REPORT TO BOARD. 14 th October Agenda No Lucie Waters, Director of Commissioning and Planning

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1 REPORT TO BOARD 14 th October 2015 Agenda No. 6.1 Title of Document: Head of Service/: Author: Clinical Lead: Contact details: Learning Disability Services Report Lucie Waters, Director of Commissioning and Planning Lola Triumph, Project Manager Tarlochan Ghale, Strategic Facilitator for Learning Disabilities Dr Farooq Rafique, Clinical Lead for Learning Disabilities Summary: The primary driving force for change and service development over the past ten years has been the Government White Paper, Valuing People: A New Strategy for Learning Disability for the 21 st Century. March The refreshed version Valuing People Now from progress to transformation identified five major priorities personalisation, what people do doing the day, better health, access to housing and making sure that change happens. Building on the principle of Valuing People Now, the government recently published a number of policy documents such as Transforming Care for people with learning disabilities and the Five Year Forward View that will shape future commissioning of services for people with learning disability and/or autism. This report summarises issues affecting people with a learning disability, carers and frontline services. The report brings together key messages from the Wandsworth Joint Strategic Needs Assessment and national policies such as Winterbourne View, NHS England: the Forward View into action for 2015/16 and Transforming Care for People with Learning Disabilities. It outlines key achievements to date and presents proposed Wandsworth CCG commissioning intentions for people with learning disability and joint health and social care priorities in 2016/17. Key sections for particular note (paragraph/page), areas of concern etc.: The whole document Recommendations: Wandsworth Clinical Commissioning Group Board is asked to note the issues highlighted in the paper and proposed health and social care work programme and commissioning intentions for 2016/17. Committees which have previously agreed the report Wandsworth CCG Management Team 1 1

2 Please state below how this document contributes to delivery of the QIPP Plan or Operating Plan: The 2015/16 CCG Operating Plan outlines the proposal for a Learning Disability Commissioning Programme and many of the 2015/16 workstreams within the programme will be taking forward in 2016/17 Financial Implications: The planned spend in 2015/16 on learning disabilities services is within the region of 7,385,430. The shared cost of 883,000 for mental and learning disability includes Healthcare for All, Wandsworth Carers Centre, Rethink Advocacy and Section 117 Aftercare contribution to the Wandsworth Borough Council. It is not possible to assess at this point in time the full financial impact of new national policies such as personal health budgets, education, health and care plans (EHC) for 0-25 year olds, disaggregating block budgets and any devolution of NHS England inpatient placement budgets. Other Implications including Patient and Public Involvement/Legal/Governance/Diversity/ Staffing The health status of people with learning disabilities (that have been recorded) show that this group is in poor health compared to the general registered population. They are more likely to have a higher rate of obesity, coronary heart disease, and respiratory disease, hearing impairment, dementia, osteoporosis and epilepsy. These result in health inequalities between groups. The life expectancy at birth for people with learning disabilities is significantly shorter than the general population. For males with learning disabilities the current life expectancy is 67 years and for women, 69 years. The proposed recommendations should help address inequalities and improve service user experience. Equality Impact Assessment Has an EIA been carried out? Yes.The EIA highlighted the following gaps: Lack of robust health process for managing young people with learning disabilities aged 14 to 17 years old in transition to adulthood Limited understanding of local capacity to respond to current and future service demand. The needs of people with learning disabilities may not be being met within mainstream services. Information Privacy Issues Has a consideration of privacy impacts been undertaken and controlled for? No No personal information has been used in the report. 2

