L Bolton Health and Social Care Commissioning Strategy 2011

Transcription

1 Specialist Care Commissioning Strategy: Adults March 2011 Bolton- Specialist Care Commissioning Strategy Page 1 of 63

2 Document Title: Specialist Health and Social Care Commissioning Strategy Description: Documenting the key priorities and actions over the next three years for commissioners across the statutory sector who have responsibility for commissioning services for adults over the age of eighteen. This document has been produced in response to the National Transforming Social Care Programme: Putting People First. Publication date: April 2011 Document review: January - March 2012 January - March 2013 Contact details: Bolton Council Adult and Community Services Department Le Mans Crescent Bolton BL1 1SA Telephone: commissioning@bolton.gov.uk Bolton- Specialist Care Commissioning Strategy Page 2 of 63

3 Contents Page Contents Executive Summary... 2 Introduction... 3 Context... 4 Analyse... 7 What do we mean by Specialist Care?... 7 Why is it necessary to move towards outcome based commissioning? What are the needs of vulnerable people in Bolton? Older People Learning Disabilities Mental Health Adults with Physical Disabilities Young People in Transition Substance Misuse Alcohol Misuse Carers Local Service Providers Plan What Needs to Change? What are local people s priorities? What should commissioner s priorities be between 2011 and 2014? What Resources will be Available? What Should Our Overarching Outcomes Be? Do What do we need to commission? Support for Providers and Market Development Commissioning Recommendations Action Plan Review Evaluation Communication Plan Monitoring Bolton- Specialist Care Commissioning Strategy Page 1 of 63

4 Executive Summary Executive Summary The purpose of this strategy is not to plan specific services, but to provide a catalyst for fostering innovative activities that will achieve positive outcomes for local vulnerable people. This Strategy has the aim of:- Improving outcomes, quality, safety and value for money of services. Shifting the emphasis of social care to a new service model of prevention, reablement, independent living and improved life choices. Shifting the culture of health and social care to one of individual choice and responsibility Safeguarding people whilst allowing them control and decision making regarding risks. Increasing service user choice over what services they receive and how they are delivered. Providing opportunities for users and carers to influence the development and delivery of services Recognising the role and contribution of unpaid carers and improving range of support services available for carers. Providing identification of future needs based on the best available information, including hidden demand and hard to reach groups. Success will be reflected in: Vulnerable adults achieving economic wellbeing Vulnerable adults maintaining their independence and being protected from harm The prevention of deterioration in health, dependency on services and delay in recovery The personalisation of the health and care system and improvements in quality of life for adults This strategy is Bolton s response to meeting the national outcomes outlines in the Vision for Adult Social Care and the emerging Adult Social Care White Paper. Bolton- Specialist Care Commissioning Strategy Page 2 of 63

5 Introduction Introduction Local people s expectations of the services they use are changing. The implementation of Putting People First will give individuals the power to commission services for themselves. Care serviceusers and their carers will, rightly, expect more from the services they purchase. These changing needs and expectations will demand radically different responses from commissioners and providers of social care services. In drafting this strategy we need to acknowledge what s working well and build on our successes. We also, however, need to change and shift the balance of the services we commission so that we continue to meet the needs of those people who need support, in a way that is fair, transparent and equitable. The recent publication of the Liberating the NHS, Capable Communities and Active Citizens and the supporting papers Commissioning for Patients and Transparency in Outcomes will have profound implications for the commissioning of social care and primary health. Primary Care Trusts will cease to exist from 2013 and commissioning responsibilities will move to consortia of General Practitioners. The GP led commissioning process detailed within the NHS White Paper will radically change the context in which social care services are commissioned. This is a critical time for Adult Social Care services. The current economic climate demands that budgetary savings are made across the public sector; despite evidence of increasing demand for health and social care services. As a consequence, there is now unparalleled pressure on the resources available to meet the needs of vulnerable adults living in Bolton. Inevitably, this will mean that the remodelling or decommissioning of both in-house services, and those procured from the market, will become a dominant theme in the work of elected members and commissioning managers during the lifetime of this strategy. The Specialist Care Commissioning Strategy has three main functions: Assessing Need: In planning the future delivery of specialist care services on behalf of Bolton Council and its commissioning partners, the Strategy highlights the needs of the local community, service users, carers and other stakeholders. This assessment has been conducted in line with the findings of the Joint Strategic Needs Assessment. Review of existing services: The Strategy has assessed which services are needed and how they are provided. The strategy aims to ensure that the needs generated by the implementation of Self Directed Support are met. The accessibility of non-social care services such as transport, housing, education, leisure and culture services will become paramount in enabling independence, choice and control. The Strategy also presents recommendations for commissioning services for and on behalf of the Health and Wellbeing Partnership through its constituent partners. Much of the work within this strategy will be enabled by a series of interconnected frameworks, strategies and planning Bolton Council is currently undertaking in relation to Putting People First: such as the Information, Advice and Advocacy Strategy and the Targeted Prevention Commissioning Strategy. Bolton- Specialist Care Commissioning Strategy Page 3 of 63

