Part 1 meeting of the Castle Point and Rochford CCG Governing Body held on 26th May Title: Transforming Learning Disability Services in Essex

Transcription

1 Part 1 meeting of the Castle Point and Rochford CCG Governing Body held on 26th May 2016 Agenda item 9 Title: Transforming Learning Disability Services in Essex Submitted by: Prepared by: Status: Kevin McKenny, Director of Integration & Transformation Simon Dickinson, ECC Project Lead For Approval Executive Summary i) Recommendations The Governing Body is asked to approve the Essex Learning Disability Transforming Care Partnership Plan as included in Appendix 1. Note the overarching issues that has been lifted from the above plan and included in the 3 year head line plan in Appendix Two Note the next steps and decisions that will be forthcoming over the next 6 months. ii) Overview Transforming Care is the national programme that forms the continued response to the abuse that took place at Winterbourne View. People with a Learning Disability and/or autism have the right to the same opportunities as anyone else to live satisfying and valued lives, and to be treated with dignity and respect. Whilst society and the system has made great strides, the purpose of the programme is to resolve the continued over-reliance on inpatient care and poor outcomes for a small number of people; most critically this relates to a minority of children, young people and adults with a learning disability and/or autism who may also display behaviour that challenges, including those who may have a mental health condition. The national document confirmed that the local Transforming Care Partnership for Essex should consist of the 7 x CCGs and the 3 x Local Authorities across Essex. The partnership has developed a Programme Steering Board, membership of which is included in Appendix Four. The challenge for the Partnership is to deliver a more community-based, preventative model to re-settle the current cohort, to assure that those children and adults with LD and/or Autism receive the right support to prevent escalation into in-patient episodes, and to ensure they can access the right support within mainstream services to lead the fulfilling lives to which they aspire. 1

2 The Partnership has therefore documented the plan in line with the templates provided and this is included in Appendix One. The Governing Body is asked to approve this plan, which will subsequently be developed into an easy-read version available to the public. iii) Key issues There are a number of key challenges to be resolved. The plan does not provide all the answers but recognises these issues and broadly sets out the journey to identify the solutions. The key issues that exist are set out below: 1. Fragmented Commissioning Arrangements with distinct responsibilities falling to NHS England, the CCGs and the Local Authorities; the challenge is the visibility, planning and care co-ordination for people who may passport between parts of the system as their needs escalate or reduce. 2. The initial review to date has identified a number of potential service gaps. The most critical of these is the need for a Community Forensics capability; this will allow a number of people currently unable to be stepped down from in-patient settings to be discharged into community placements. In addition, there are also potential gaps around the right sort of crash pad / housing accommodation that can act as a step up / step down environment to help some highly complex people manage the transition from an in-patient setting into living in the community. 3. Continuity of care and holistic care planning the complexity of the fragmented commissioning responsibilities can result in disjointed care planning that can increase the risk of breakdown of planned care arrangements. 4. Alongside this complex commissioning environment, the provider and workforce landscape is also highly diverse and fragmented, which can result in poor outcomes for service users where providers do not make the right reasonable adjustments. Across the Partnership there in excess of 1,000 providers currently delivering services to the broadest Learning Disability and Autism cohorts. 5. The expectation of NHS England is that the Partnership works closely to address these and other issues. This has started to raise some issues about the right geographic footprint for contractual and service delivery planning; for example, there is a separately contracted Assessment and Treatment facility in both the North and the South of the region and similarly there are two separate crisis response teams. These issues relate not solely to CCG Geography in that the Transforming Care service model places a very high expectation on very close working between care and health professionals; hence the need to identify where service user requirements and value for money considerations would indicate a Pan Essex or more local footprint for specific services. These questions will be addressed in the coming months with recommendations with clear options expected for decision during the autumn. 6. The current scope of the delivery planning and options analysis is looking exclusively at Adult learning Disability and Autism, although it is fair to say that the work on Autism is slightly less well advanced, but no less critical. The national programme has also set expectations that all Partnership nationally must also review the delivery framework and model for Childrens services. This work has started across Essex, but further progress is expected in the coming months as the complex stakeholder environment becomes better sighted and briefed on the issues. 2