3 Learning Disability Services Report to Wandsworth Clinical Commissioning Group Board Introduction 1. This paper outlines for the Wandsworth Clinical Commissioning Group Board the progress in developing and implementing ongoing and new initiatives to improve services and outcomes for people with learning disabilities in Wandsworth. 2. The report focuses on the following: The demographic profile of people with a Learning Disability The provider landscape Issues Affecting People with Learning Disability in Wandsworth (Appendix A) Key commissioning developments and achievements in 2014/15 and 2015/16 (Appendix B) Key priorities and commissioning intentions for 2016/17 National Context 3. The primary driving force for change and service development over the past ten years has been the Government White Paper, Valuing People: A New Strategy for Learning Disability for the 21 st Century. March The refreshed version Valuing People Now from progress to transformation identified five major priorities personalisation, what people do doing the day, better health, access to housing and making sure that change happens. 4. Building on the principle of Valuing People Now, the government recently published a number of policy documents that are shaping future commissioning of services for people with learning disability and/or autism who have a mental illness or behaviour that challenges. They are: Winterbourne View: Time for Change - Transforming the commissioning of services for people with learning disabilities and/or autism 3 (2014) - The report recommended that the Government and NHS England should require all local commissioners to follow a mandatory commissioning framework which would include devolution of budgets and responsibility for commissioning services from NHS specialised commissioning to Clinical Commissioning Groups. NHS England - The Forward View into action: Planning for 2015/16 (2015) identified transforming care of people with learning disabilities as a priority for operational delivery in NHS Commissioners are charged with reducing the reliance on inpatient care for people with learning disabilities or autism. The Forward View also requires all CCGs to develop plans for a major expansion of personal health budgets, and to ensure that people with learning disabilities are included by April A personal health budget is an amount

4 of money to support a person s identified health and wellbeing needs, planned and agreed between the person and their local NHS team Transforming Care for people with learning disabilities Next Steps (2015) describes wide ranging work that would be undertaken to strengthen the rights of people with learning disabilities and their families; improve commissioning and implementation of a mandatory framework; closures of inpatient institutions and building capacity in community services. National priorities for learning disability are: - Delivery of the national framework for a service model for health and care services for children and adults with a learning disability and/or autism who have a mental illness or behaviour that challenges. The service model will emphasise personalised care and support planning and personal health budgets - The Standard Contract 2015/16 will contain provisions requiring all providers of NHS funded services for people with learning disability and/or autism to comply with new standards for admission and discharge. NHS Commissioners will be expected to monitor closely in 2015/16. NHS England will consider specific mandatory financial sanctions for failure to adhere to new standards Personal Health Budgets The Government s vision for personal health budgets is to enable people with long term conditions and disabilities to have greater choice, flexibility and control over the health care and support they receive. The NHS Mandate includes a commitment that by April 2015 everyone with long- term conditions including people with mental health problems will be offered a personalised care plan that reflects their preferences and agreed decisions. From April 2015, all CCGs are being asked to develop plans for a major expansion of personal health budgets, and to ensure that people with learning disabilities are included by April Demographic Profile of People with Learning Disability The 2014/15 Joint Strategic Needs Assessment refresh highlighted the following key messages: 5. The population of Wandsworth has some characteristics that are typical of an inner London borough and some that are unique: recent benchmarking work by the Clinical Commissioning Group (WCCG) has identified that there are in effect two Wandsworths. 6. The first population is relatively young, relatively affluent, in work and in good health. This population is disproportionately high (causing a demographic bulge ) and transient: around 25% of the borough s population changes each year. This Wandsworth population is predominately working age young adults, with a pattern of couples having children while living in Wandsworth and then moving out when children approach school age. 7. The second population is relatively older, relatively poorer (less employment) with more deprivation factors. 4