6 Context Context Why are we writing this strategy? Health and Social Care is going through a time of unprecedented change. The self-directed support agenda and the reforms contained in the NHS and Public Health White Papers will completely transform the way in which health and wellbeing services are commissioned and delivered. This strategy is one of several responses to these changes and has a foundation in the following policy documents. Bolton: Our Vision Bolton: Our Vision outlines Bolton s plans to become a place where everyone has an improved quality of life and the confidence to achieve their ambitions. The two main aims of the Vision are to: Narrow the gap between the most and the least well off and To ensure economic prosperity. On average the difference in life expectancy between the most disadvantaged areas and Bolton as a whole is 7.4 years. The problems that contribute to this statistic have deep-rooted causes that defy quick fixes and poor health cannot be solved by one agency alone. Within Our Vision Bolton s Local Strategic Partnership outlines the action it will take to: Reduce the strain on health and social care services, Give people who receive care and support greater control over their lives and Support people to continue to live independently. This strategy forms a single element of the planning commissioners are undertaking to ensure that they are able to meet these commitments in the future. Putting People First Putting People First aims to deliver the transformation and personalisation of adult social care. This strategy is one element of a much wider to programme designed to introduce a new system of care and support. This system aims to enable people to live their lives as they wish by promoting independence, choice, well-being and dignity. Putting People First in Bolton aims to ensure that for local people: It s quick and easy to find my way through the care and support system I ve been the one deciding what care works for me it s been my choice I ve been able to find the right kind of care and support to meet my needs Putting People First establishes a collaborative approach to transforming adult social care. Bolton Council, in partnership with a wide range of organisations and agencies, is challenged to ensure there is personalised support for people with multiple and complex needs, for people to maintain their independence and for people with emerging needs. Bolton- Specialist Care Commissioning Strategy Page 4 of 63

7 Context The mechanisms to achieve this include individual budgets, joint commissioning between health and social care commissioners and an increase in care outside hospitals and residential care homes. Putting People First sets out a vision for adult social care of services that are seamless, proactive and person centred. Self Directed Support Introduced by Putting People First, Self Directed Support is a model of social care designed to give individuals and their carers as much control over their own support. People will have greater control in identifying the type of support or help they want and will have greater choice and influence over the services on offer. Self Directed Support fundamentally changes the relationship commissioners have with suppliers and their customers. This presents commissioners with a significant challenge. As people increasingly take the option of self-directed support, the role of strategic commissioners will change to become more concerned with market development and management. Securing value for money and financial sustainability will, however, remain key concerns for commissioners, who must continue to ensure cost-effective and appropriate use of public money. Commissioners will need to understand the choices that people are making in term of provision and what they would have chosen where there is a gap in the market. Within this commissioning environment local service providers will need to be both flexible and agile. Providers will need to increase the range of support packages available to help people to remain at home longer and consider more innovative alternatives to meeting the care needs of vulnerable people. Commissioners will need to enable providers outside the social care market to contribute to the independence of local people, by fostering innovation and improved choice. A pilot scheme will run from October 2010 in the South East of Bolton. From April 2011 existing service users will be offered the opportunity to move to Self Directed Support during their scheduled review. This pilot will inform future commissioning strategies by identifying gaps in current provision and new opportunities for providers. Equity and Excellence: Liberating the NHS The NHS White Paper has profound implications for the way health and social care services will be commissioned in the future. The paper proposes the development of three outcome frameworks, one each for Social Care, Health Care and Public Health against which local performance will be monitored. GP consortia will have responsibility for commissioning the majority of health care services with the remainder being the responsibility of a National Commissioning Board. Local Authorities are to have lead responsibility for public health in conjunction with a National Public Health Service. A Social Care White Paper is expected during 2011 which is likely to complement the NHS White Paper with anticipated alignment between the two documents. At a local level, the Bolton Council will have the responsibility for establishing a Health and Wellbeing Board which will have responsibility for promoting joined up commissioning of local NHS services, social care and health improvement and to ensure that coherent and coordinated commissioning strategies are informed by joint strategic needs assessment. Bolton- Specialist Care Commissioning Strategy Page 5 of 63

8 Context Capable Communities and Active Citizens: A Vision for Adult Social Care Capable Communities aims to deliver the transformation of adult social care. This strategy is one element of a much wider to programme designed to introduce a new system of care and support that gives communities, and the voluntary sector, a bigger role in maintaining the independence of vulnerable people. This system links strongly into and is supported by policies relating to the Big Society. Capable Communities aims to enable people to live their lives as they wish by promoting independence, choice, well-being and dignity. Commissioners are challenged to ensure there is personalised support for people with multiple and complex needs, for people to maintain their independence and for people with emerging needs. In doing so commissioners must recognise the impact of services outside social care such as advocacy, housing, education and leisure. Transparency in Outcomes Alongside the Capable Communities, the Department of Health has launched Transparency in Outcomes: a new strategic approach to quality and outcomes in adult social care. This approach is the first step in developing a framework which places outcomes at the heart of social care, improves quality in services, and empowers citizens to hold their councils to account for the services they provide. Transparency in Outcomes is currently in a consultation phase. Joint Strategic Needs Assessment The purpose of the Joint Strategic Needs Assessment, (JSNA,) is to pull together in a single, ongoing process all the information which is available on the needs of our local population and to analyse them in detail to identify: The big issues to be addressed regarding health and well-being locally and The actions that local agencies will need to take to address those issues. This strategy builds on the basis of the JSNA to provide a commissioning-focussed assessment of the current health and social care needs of Bolton s population. Marmot Review Fair Society, Healthy Lives - the Marmot Review was published in February It states that preventable health inequalities are unfair and socially unjust, and reducing them, together with improving health and wellbeing, can be achieved through two overarching policy goals: 1. Create an enabling society maximising individual and community potential 2. Ensure social justice, health and sustainability are at the heart of all policies. This strategy represents one part of a suite of planning activities that represent Bolton s contribution to meeting the goals set out in the Marmot Review. Bolton- Specialist Care Commissioning Strategy Page 6 of 63

