,108,745 Unidentified QIPP - 705,463 Total SLA ,538,056 Newcastle West CCG Plan Activity Hebron Villa 10 Block OBD ,199 All other services Various Various 21,961,302 Unidentified QIPP - 733,710 Total SLA ,367,791 North Tyneside CCG Plan Activity Hebron Villa 10 Block OBD ,575 All other services Various Various 19,094,496 28

29 Unidentified QIPP - 549,485 Total SLA ,731,586 Northumberland CCG Plan Activity Hebron Villa 10 Block OBD 1, ,450 All other services Block OBD 48,406,122 Unidentified QIPP - 1,672,007 Total SLA 1,626 47,306,565 Gateshead CCG Plan Activity Hebron Villa 10 Block OBD ,017 All other services Various Various 19,374,288 Unidentified QIPP - 756,701 Total SLA ,671,604 South Tyneside CCG Plan Activity Hebron Villa 10 Block OBD ,941 All other services Various Various 21,401,142 Unidentified QIPP - 842,963 Total SLA ,800,120 Sunderland CCG Plan Activity Hebron Villa 10 Block OBD ,747 All other services Various Various 51,341,828 Unidentified QIPP - 2,012,291 Total SLA ,653,284 Durham Dales Easington & Sedgefield CCG Plan Activity Hebron Villa 10 C&V OBD 78 27,671 All other services Various Various 1,586,175 Unidentified QIPP - 62,857 Total SLA 78 1,550,989 North Durham Plan Activity Hebron Villa 10 C&V OBD ,118 All other services Various Various 925,777 29

30 Unidentified QIPP - 37,737 Total SLA ,158 NCA Plan Activity Hebron Villa 10 NCA/CpC OBD 1, ,304 All other services Various Various Unidentified QIPP Total SLA 1, ,304 Proposed SLAs Newcastle N&E CCG Plan Activity LD Forensic Transition Team Block - 103,564 All other services Various Various 21,223,728 Unidentified QIPP - 789,236 Total SLA - 20,538,056 Newcastle West CCG Plan Activity LD Forensic Transition Team Block - 107,630 All other services Various Various 22,126,163 Unidentified QIPP - 866,002 Total SLA - 21,367,791 North Tyneside CCG Plan Activity LD Forensic Transition Team Block - 143,417 All other services Various Various 19,347,301 Unidentified QIPP - 759,132 Total SLA - 18,731,586 Northumberland CCG Plan Activity LD Forensic Transition Team Block - 440,824 All other services Various Various 48,782,927 Unidentified QIPP - 1,917,186 Total SLA - 47,306,565 Gateshead CCG Plan Activity 30