5 8. By 2020, the number of people with a learning disability in Wandsworth is projected to increase by 10% from an anticipated population of 5,500 in Of the 5,500, it is estimated that 1342 adults with learning disabilities are known to services. This represents approximately 23% of the total number of people with a learning disability. 9. The life expectancy at birth for people with learning disabilities can be more than 25 years lower than the general population. For males with learning disabilities the current life expectancy is 67 years and for women, 69 years. For those with Down s Syndrome it is 55 years. The general population life expectancy is 77.9 years for men and 82 years for women. 10. The increase in population may be partly due to the increase in numbers coming through transition to adulthood and families moving into Wandsworth because of access to special schools: there is a recognition that children with learning disability/children with a Statement of Educational Need perform better in Wandsworth special schools and mainstream schools than many of their peers nationally. 11. The wards of Latchmere, Graveney and Roehampton have the highest proportion of people (GP registered population) with learning disabilities living in them. Two and a half times the proportion of people with learning disabilities live in areas of highest deprivation (relative to Wandsworth) compared to least deprived. Ethnic minorities are over represented among this cohort. 12. People with a Learning Disability are more likely to have a higher rate of obesity, coronary heart disease, and respiratory disease, hearing impairment, dementia, osteoporosis and epilepsy. These result in health inequalities between the two groups. Almost half of people with Down s Syndrome are affected by congenital heart problems. Commissioning Spend on Learning Disability Services 13. The planned spend in 2015/16 on learning disabilities services is within the region of 7,385,430. The shared cost of 883,000 for mental and learning disability includes Healthcare for All, Wandsworth Carers Centre, Rethink Advocacy and Section 117 Aftercare contribution to the Wandsworth Borough Council. 14. Table 1 and Figure 1 below provides breakdown of 2014/15 Wandsworth CCG budget in financial terms and percentages. Table 1: Breakdown of Wandsworth CCG 2015/16 Budget for Learning Disability Services Sector Spend Amount ( 000) Community Learning Disability Services 3,055,950 Individual Learning Disability Placement (Hospital and Care Homes) NHS Continuing Healthcare for Service Users with Learning Disability 1,618,000 2,621,480 5

6 Acute Liaison Service at St George s Hospital NHS Foundation Trust Shared Learning Disability and Mental Health costs 90, ,000 Figure 1: Percentage Breakdown of Wandsworth CCG 2015/16 Spend on Learning Disability Services Acute Liaison Service at St George s Hospital NHS Foundation Trust 1% Shared Learning Disability and Mental Health cost 11% Community Learning Disability Services 37% NHS Continuing Healthcare for Service Users with Learning Disability 32% Governance Individual Learning Disability Placement (Hospital and Care Homes) 19% 15. Commissioning arrangements for people with learning disabilities are managed through the Wandsworth Learning Disability Partnership Board, which was established following the publication of the White Paper Valuing People: A New Strategy for Learning Disability for the 21 st Century (2001). The Board brought together relevant local agencies and stakeholders, including people with learning disabilities and their carers. 16. The main purpose of the Board has been to drive forward the Valuing People agenda, contribute to the planning of services, including the setting of priorities and monitoring of provider performance. The Board s action plans are informed by the annual Director of Adult Social Services and NHS England Joint Health and Social Care Learning Disabilities Self- Assessment Framework (SAF) 17. The Learning Disability Partnership Board is now referred to as the Learning Disability Clinical Reference Group to formally incorporate a clinical leadership role. The Group is cochaired by Clinical Lead for Learning Disability, Dr Farooq Rafique and a service user 6

7 representative. The Terms of Reference for the Group has been revised to reflect the changes. Provider Landscape for Wandsworth CCG Learning Disability Services 18. There are around 850 adults with learning disabilities receiving social care services funded by Wandsworth Social Services. These are individuals who are eligible under the Fair Access to Care Services (FACS). Approximately 715 adults are accessing community and inpatient bed based placements. 19. The community provider reported a steady increase in the number of referrals from the beginning of 2014, and this trend is continuing at the moment. There may be local reasons for this pattern, but there are also recognised reasons nationally for increased demand for learning disabilities teams e.g. more children with very severe disabilities are surviving into adulthood; adults are getting older in the general population, including people with learning disabilities. 20. The provider landscape of learning disability services commissioned by Wandsworth CCG as follows: 21. St George s University Hospitals NHS Foundation Trust Community Learning Disability Services - St George s University Hospitals NHS Foundation Trust Community Learning Disability Health Service (SGH) provides a multidisciplinary approach to supporting individuals with learning disabilities who are registered with Wandsworth GP. 22. Service users referred to SGH present with a range of difficulties in addition to their learning disability such as epilepsy or dysphasia which may relate to their physical conditions or emotional, behavioural or practical issues with living independently. Some of the individuals have lifelong conditions, in addition to their learning disability, which require support at different periods throughout their lives. Sometimes they may require short interventions, at other times much longer interventions. At times there may be only one profession involved, at other times multidisciplinary work will be necessary. Some service users may need ongoing maintenance or prevention work from the team, such as the work around postural management, footwear and mobility. 23. South West London and St George s Mental Health Trust - The South West London and St George s Community Learning Disability and Mental Health Service (SWL & SGH) offers a secondary care health service to adults who have learning disability and mental health disorders and associated needs. The service is designed to meet the needs of individuals whose needs cannot be met by mainstream mental health services. 24. SWL & SGH service works with the following cohort of patients: Service users with learning disabilities requiring hospital placements. These are users with mental health problems and intellectual disabilities including autism who require specialist learning disability assessment and treatment within an inpatient hospital environment. The majority of these placements are outside Wandsworth. 7