9 Analyse Analyse What is the Situation Now? In this section we will address the following questions: What is Specialist Care? Who are the services we commission for? What are the social care needs that will emerge in the future? What are the future resource implications of meeting the needs of people who require very high levels of care? What do we mean by Specialist Care? Specialist Care is aimed at vulnerable people whose needs are assessed at the critical or substantial levels of the Fair Access to Care eligibility criteria. Such services form the basis of a care managed package that promotes the health, wellbeing and quality of life of an individual. Specialist Care Services are focused services that: Maximise independent living Focus on those adults whose needs are complex Provide specific interventions according to the needs of the user Provide an ongoing service that is regularly reviewed and modified Provide a clear care pathway which connects services Contribute to preventing unnecessary hospital admission and /or Support timely hospital discharge Prevent unnecessary admission to residential or institutional care Are personalised and self-directed; putting control in the hands of the service user and their carers. Universal Targeted Specialist Meet the needs of the general population No eligibility criteria Focus on prevention Focus on wellbeing, prevention and independence Meet the needs of those with low or moderate needs Focus on enablement and longer-term care Strict eligibility criteria Meet the needs of those people assessed as having critical or substanital needs Bolton- Specialist Care Commissioning Strategy Page 7 of 63

10 Analyse Who are the services we commission for? Services meeting the specialist health and social care needs of the following people are included within this definition. People with Substance Misuse and / or Alcohol Misuse Problems People with a Learning Disability. People with a Physical Disability. People with Sensory Impairment. People experiencing Mental Health problems. People with Long Term Life Limiting Conditions. People experience health conditions associated with ageing. Social Care services covered by this strategy are subject to Fair Access to Care eligibility criteria at substantial and critical levels. Why do we commission? Commissioning is the process by which purchasers of services anticipate future needs and manage resources to meet these needs in the most effective and cost efficient manner. The commissioning process is designed to improve the quality of life of service users and their carers by: Talking to carers, service users and providers about local need. Analysing the needs and aspirations of users and carers. Understanding demand and supply. Linking financial planning and service planning. Making the best use of all available resources. Nurturing relationships with providers and working in partnership with them. Developing local health and social care markets. See Appendix 1 What is Commissioning for further information. Who do we commission with? The local market for providing social care is a mix of voluntary and community sector, small independent and larger independent providers. Overall no provider has substantial market share over the entirety of the social care market. Adult and Community Services commissions approximately 70 million of social care services 1 from external providers, serving approximately 12,500 people. This includes residential care, domiciliary care, day care and a range of other community based services for vulnerable people. Data obtained from contracting teams indicate that these specialist care services are provided by individual providers which can be broken into the following service types: 1 MOPED Financial Modelling Tool October 2010 (Tribal/ Bolton Council) Bolton- Specialist Care Commissioning Strategy Page 8 of 63

11 Analyse Bolton Service Providers 2009/10 Adult community care Adult day Care home with nursing provision Care home without nursing provision Domiciliary care Home nursing care Other adult domiciliary Other adult residential Other service types 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Commissioned In House 2 Data obtained from Adult Social Care Contracts Officers: Summer 2010 Bolton- Specialist Care Commissioning Strategy Page 9 of 63

12 Analyse Why is it necessary to move towards outcome based commissioning? Effective commissioning improves local people s quality of life. However, measuring the effectiveness of commissioning decisions is a complex task. Outcomes are a means of measuring success that gives significant flexibility to providers by describing the ends we need to achieve and not the means by which we intend to achieve them. Both Liberating the NHS and Capable Communities and Active Citizens make reference to the implementation of a new outcomes framework for health and social care. This framework will be used to monitor the quality and cost effectiveness of both General Practitioner and Social Care commissioning. Bolton Council will have a duty to oversee these outcomes and scrutinise performance of commissioned health and social care services. What are outcomes? Outcomes are specific changes in behaviour, condition or satisfaction that deliver a positive impact for local citizens. Embedding outcomes in health and social commissioning will help both providers and commissioners to think about what an individual needs. They are vital in designing interventions to meet identified needs without dictating how those interventions are delivered. Within this strategy we will attempt to define overarching outcomes to provide a foundation for a local outcomes framework and an overview of the outcomes to which health and social care providers contribute. These will reflect local priorities and link to the overall national outcomes framework. Bolton- Specialist Care Commissioning Strategy Page 10 of 63