3 Costs Pressures / Implications A Financial review was carried out in advance of the required recent submission to NHSE England. Under the umbrella of the Transforming Care Partnership programme, the Partners currently invest 101.4m per annum. Going forward, there are likely to be short to medium-term cost pressures to the Partnership. The intention is to present a report, with updated costings and the proposed principles and options for how the costs might be shared to the TCP Finance leads meeting on 8 th June 2016 and the Programme Board currently being organised for the following week. The Plan The planning template, attached as Appendix One, is based upon the framework and diagram below provided by NHS England. In real terms this translates into the following broad sections Definition of the current Essex wide system Analysis of current in-patient usage and the case for change Principles and target outcomes / vision Target future model of care Approach to managing the transformation and a headline 3 year planning window that provides a set of target timeframes for implementing a number of the expected changes. In terms of actual delivery, there are three very broad phases of work: Firstly, a review of the pathways and identification of the issues for all of the five cohorts across both children and adults. The target is to complete this by mid-july. It is expected that this will lead to three types of projects both locally and across the Partnership which will be implemented over the subsequent months Secondly, the potential procurement of Specialist LD health capability that could then deliver a sustainable transformation in the system for Adults. The expectation is that this process could start towards the end of the current calendar year Thirdly, planning and implementation of any broader changes as necessary across the services supporting the at risk children population and their families including those going through transitions. iv) Associated papers Building The Right Support published by ADASS and NHSE on Oct

4 Governing Body monitoring information Internal governance Stakeholder and community engagement Resource implications Legal implications NHS Constitution This report supports the following NHS Constitution principles: Equality and diversity implications Further information For further information about this report, please contact: Please ensure all sections are completed. 4

5 Part 1 Meeting of the Castle Point and Rochford CCG Governing Body held on 26th May 2016 Agenda item X Title: Transforming Learning Disability Services in Essex Introduction Transforming Care is the national programme that forms the continued response to the abuse that took place at Winterbourne View. People with a Learning Disability and/or autism have the right to the same opportunities as anyone else to live satisfying and valued lives, and to be treated with dignity and respect. Whilst society and the system has made great strides, the purpose of the programme is to resolve the continued over-reliance on inpatient care and poor outcomes for a small number of people; most critically this relates to a minority of children, young people and adults with a learning disability and/or autism who may also display behaviour that challenges, including those who may have a mental health condition. The document published by ADASS and NHSE on October , called Building The Right Support set out the expected outcomes and the service model that are to be implemented and delivered by March This service model framework is included as appendix Three. In November 2015, NHS England then published the Transforming Care National planning framework, which provided a set of templates to be used to set out the plans for how the Local Partnership will review the current system and implement the service model. The documents also provided further clarification of the expected outcomes, namely Reduced reliance on inpatient services (closing hospital services and strengthening support in the community) to achieve an expected level of CCG commissioned beds and NHS England-commissioned beds (such as those in low, medium or high-secure units) per 1 million population Improved quality of life for people in inpatient and community settings Improved quality of care for people in inpatient and community settings. The document confirmed that the local Transforming Care Partnership should consist of the 7 CCGs and the 3 Local Authorities across Essex. The partnership has developed a Pogramme Steering Board, membership of which is included in Appendix Four. The challenge for the Partnership is therefore to deliver a more community-based, preventative model to re-settle the current cohort, to assure that those children and adults with LD and/or Autism receive the right support to prevent escalation into in-patient episodes, and to ensure they can access the right support within mainstream services to lead the fulfilling lives to which they aspire. 5