8 Service users with learning disabilities, low level mental health problems and/or challenging behaviour requiring residential placements within the community or additional support within their own home. Service users with learning disabilities, mental health problems and/or challenging behaviour in forensic units. The service provides in-reach to Wandsworth patients on Care Programme Approach (CPA) in forensic units whose placement are commissioned by NHS England. 25. The two Consultant Psychiatrists supporting the service, Dr Oyepeju Raji and Dr William Howie share responsibility for Wandsworth patients. Dr Oyepeju Raji is responsible for Battersea and West Wandsworth (Roehampton, Putney, Southfields and Earlsfield) and Dr William Howie is responsible for Tooting, Balham, Streatham and St George s Hospital area. 26. Hospital and Care Home Individual Service User Placement Providers - Wandsworth CCG commissions bed based placements for patients who have been detained under the Mental Health Act and those that meet the Winterbourne View criteria 4 ; patients in Assessment and Treatment Units and service users who were previously in ex NHS campuses who have now been resettled in step down accommodations. 27. There are a total of 16 providers of individual service user placements for people with learning disabilities - five hospital and eleven care homes. The service user placements include placements for the current four Winterbourne View patients. 28. The learning disability care home placements include 6 ex-campus service users who have been discharged from long stay accommodation under the Department of Health Winterbourne View (WV) transformation programme. The ex-campus service users are case managed by CCG funded social worker. The service specification between Wandsworth CCG and Wandsworth Borough Council Directorate of Education and Social services is due for review in December NHS Continuing Healthcare for people with learning disability - The NHS Continuing Healthcare assessment and review is undertaken by South East Commissioning Support Unit (SECSU) on behalf of Wandsworth CCG. As of April 2015, there were 37 people with learning disabilities who have been assessed as eligible for continuing health care. 31. St George s University Hospitals NHS Foundation Trust Acute Liaison Service - The St George s University Hospitals NHS Foundation Trust Acute Learning Disability Liaison Service work with healthcare professionals, people with learning disabilities and their carers to plan hospital admissions and facilitate patient discharge. The team achieve this by helping patients navigate acute services, act as an expert resource to staff, carers and families and by ensuring reasonable adjustments are addressed. The service is available to all patients with learning disabilities accessing acute services at St George s Hospital. Key Achievements in 2014/15 and 2015/ Reformation of the Learning Disability Partnership Group redesigning the Learning Disability Clinical Reference Group to ensure reporting lines to the Wandsworth Health and 8