13 Analyse What are the needs of vulnerable people in Bolton? Overview of the Big Issues for Bolton 3 Overall life expectancy is increasing Inequalities in life expectancy exist; directly linked to levels of deprivation. Dementia is likely to increase in prevalence. There will be more people with long-term health conditions and physical disabilities. Carers will require more creative and flexible support. As life expectancy rises, more older-people will have caring responsibilities. Demand for mental health related services is increasing. There will be a small increase in the number of people with profound learning disabilities. Modelling national trends against these findings creates the following assumptions: The ageing population will increase the demand for a range of social-care services, most significantly home care, reablement, carer support, befriending, personal assistance and advocacy. Review of the Fair Access to Care criteria and declining budgets will create a gap in the market at the low and moderate needs levels; as public funding is no longer available to address these needs. Self Directed Support will create demand for flexible, agile and integrated services. During the lifetime of this strategy the rates of growth in need will remain stable for Adults of working age. Local Needs Assessment by Current Service Areas Older People At the time of writing services for older people represent the greatest area of expenditure for adult social care services in Bolton. Financial modelling tool reveal the residential care is the greatest area of expenditure, followed by nursing care and home care. 18,100 people aged over 65 have social care needs. (44% of total population aged over 65) The number of older people with social care needs may rise by up to 46% within 20 years. The number of people over 65 with dementia is likely to rise by 60% within 20 years. Locally dementia is associated with depression, anxiety, and alcohol related problems. There is evidence that older people with depression may not be assessed or treated. An ageing population will have considerable implications for services in Bolton and more work is required to plan services to meet effectively the future challenges of demographic change. The most recent estimates show the over-65 population of Bolton as 41,400, with 5,200 over 85. The over-65 population across Bolton is projected to increase by 41% over the next 20 years 4. 3 Published within the Joint Strategic Needs Assessment (JSNA) Revised ONS Mid Year Estimates, published September Bolton- Specialist Care Commissioning Strategy Page 11 of 63

14 However, the over-85 population is projected to grow significantly faster, with an 84% increase over 20 years. Analyse As the population ages, the costs of maintaining quality of life will increase. The over-85 group is the most likely to require social care, increases in the proportion of the population over the age of 85 is likely to have a significant impact on the demand for social care services. Although most people over the age of 85 rate their own health as good or excellent compared with others the same age, at least 50% have heart disease, high blood pressure, osteoarthritis or cataracts. Close to nine in ten people over 85 have at least three long-term conditions 5. The prevalence of dementia increases with age and is estimated at approximately 20% at 80 years of age 6. Dementia costs the UK economy 17 billion a year. In the next 30 years, the number of people with dementia in the UK will double to 1.4 million, while costs could treble to over 50 billion a year 7. Bolton's Joint Strategic Needs Assessment (JSNA) for older people contains detailed analysis of the health and wellbeing needs of older people in Bolton. When analysing the needs data available on the care needs of local older people, the following categories were used to classify demographic data. Low need: People who have difficulty in performing domestic care tasks and/or have difficulty with bathing, showering or washing all over; but not with other personal care tasks. Moderate need: People who have difficulty with one or more other personal care tasks. High need: People who are unable to perform one personal care task without help. Very high need: People who are unable to perform two or more personal care tasks without help 5 Biological, clinical and psychosocial factors associated with healthy ageing J. Collerton et al. 6 Dementia UK: The full report 7 Department of Health, National Dementia Strategy, Department of Health, February 2009 Bolton- Specialist Care Commissioning Strategy Page 12 of 63

15 Analyse % of people in Bolton aged 65+ with care needs 2009 Low needs 22% 6% 23% Moderate needs High needs 21% 28% Very high needs, physical Very high needs, cognitive/functional Within the local population of those people aged over 65 years, 18,140 people have some level of social care needs; with 5,130 having very high needs. Within those requiring formal social care as a consequence of those care needs approximately 1,200 have severe cognitive impairment and functional disability. It is estimated that this growth in demand for very high cognitive/functional needs will happen more slowly than for very high physical needs. People with Care Needs % increase All people 65+ With Care needs With very high needs The proportion of older people with social care needs who are receiving public funding for their care is low, with 83% of people receiving care either unsupported or self-funding. Predictive demand models indicate that this proportion should remain stable, even with increasing numbers of older people with care needs. It is currently unknown to what extent the number of older people with care needs who are funding their own social care impact on the costs of hospital and other health care services. 8 Planning4care Strategic Needs Assessment Tool 2009 Bolton- Specialist Care Commissioning Strategy Page 13 of 63

16 Analyse People aged 65+ in Receipt of Community Based Services / /2010 Day Care Direct Payments Equipment and adaptations Home Care Meals Other Professional Support Respite care Projected Support Needs for People Over 65 All People Well Supported by Informal Care All People Needing Formal Care Self Funders with Very-High Needs Unsupported or Self-Funding Publicly Funded with Very- High Needs Publicly Funded Dementia Between 2010 and 2030 the number of people with dementia is projected to rise by 60% and by 63% for those with severe cognitive impairment and functional disability. In a third of cases dementia is associated with other psychiatric symptoms such as depression, anxiety, and alcohol related problems. Bolton- Specialist Care Commissioning Strategy Page 14 of 63