6 The Partnership has therefore documented the plan in line with the templates provided and this is included in Appendix One. The board is asked to approve this plan, which will subsequently be developed into an easy-read version available to the public. Current Issues There are a number of key challenges to be resolved. The plan does not provide the answers but recognises these issues and broadly sets out the journey to identify the solutions. The key issues that exist are set out below: 1. Fragmented Commissioning Arrangements with distinct responsibilities falling to NHS England, the CCGs and the Local Authorities; the challenge is the visibility, planning and care co-ordination for people who may passport between parts of the system as their needs escalate or reduce. In simple terms, those responsibilities are as follows a. NHS England commission specialist beds for the most at risk / complex population. Going forward NHS England Specialist Commissioning will continue to commission these beds, but will work more closely with the Essex CCGs and the three Local Authorities b. The CCGS commission both local Assessment and Treatment beds and some spot placements for people who may also need interim or longer-term in-patient care. The current LD Specialist Contracts also include the resources who provide the specialist LD health professionals including LD psychiatrists and LD nurses c. A key element of Transforming Care is also to assure that mainstream Primary and Secondary care, including Mental health, are able to provide the necessary accessibility (sometimes called making the right reasonable adjustments) for all children and adults with Learning Disability and / or Autism. This may require some minor additional / different checks / definitions for the very small number of cases where consideration is necessary about whether the appropriate environment for very specific cases / scenarios is within a mainstream mental health or specialist LD service inpatient setting d. Finally the Local Authorities are responsible for commissioning all other residential, domiciliary, housing, employment support and care services for children and adults with Learning Disability and / or Autism. In delivering the improved outcomes and reduced reliance on in-patient care, there is the need for the right alignment of this capability in the community to the holistic target outcomes for all those who may need that support. 2. The initial review to date has identified a number of potential service gaps. The most critical of these is the need for a Community Forensics capability; this will allow a number of people currently unable to be stepped down from in-patient settings to be discharged into community placements. In addition, there are also potential gaps around the right sort of crash pad / housing accommodation that can act as a step up / step down environment to help some highly complex people manage the transition from an in-patient setting into living in the community. 3. Continuity of care and holistic care planning the complexity of the fragmented commissioning responsibilities can result in disjointed care planning that can increase the risk of breakdown of planned care arrangements. 4. Alongside this complex commissioning environment, the provider and workforce landscape is also highly diverse and fragmented, which can result in poor outcomes for service users where providers do not make the right reasonable 6

7 adjustments. Across the Partnership there in excess of 1,000 providers currently delivering services to the broadest Learning Disability and Autism cohorts. 5. The expectation of NHS England is that the Partnership works closely to address these and other issues. This has started to raise some issues about the right geographic footprint for contractual and service delivery planning; for example, there is a separately contracted Assessment and Treatment facility in both the North and the South of the region and similarly there are two separate crisis response teams. These issues relate not solely to CCG Geography in that the Transforming Care service model places a very high expectation on very close working between care and health professionals; hence the need to identify where service user requirements and value for money considerations would indicate a Pan Essex or more local footprint for specific services. These questions will be addressed in the coming months with recommendations with clear options expected for decision during the autumn. 6. The current scope of the delivery planning and options analysis is looking exclusively at Adult learning Disability and Autism, although it is fair to say that the work on Autism is slightly less well advanced, but no less critical. The national programme has also set expectations that all Partnership nationally must also review the delivery framework and model for Childrens services. This work has started across Essex, but further progress is expected in the coming months as the complex stakeholder environment becomes better sighted and briefed on the issues. Costs Pressures / Implications A Financial review was carried out in advance of the required recent submission to NHSE England. Under the umbrella of the Transforming Care Partnership programme, the Partners currently invest 101.4m per annum. Going forward, there are likely to be short to medium-term cost pressures to the Partnership that are caused by two factors The higher cost of community based care packages. Over the last 2 years, approximately 15 people across the Partnership have been successful discharged into the community. The analysis demonstrates that the costs for these packages are approximately 10% higher than the existing inpatient services that were replaced / discontinued A number of new services which are required to ensure that new demand for inpatient services can be managed effectively to enable the bed complement to be reduced from 73 to 46. The new infrastructure includes Outreach Services, extension of existing Intensive support, Community Forensics and Crisis Accommodation Support. Whilst these will be recurring costs, in the short-term to help deliver the improved outcomes and in recognition of these financial pressures, the Essex Partnership is asking NHS England to fund a number of transformation bids, covering the following sorts of capability: the first 18 months of revenue costs that relate to the services above, some one-off revenue expenditure to support the programme itself a contribution towards the capital cost of new homes in the community. The partnership has indicated to NHS England that these costs would equate to 9.2million split between the short-term revenue and the capital requests. Feedback on these bids is likely to be known during July, however the Partnership is unlikely to be successful in securing the totality of these resources; further modelling is being undertaken to identify some options for how to progress based upon some different assumed levels of funding that might be received. 7