9 Wellbeing Board. The Reference Group is now co -chaired by a Clinical Lead, Dr Farooq Rafique and by a service user. 31. Learning disability awareness training for primary care and midwives at St George s Hospital Awareness training was commissioned by the CCG to support GPs delivering the NHS England Learning Disability Enhanced Service. The training was also extended to other primary care professionals and midwives at St George s Hospital. 32. Pilot Cancer Screening for People with Learning Disability - St George s Community Learning Disability Team was commissioned to increase the uptake of health promotion and screening activities for cervical smear test, breast self-examination and mammography. There has been historic low uptake among people with learning disability. Comparative figure for uptake of screening show that the proportion of eligible women in the general population attending cervical screening is just below the target rate of 80%. But the uptake by women with learning disabilities ranges from 7% -27%. An evaluation report will be available in March Reasonable Adjustment Training for Healthy Living Services - St George s Community Learning Disability Team was commissioned to deliver a one day training to support mainstream services to make reasonable adjustment to support people with learning disability accessing mainstream services. Participants were given strategies that could be implemented in services to increase the accessibility for people with learning disabilities. The training was attended by Smoking Cessation, Physical Activity, Health Trainers, Sexual Health and Family Planning, Drug and Alcohol Services. The following changes have been made as a result of the training: Redevelopment of recurrent resources including information leaflets, initial questionnaire, service guides and appointment letters to be more accessible to people with learning disabilities. Review of current appointment structure, waiting rooms and service entry pathways including factors such as waiting rooms and service entry pathways including factors such as waiting times, information on steps involved in clinics or sessions etc. Healthy Living Services will provide Wandsworth day services and community learning disability organisations service information pack. This will include details, contact and referral processes for healthy living services. Market day/roadshow where healthy living services can reach out to the learning disability community were held in May Health Matters Training for People with Learning Disabilities - Wandsworth Care Alliance was commissioned to run series of health related training sessions primarily aimed at people with learning disabilities and also their support staff and family carers. The sessions covered areas such as diabetes, epilepsy, cancers, gum disease, annual health checks, obesity and healthy eating, eye care, hearing loss, stopping smoking and sexual health. 35. Leaflets for People with Learning Disabilities - Easyhealth was commissioned to produce easy read leaflets on depression and anxiety to enable health professional to communicate effectively with people who suffer from depression and anxiety. Two hundred copies were printed and distributed to local and national organisations such as Choice Forum and Health Stones. 9

10 36. Joint Health and Social Care Self-Assessment Framework (SAF) - Wandsworth CCG continues to participate in the national assessment, ongoing since The pilot cancer screening liaison service was funded as a result of the gaps identified in SAF 2013/ Winterbourne View - The CCG achieved the required reduction in patients in hospital-type accommodation in 2014/15, after a ministerial direction to reduce the number of patients in hospital settings by 50% in that financial year. 38. Wandsworth Health and Social Care Winterbourne View Steering Group reports to NHS England on a fortnightly basis and uploads data to the Health and social information centre (HSCIC) on a monthly basis. In response to national directives, the Wandsworth Transforming Care Group was recently established to oversee care and treatment reviews for people with mental health and learning disability in inpatient units. A Wandsworth Risk Register has been developed to identify service users at risk of readmission to inpatient units. This covers Child and Adolescent Mental Health (CAMHS), CCG funded service users/patients and those currently funded by NHS England specialised commissioning, who will step down into CCG funded placements as their condition permits. 39. Establishment of case management protocols for ex Winterbourne View patients Wandsworth CCG is funding a Wandsworth Council employed social worker to provide case management of people with learning disabilities in ex NHS campuses including those identified through the Winterbourne View process. 40. PACT - As part of Wandsworth CCG primary care transformation programme, GP Practices are commissioned to provide enhanced services to the most vulnerable and complex patients especially those with learning disability or with multiple co-morbidities, housebound, resident in Nursing Homes, dementia/stroke patients, those within five years of a receiving a cancer diagnosis and stable haematology patients. The CCG will build on this arrangement in 2015/16 and beyond. Learning Disability Commissioning Intentions and Work Programme for 2016/ The Issues Affecting People with Learning Disability in Wandsworth (Appendix A) covers the following areas: National priorities and keys issues from JSNA 2014 Needs Assessment Review of Commissioned Services for People with a Learning Disability (March 2015) Joint Health and Social Care Learning Disabilities Self-Assessment Framework (SAF) for 2013/14 (March 2015) Wandsworth CCG Continuing Healthcare Review Project for People with Learning Disabilities Feedback from parents, carers and professionals working within learning disability services 42. The Wandsworth CCG Director of Commissioning and Planning and Wandsworth Borough Council Director of Education and Social Service co-chaired health and social care commissioners workshop on 7 May The workshop aimed to achieve the following: 10