17 Analyse Estimated Rise in the Prevalence of Dementia 9 People with Dementia % increase All people 65+ With Dementia With Dementia and very high needs A high proportion of people with dementia need some care, ranging from support with daily living (such as cooking or shopping), to full personal care and twenty-four hour supervision. At any one time between one third and one half of all people with dementia live in resource and cost-intensive residential or nursing home care facilities. Medical care costs also tend to be relatively high for people with dementia. National studies show that over half of all people with dementia in the United Kingdom are in care homes. However, the number of available long-stay places in care homes has fallen by one-sixth over the past decade. Projection of future demand suggests that well over double the present total places in care homes would be required by 2043 to maintain the present ratio of institutional to community services for dementia 10. Consequently a crisis of availability is predicted within the next 20 years. The current and projected financial context points commissioners in the direction of investment in affordable domiciliary care. However there remains a need to accept that the main function of long-stay residential care for older people is to meet the needs of people with advanced cases of dementia. This will bring with it requirements for market development, improvement in staff ratios and changes to workforce development. Residential and Nursing Care for Older People Publicly funded places in residential care in Bolton comprise in the region of one-third of the whole population places in residential care needs. In 2008/09 Bolton Council supported 1,094 older people in residential and nursing homes, 646 of whom are people with very high needs. However the total numbers of residential, nursing or extra care housing places per week required to meet social care needs of people aged over 65 who require formal care is 3, This represents a significant proportion of places that are self funded. The demand for residential care will increase by 2.5% per annum, with limited capacity within public sector provision and a reduction in public sector budgets, this demand would need to be met by the independent sector. 9 Planning4care Strategic Needs Assessment Tool Macdonald A, Cooper B Age and Ageing Oxford Journals Planning 4 Care 2009 Bolton- Specialist Care Commissioning Strategy Page 15 of 63

18 Analyse Home Care Publicly funded home care sessions in Bolton comprise 21% of the whole populations home care needs. It is estimated that 91,700 home care hours a week are required to meet the social care needs of all people aged 65 and over in Bolton requiring formal care 12 (including those who are either unsupported or funding their own care). Bolton Adult Social Care Services provides an estimated 19,300 home care hours a week (including 8,200 to people with very high care needs). Spend on service for people aged over 50 Respite Care Preventative Care Extra Care Personal Budgets Equipment Adult Placements Carers Reablement Residential Care Home Care Day Care Nursing Care Learning Disabilities Commissioning of Learning Disabilities services is currently the second highest area of expenditure with day services, home care and respite comprising the most expensive services. Increasing numbers of young people with complex needs surviving into adulthood Increasing pressures in meeting the needs of people with autism and learning disabled people with dementia Three times as many people with learning disabilities die of preventable causes than the general population Bolton's Joint Strategic Needs Assessment (JSNA) for learning difficulties and disabilities contains detailed analysis of the health and wellbeing needs of people with learning disabilities in Bolton. In analyzing the prevalence of Learning Disabilities in Bolton we have adopted the standard severity classifications as used in the classification of Special Educational Needs and adopted by the British Institute of Learning Disabilities. 12 Care Equation and Oxford Consultants for Social Inclusion 2009 Bolton- Specialist Care Commissioning Strategy Page 16 of 63

19 Analyse Profound and Multiple Learning Disability (PMLD) this indicates an individual with profound intellectual impairment and additional disabilities; which may include sensory disabilities, physical disabilities, autism or mental illness. Challenging or self-injurious behaviour may also be present. Severe Learning Disability (SLD) is an in individual with an IQ between 20 and 50 Moderate Learning Disability (MLD) is an individual with an IQ between 50 and 70. The overall number of people aged with learning disabilities is projected to increase by around 0.2% across Bolton to 2029, slower than the increase across the North West (4%). Nationally, evidence suggests that the number of people with severe LD may increase by around 1% per annum for the next 15 years 13 as a result of: increased life expectancy, especially among people with Down s syndrome growing numbers of children and young people with complex and multiple disabilities who survive into adulthood a sharp rise in the reported numbers of school-aged children with autistic spectrum disorders, some of whom will have learning disabilities greater prevalence among some populations of South Asian origin. Estimated numbers of adults in Bolton Aged with Learning Disabilities, by severity 14 % change Bolton NW England PMLD SLD Total MLD Total SLD / MLD with serious challenging behaviour Total The large projected growth in the PMLD group is due to expected future improvements in infant mortality and life expectancy for those with PMLD, resulting in increased prevalence rates for PMLD. This also has an expected impact on those individuals with caring responsibilities for people with PMLD Bolton has a very much lower proportion of working age adults in long-stay residential care and a higher proportion living independently in the community than the average for the North West of England, and a higher proportion of people living in the community with family or friend. 13 NICE: QOF Briefing: Learning Disabilities Planning4care Strategic Needs Assessment 2009 Bolton- Specialist Care Commissioning Strategy Page 17 of 63