8 Looking beyond the first 18 months, the estimate at this stage is of recurring cost pressures across the Partnership of approximately 3.5million per annum. A further review is being carried out to quality assure the financial model and to seek opportunities to reduce the additional cost burden to NHS England and Essex commissioners. The review will consider the following areas: Costings of new community based care packages (27 in total). New proposed community infrastructure services Capital bid requirements The Impact of Dowry system on individual commissioner contributions. The emerging Dowry rules are designed to facilitate the transfer of resources from commissioners to enable them to fund their Community based care packages. The detail remains insufficient to calculate accurate implications for the Partnership, but there are likely to be some additional pressures that may fall to the Partnership for people discharged from NHS England Specialist Commissioned. The review will also consider the principles for how and where all of these cost pressures should lie across the Partnership; the objective is to align the cost pressures and the financial opportunities to the agencies with the greatest influence in achieving the related outcomes. Thereafter the individual local and individual financial implications will be understood. At the same time, the review will also identify any opportunities to establish compensating savings which could result from re-procurement. These are likely to be found in the following areas: Remaining inpatient services Community based care packages Community Health services The intention is to present a report, with updated costings and the proposed principles and options for how the costs might be shared to the TCP Finance leads meeting on 8 th June 2016 and the Programme Board currently being organised for the following week. The Plan The planning template, attached as Appendix One, is based upon the framework and diagram below provided by NHS England. In real terms this translates into the following broad sections Definition of the current Essex wide system Analysis of current in-patient usage and the case for change Principles and target outcomes / vision Target future model of care 8

9 Approach to managing the transformation and a headline 3 year planning window that provides a set of target timeframes for implementing a number of the expected changes. In terms of actual delivery, there are three very broad phases of work: Firstly, a review of the pathways and identification of the issues for all of the five cohorts across both children and adults. The target is to complete this by mid-july. It is expected that this will lead to three types of projects both locally and across the Partnership which will be implemented over the subsequent months o definition and implementation of the improvements that can be delivered through short-term tactical re-commissioning with current providers o agreement upon and implementation of the necessary actions to deliver the step changes in terms of workforce development, personal health budgets and market management o definition, planning and implementation of the new interim services (prior to any broader procurement) to meet any service gaps like for example the Community forensics pilot Secondly, the potential procurement of Specialist LD health capability that could then deliver a sustainable transformation in the system for Adults. The expectation is that this process could start towards the end of the current calendar year Thirdly, planning and implementation of any broader changes as necessary across the services supporting the at risk children population and their families including those going through transitions. Next Steps The key next steps are: To seek CCG approval to initiate a mini-tender to secure a pilot community forensics service this will be funded by the NHS transformation funding for the first 18 months, at which stage the ongoing service could be included within a reprocurement exercise and would need to be funded locally More detailed modelling of the expected costs to provide better visibility of the forecasts pressures, the principles and options for how these costs might be best managed across the Partnership to encourage / incentivise the right outcomes and options and plans for mitigating the costs across the Partnership Updated submissions to NHS England for transformation funding with expected feedback during July Options and business case for a procurement the scope (geographically and in terms of the service offers / functions) and the options for commissioning and contract management both locally and pan Essex of any shared contracts Completion of the pathway reviews with identified findings targeted for presentation to the Partnership Programme Board in August. Conclusion The Governing Body is asked to approve the Essex Learning Disability Transforming Care Partnership Plan as included in Appendix 1. Note the overarching issues that has been lifted from the above plan as included as Appendix Two Note the next steps and further papers and decisions that will be forthcoming over the next 6 months. 9