11 To establish shared understanding of the health needs and overlapping social care needs of people with learning disability To develop a shared understanding of the roles of case coordination and care management To test the assumption that an integrated health and social care community learning disability team could provide added value to people with learning disability To agree on commissioning priorities for learning disability in 2016/ The following health and social care learning disability priorities were agreed for 2016/17: Decrease health inequalities for the population of people with a learning disability through the following: o An increase the offer of Personal Health Budgets and Social Services Direct Payments o An increase access to community services o A joint health and social care approach to managing transition o increased visibility of safeguarding processes o shared understanding, definition and implementation of care coordination and case management (including local process and implication of delivery) o shift from inpatient to community care with a focus on prevention of admission to institutional care o increase access to employment o increase support for carers 44. The commissioning intentions for 2016/17 are described in Appendix B. Conclusion 45. Support to people with Learning Disability, and their families, has been a key priority area for the CCG in 2015/16 and will continue to be through 2016/17. Responding to a series of drivers demographics, national guidance, service user feedback the CCG has developed and delivered a series of improvements to services and intends to build on that in 2016/17, with the right focus, capacity and governance in place to deliver continued improvements in services to this population. 11

12 Appendix A Issues Affecting People with Learning Disability in Wandsworth Joint Strategic Needs Assessment Additional issues that were highlighted in the 2014 JSNA: 46. The health status of people with learning disabilities (that have been recorded) show that this group is in poor health compared to the general registered population. They are more likely to have a higher rate of obesity, coronary heart disease, and respiratory disease, hearing impairment, dementia, osteoporosis and epilepsy. These result in health inequalities between the two groups. Almost half of people with Down s syndrome are affected by congenital heart problems. 47. People with learning disabilities often have physical and sensory disabilities in addition to learning disabilities. Their learning disability means that they will also have difficulties with communication. They are also more likely to have other conditions such as epilepsy and autism, for example people with Down s Syndrome are at higher risk of developing dementia and of developing it earlier than the general population 5. Due to these factors, individuals with learning disabilities also have much higher levels of challenging behaviour and mental health problems 6 Their learning disability also means that they will struggle with, and therefore need support with, everyday activities, organising and managing their lives and their home environment as well as with relationships. 48. Efforts to improve wellbeing and reduce cost so far include developing supported housing rather than residential care, supporting service users in finding employment and developing new models of respite. The anticipated increase in prevalence will increase demand for community and bed based learning disabilities and on prospects for finding employment and accommodation. 49. Services for people with learning disabilities are generally well resourced in Wandsworth but not well coordinated around the needs of the service users. This is particularly evident in the arrangement for Continuing Healthcare assessment for people with learning disabilities. There is also no coherent local information about core group of service users accessing primary, community, social care, acute and residential placement services 50. Data relating to people with learning disabilities being admitted to hospital where their care could have been undertaken in the community is out of date and needs to be refreshed as it was previously higher than expected. 51. There is disparity between those identified through GP registers and the number receiving social services through the council social service department or the number of recorded on Frameworki system. Amalgamating these sources will result in a comprehensive register allowing identification of those not registered with a GP and therefore not had a health check. 5 Alzheimer s Society (2010) Learning Disabilities and Dementia. alzheimers.org.uk/factsheet/ Heyvaert. M, Maes. P, Onghena et al. 2010) A meta-analysis of intervention effects on challenging behaviour among persons with intellectual disabilities 12