20 Analyse NASCIS estimates that 565 people with learning disabilities aged known to social care services are supported in the community. This is a higher proportion than the national average. Of these, approximately 330 are living permanently with family or friends and a further 100 live independently in owner-occupied or rented accommodation. For 52.5%of those supported in the community, there is also a carer service provided, with carer advice or information being given in a further 4.9% of cases. Adults with LD supported in the community by service type 15 (NASCIS 2009/2010) Total Supported in the Community Day Care Direct Payments and Personal Budgets Equipment and Adaptation Shortterm residential care Professional Support Home Care Other Numbers in Bolton Those over People with learning disabilities have a shorter life expectancy and increased risk of early death when compared to the general population. Life expectancy is increasing, in particular for people with Down s syndrome, with some evidence to suggest that for people with mild learning disabilities it may be approaching that of the general population. All cause mortality rates among people with moderate to severe learning disabilities are three times higher than in the general population, with mortality being particularly high for young adults, women and people with Down s syndrome. Life expectancy is shortest for people who have the most support needs 16. The leading causes of death also differ from those in the rest of the population. People with an LD: are 3 times more likely to die from respiratory disease have a higher risk of coronary heart disease have higher rates of gastrointestinal cancer and stomach disorders. 17 People with an LD also have more complex health needs than the rest of the population. The types of health needs most commonly experienced differ from those of the rest of the population, and some types of health needs are specific to these individuals. They are also generally poor living on benefits or a low income, which further exacerbates health issues. It is also acknowledged that people with an LD who are of South Asian origin are at an even greater disadvantage in terms of morbidity and mortality RAP P1 and RAP P2F 2009/2010 as reported on the Online Analytical Processing Tool 16 Bittles et al Emerson and Baines 2010 IHAL Mir et al Bolton- Specialist Care Commissioning Strategy Page 18 of 63

21 Analyse Spend on service for people with Learning Disabilities 0% 20% 77% 3% Day Care Respite Care Supported Living Personal Budgets Mental Health In terms of adult social care services, Mental Health is the third highest expenditure area. In terms of cost and numbers of people affected by mental ill health, the two biggest areas of growth are dementia and depression and anxiety Depression and anxiety affects approximately 20% of Bolton s population. There are inequalities across Bolton with prevalence higher within ethnic minority communities and communities experiencing deprivation. Dementia is projected to increase in prevalence giving rise to significant financial and societal costs. Early diagnosis and intervention will improve outcomes across mental health. There is an opportunity to integrate physical health and mental health care pathways. The level of need in the population The most recent Bolton Health Survey was conducted in Using the self reported prevalence deemed from the survey, it is estimated that, approximately 48,000 of Bolton s adult residents suffered with nervous trouble or depression in the previous 12 months. There are estimated to by 36,610 adults in Bolton with a common mental disorder. This would equate to one quarter of routine GP consultations. However, Bolton GPs believe that there is an under-reporting of mental ill-health. The findings of the Bolton Health Survey noted that people from Bolton s ethnic minority communities report the lowest level of self-perceived depression or nervous trouble. These communities, however, show the highest level of mental health need based on reported symptoms. While the Bolton Health Survey ( ) is only able to analyse prevalence by the main ethnic groupings in Bolton, the local Ethnic Pakistani population continues to have the highest selfreported prevalence of mental ill-health of any ethnic group in Bolton. Bolton- Specialist Care Commissioning Strategy Page 19 of 63

22 Analyse The increasingly ageing population will have a profound effect upon mental health services. Prevalence based predictions 19 estimate that the number of people with dementia in Bolton will rise from 2,780 in 2009 to 4,460 in There is some evidence of local unmet need for depression and dementia as the number of patients on GP registers reporting depression or dementia are far below the prevalence rate surveyed in the general population. Severe mental disorders such as schizophrenia and manic depression are less common. It is estimated that at any one time there are one in 100 people with a psychotic illness such as schizophrenia. Within the next 20 years the proportion of people with common mental disorders is projected to increase by 6.9% in Bolton by 2029, compared with increases across the North West of 9.9%. The proportion of people with psychosis is projected to increase by 2% in Bolton between 2009 and 2029; with the fastest increase seen in the age groups. The implication for services is that there are around 4,250 people who are likely to be affected by severe mental disorders who require high levels of support from secondary mental health services. An additional 800 will require high levels of support from substance abuse services as well as mental health services in some cases. Mental ill-heath shows strong links to deprivation, with the areas of greatest mental health being: Tonge Moor and Hall i th Wood Halliwell Road Breightmet and North Withins Victory Lever Edge Highfield and New Bury Town Centre. Current services in relation to need At present, the vast majority of those receiving support from mental health services in Bolton are treated in the community. However, in terms of enduring and severe mental illness, 3% of those receiving social care were supported in residential accommodation, while 14% of those known to NHS mental health services had been an inpatient during the year. Half of all contacts in NHS community/outpatient mental health services are with a Community Psychiatric Nurse. Between 2005 and 2009 there was an 11% increase in the number of people aged accessing social care as a result of mental health problems adults between the ages of 18 and 64 years were supported by mental health services during Planning 4 Care Bolton Health Needs Assessment: Mental Health 2009 (Need within secondary care community mental health services) 21 Planning4care 2010 Bolton- Specialist Care Commissioning Strategy Page 20 of 63