13 Winterbourne View 52. The Department of Health Winterbourne View (WV) programme reduction in inpatient admission of people with a learning disability from 12 people to 4 in Wandsworth delivery of the WV is supported by Health and Social Care Steering Group that meets on a fortnightly basis. The Wandsworth WV Steering Group is undertaking intensive work to prevent admission. There are limited alternatives to hospital admission for Wandsworth service users/patients. 53. The steering group meets every two months, its main function being to ensure we are doing all we can to progress the discharges of people still in hospital and to review the people we have placed in the community who were in hospital. The CCG submits information fortnightly to NHS England about the people still in hospital. Autism 54. Autism is neither a learning disability nor a mental health problem, although mental health problems can be more common among people with autism and it is estimated that one in three of adults with a learning disability also have autism. Autism is used to refer to all diagnoses on the autism spectrum, including Asperger syndrome, high functioning autism or classic autism. It is estimated that more than half a million people in England have autism. This is equivalent to more than 1% of the population and similar to the number of people with dementia According to the JSNA, 2014, data on prevalence of autism in Wandsworth is currently not available. Recording of data only started in September Estimate of prevalence is based on Projecting Adult Needs and Service Information (PANSI) system. For 2012 it was estimated that there were 2,200 adults aged with an autistic spectrum disorder of whom 1,200 were estimated to have a learning disability Transition for Young People with Learning Disabilities 56. The implementation of the Children and Families Act 2014 has major implications for how the NHS organises and delivers services to children and young people who have a Special Education Need and/or Disability between the ages of 0 and 25. It will reform the system of support across education, health and social care to ensure that services are organised with the needs and preferences of the child and their family firmly at the centre, from birth to the transition to adulthood 8. Review of Commissioned Services for People with a Learning Disability 57. The review of commissioned services for people with learning disability was undertaken to gain a better understanding of commissioned services for people with learning disability 7 NAS%2FThink%2520Autism%2520Strategy.ashx&ei=wWj4VPqlJOOU7Qb1k4DIDg&usg=AFQjCNGodmrF84SaosIA-ePgn7jMvCz- Dw&bvm=bv ,d.ZGU

14 over the age of 18 and young people in transition to adulthood in Wandsworth. The review highlighted the following gaps in services: Low levels of people with learning disability accessing cancer screening within primary care Waiting lists for Psychological, Nursing, Occupational Therapy and Physiotherapy Interventions No formal arrangements for provision of psychiatric assessment and psychiatry in Special Interest in Epilepsy Review of access to Access to Accident and Emergency There is a need to revisit use of Hospital Passport which is now called Healthcare Passport There is need for the South East Commissioning Support Unit Continuing Healthcare (CHC) Team and St George s University Hospitals NHS Foundation Trust Community Learning Disability Team to better coordinate CHC assessment for people with learning disability and physical health needs. There is currently a gap in community placement provision for people with severe challenging behaviour. Some patients are currently in hospital settings instead of specialist community setting Demand for specialist assessment such as dementia and interventions for those clients who would not be able to access mainstream services There is a joint commitment to strengthen health and social care commissioning with Wandsworth Borough Council on the following: - joint commissioning programmes for Supported Living Accommodation - engagement with the children s services teams on transition for young people to adulthood - establish responses to national frameworks and assurance such key performance indicators, Education, Health and Care Plan (EHCs) and Personal Health Budgets Joint Health and Social Care Learning Disabilities Self-Assessment Framework (SAF) for 2013/ National Association of Director of Adult Social Services and NHS England Joint Health and Social Care Learning Disabilities Self-Assessment Framework return for financial year 2013/14 was undertaken from September 2014 to March 2015 to support the Transforming Care Programme for people with learning disabilities. Statistical data for SAF return is centrally extracted from EMIS Web, the main Wandsworth GP clinical system. The Wandsworth SAF assessment highlighted the need for improvement in the following areas: data collection process so that we have information on the accurate number of people with learning disability accessing local healthcare services early identification ( in partnership with NHS England ) of offenders with a learning disability transitional arrangement for young people better understanding of the needs of people with Autism involvement of service users and carers in decision making 14