23 Analyse In , there were 575 people aged over 65 supported by social care services for their mental health problems. This represents an increase of 8% since Older people with mental health problems were more likely to require home care, with 59% of those receiving services accessing a home care service. A significant group of people whose needs are not met effectively are those who present as an emergency in any number of services but, primarily, either in accident and emergency or by the crisis resolution and home treatment team. Work is underway to develop a care pathway across health and social care through bringing together clinicians and practitioners to identify what commissioning arrangements need to be set up to ensure that individuals are signposted to the right place, first time. A Better Future in Mind 22 indicate that the North-West has the highest level of hospital admissions for mental health related conditions. Bolton has the fifth highest spend on secondary care inpatient beds out of a total of twenty-four PCTs in the region. The total spend on secondary care represents 60% of the total mental health commissioning budget - when secure inpatient accommodation is built into the equation the total percentage spend on inpatient services is 86%. This compares with just over 0.5% spent on primary care mental health services. Spend on Services for People with Mental Health Problems 2% 4% 3% 4% 5% 0% 5% 3% 3% Primary Health Voluntary Sector Independent Sector NHS Treatment Secure Services 21% Residential Care 50% Day Care Professional Services Supported Living Preventative Care Mental Ill-Health and Substance Misuse (Dual Diagnosis) In many instances the mental health problems of individuals who also misuse drugs or alcohol are often not serious enough to meet the threshold of mental health services. In instances where mental health and substance/alcohol misuse were noted in the referral, people found it particularly difficult to obtain an initial assessment. 22 A Better Future in Mind Mental Health Services in the North West NHS North West October Bolton- Specialist Care Commissioning Strategy Page 21 of 63

24 Analyse A significant proportion of individuals with dual diagnosis have concurrent mental-health problems, including personality disorders. They are also in contact with a number of services and interventions including substance misuse services, homelessness services, probation services and prison. Many of the clients were also described as having common personality disorder traits which made ongoing engagement difficult and resource intensive. These problems include erratic attendance, not fully understanding explanations and not engaging fully with ongoing support or programmes. Adults with Physical Disabilities There is currently no single definitive measure of disability. In addition the financial modelling tools show a low level of confidence in data relating to spend in this service area. Consequently, further research and verification is required. However, there is a broad range of data which may be relevant for future commissioning priorities. Recent local studies have used the medical definition of disability. This definition focuses on the individual and regards physical disability as a physical impairment that has a substantial long-term adverse effect on the ability to carry out day-to-day activities. Using this definition Manchester University has estimated that the percentage of people with a limiting long term illness or disability in Bolton is between 19.4% and 24.1% depending on a range of assumptions 23. If disability levels remain constant the following chart projects the number of people in Bolton with a physical disability within 20years of the original survey. Rates of Physical Disability in Bolton Mobility Hearing Sight Personal Care High severity Lowseverity 23 Projections of limiting long-term illness and disability for the Greater Manchester districts 2009 Bolton- Specialist Care Commissioning Strategy Page 22 of 63

25 Analyse The 2007 Bolton Health Survey found that 19% of the population had mobility difficulties with their lower limbs, 14% had mobility difficulties with their upper limbs and 17% had mobility difficulties associated with their back. Bolton women are generally more likely to have mobility difficulties than men, particularly with the mobility in the upper body. Low mobility is also prevalent in South Asian ethnic minorities and those living in the most deprived areas of the borough. At the time of writing the latest data available from NASCIS indicated that there were a total of 6315 people with physical disabilities known to adult social care services in Bolton during the financial year 2009/ of these adults were under the age of 65. Number of adults with Physical Disabilities receiving Social Services by age group by service type in Bolton Community based services in own home 1175 Residential and Nursing Care 20 Total 1195 Age The number of people with a physical disability aged years known to services has increased by 9% in Bolton since , higher than the national average increase of 6%. It appears therefore that there has been an increase in social care provision for those with physical disabilities over recent years in excess of wider trends across the North West and nationally. Unfortunately reliable data is not available to assess whether this is a result of increased need locally or changing service characteristics. Assuming that social care services are provided to those with the most severe disabilities, it is likely that 55% of those with the most severe disabilities in Bolton (based on 2001 Health Survey for England estimates) are benefiting from these services, higher than the average across Greater Manchester (46%). Number of people with physical disabilities known to Adult Social Care in Bolton (Rounded to nearest 5) Services in own home Residential and Nursing Care Year 18 to and over 18 to and over 2005/6 No of service users /07 No of service users /08 No of service users /09 No of service users /10 No of service users NASCIS RAP P1 Bolton- Specialist Care Commissioning Strategy Page 23 of 63