15 Wandsworth CCG Continuing Healthcare Review Project for People with Learning Disabilities 59. Wandsworth CCG commissioned South East Commissioning Support Unit (SECSU) to undertake a 6 month project to expedite 34 Learning Disabilities Continuing Healthcare (CHC) reviews and to formulate recommendations on how this work stream could be managed more effectively. At the time of the review there were no suitably qualified nurses within the CHC nurse assessor team. The review recommended the following options for service delivery: Service Delivery Model - options for the development and delivery of a comprehensive review process, either through the SECSU, in house in the CCG or commissioned from a local provider. The CCG has chosen to retain a specialist LD service (with appropriately qualified nurse) from the SECSU. Partnership Working - The need to map out the responsibilities of all the other CCG commissioned Community Services and their responsibilities in relation to CHC. Joint Training - Develop a CHC rolling joint training programme to Community Services such as the LD Community Team, Local Authority Assessment Teams and District Nursing Teams. A joint training approach will support shared understanding of the CHC Framework and application of the criteria. Better understanding of the Framework should reduce the volume of inappropriate referrals and add clarity on each service responsibility for the patients that need to go through the full CHC process. A common understanding of the CHC Framework and local processes should enhance local partnership working and reduce volume of avoidable local disputes, which can be resource intensive for the CCG and Local Authorities. Commissioning Care Model - The CCG needs to consider implementing the Care Funding Calculator tool. The Care Funding Calculator tool would support more transparent cost modelling which can be used a baseline to review weekly cost and when the patient s need increase or decrease. Strategic Commissioning The need for more strategic commissioning with the local authority, housing, and specialist community services to support the of more appropriate accommodation and supported living arrangements and bespoke care for people with learning disability. Patient Carers Engagement 60. Below is summary of key messages from engagement with patients and carers: There is generally good access to GP Practices. It was suggested that GP Practices consider an appointment system that fast track people with learning disabilities. People with learning disabilities and their carers need help with navigating the hospital system. Further improvement needed in management of transition from children s services to adult services There are gaps with availability of advocacy service for people with learning disability 15

16 Appendix B Commissioning Intentions 2016/17 Learning Disability Services WCCG Commissioning Intentions for Learning Disabilities 1. Implement the core offer for Personal Health Budgets for people with learning disability and challenging behaviour. 2. Continue the work of the Transforming Care programme, ensuring that patients are cared for in community settings where possible. 3. Develop a strategy for facilitating repatriation of patients in hospital type accommodation from inpatient units outside the area to Wandsworth. 4. Joint programmes with Wandsworth Borough Council Directorate of Education and Social Services Primary Care & Community Care Review of existing community learning disability services delivered by South West London & St George s Mental Health Team and St George s University Hospitals NHS Foundation Trust. Commission primary care services that will improve physical health of people with learning disabilities to optimise impact and outcomes for patients through delivery of excellent primary care to all people registered with a Wandsworth GP. Winterbourne View Working in partnership with Wandsworth Borough Council to develop a strategy for facilitating repatriation of patients in hospital type accommodation from inpatient units outside the area, back to Wandsworth. Personal Health Budgets Agreeing and implementing the core offer for Personal Health Budgets for people with learning disability and challenging behaviour. The change will be implemented through Commissioner, Provider and Service User consultation and by joint agreement with stakeholders. Supported Living Accommodation Working in partnership with Wandsworth Borough Council to review capacity within supported living accommodation to respond to the needs of people with learning disabilities. Care co-ordination and case management Pilot delivery of case management and care co-ordination within locally agreed definitions. Integrated Community Learning Disability Health and Social Care Team 16

17 Working in partnership with Wandsworth Borough Council to consider the benefits of an integrated community health and social care team. A review of community learning disability services in line with local review and national policies. Training & Development - Commission training programme to up skill mainstreams providers to better respond to the needs of people with autism and/or people with learning disability. - Ensure that all commissioned services have service specifications that reflect the nature and cost of what they are delivering. To support delivery of better care and a healthier future for Wandsworth through our clinical leadership, robust commissioning processes and excellent staff, focussed on delivering quality services and improved outcomes for patients. Inpatient facilities Improve inpatient facilities for people with Learning Disabilities and Autism. Given the poor provider marketplace and the increased focus on caring for people with LD close to home and in intensively managed pathways, we would like to explore the potential to significantly improve and increase the current offer for this patient cohort. This may potentially be picked up wider than WCCG as both for SW London, and across London, this is a significant issue. 17