26 Analyse The most recently available audited data reveals that there were 17,780 people claiming Disability Living Allowance in Bolton in May 2009, almost 9% of the adult population. The number of DLA claimants in Bolton has grown by 22.5% since May Disability Living Allowance is intended to meet the costs for personal care, attendance and some travel costs for disable people under the age of 65.. Notable features of the social care services provided in Bolton are: In % of people with physical disabilities aged 18 to 64 known to services were supported in the community (compared with an average of 83% across the North West); Of those supported in the community a higher than average % receives equipment and adaptations (74% of those aged 18 to 64 years compared with 55% across the North West.); Bolton s Housing Market Assessment 2009 found that: Only 23.9% of wheelchair user households live in a property with suitable adaptation; Of household members with support needs, some 19.6% (2,689 implied) felt they needed care or support which is not currently provided; 9.8% of all dwellings have been adapted to meet the needs of a disabled person. In terms of the nature of adaptations, 53.4% have handrails / grabrails, 45.1% have bathroom adaptations and 30.3% have a ground floor toilet; 13% of BME households stated that their current accommodation was inadequate as their housing was affecting the health of a household member. There is a significant unmet need for housing provision for people with disabilities aged 50+ among those on the housing register. Young People in Transition There is anecdotal evidence that for many young people the process of transition from child to adult services is problematic and costly. Certainly, in Bolton, the costs of transition services appear to have quadrupled over the last four years. There is a need to understand the impact of support provided for any young people who no longer meet eligibility criteria once they have made the transition to Adult Services. To adequately meet the needs of young people in transition commissioners will require quantitative data on parents' and young people's satisfaction with service support; met and unmet needs; services used; and perceptions of receiving coordinated support. Further data enabling the comparison between different services and different groups of young people is also necessary. Bolton- Specialist Care Commissioning Strategy Page 24 of 63

27 Analyse Transition Costs Transition Costs The analysis, combined with other factors in our local environment, result in the following key messages: Numbers of young people are increasing in the long term; over the next three years, the challenge will be primarily around individual transition issues rather than volume, although the needs of south Asian young people may present new challenges. From 2015 onwards, volume increases, and forward planning for transition will become critical on both quality and financial grounds; The dip in numbers of year olds in the general population is unlikely to be fully reflected in the learning disabled population due to reduced mortality. This group is also likely to be affected by the loss of or reduced support from older carers; Substance Misuse There are an estimated 2,472 problematic drug users in Bolton as of November There are 1,446 drug users in effective treatment as of November Treatment services are judged to be working well. There are changing drug use trends moving away from heroin and crack cocaine. Alcohol use in combination with multiple drug use a growing trend. The majority of Bolton s drug-users who are currently in-treatment are receiving treatment for opiate and/or crack cocaine use. However, the problematic drug using population with a history of heroin and crack misuse is ageing; consequentially the treatment needs of this population are changing. There are multiple health consequences of long-term use of heroin and/or crack cocaine; including both direct effects of the drugs themselves, effects resulting from intravenous drug use and the often chaotic marginal lifestyle associated with misuse of Class A drugs. This population is more likely to experience Bolton- Specialist Care Commissioning Strategy Page 25 of 63

28 health problems as a result of long term use including heart disease, pneumonia, cancers, collapsed veins, heart valve infection and liver disease. Analyse Drugs are becoming pervasive within youth culture and, as a result, new trends of non-problem drug use are emerging. This type of substance use tends to involve the use of a cocktail of drugs including cannabis, cocaine, alcohol, ecstasy, ketamine, mephedrone and other misused substances described as legal highs. The Home Office estimates of opiate and crack use indicate a continuing trend toward combined opiate and crack use rather than either being used in isolation. The joint use of heroin and crack accounts for a larger proportion of problematic use in the groups of clients in treatment last year, or for two to four years, than for clients in treatment for a longer period. This indicates that this use profile continues to become more common. In addition the number of non-heroin and crack users in Bolton may be rising as the problem drug use population plateaus. There is also evidence of an emerging trend of multiple drug use, particularly among young people. The long-term health consequences of this type of multiple drug use include cardiovascular problems, cognitive deficiencies and depression, the risk of blood-borne virus infections and liver disease as a result of alcohol use. There will also be long-term health effects of newer and emerging substances such as ketamine and mephedrone, though the full impact of these will not be known for several years. Changing Drug Use by Treatment Profile 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% In Treatment March 2009 In Treatment During 2009 Known to treatment Other Substances Benzodiazepine Cannabis Ampetamine Cocaine Crack Opiate Opiate and Crack Analysis of the treatment system indicates that services are working together well; staff are beginning to demonstrate understanding of all that the different services have to offer clients, and new clients entering the treatment system are being encouraged and supported by staff to access its various components. However, referrals from community support into the treatment system can and must be increased and improved; another identified issue is the significant number of clients who have been in treatment for a longer period of time, who as a consequence may have reduced access to the opportunities offered to new clients, i.e. blood-borne virus testing and access to psycho-social interventions rather than prescribing in isolation. Bolton- Specialist Care Commissioning Strategy Page 26 of 63

29 Analyse During the research phase of this strategy it was noted that a high proportion of drug treatment clients in Bolton are likely to have mental health needs. Efforts are needed to ensure that nonproblem drug users with less severe mental health problems are not overlooked by the dual diagnosis treatment system. In terms of future need, as the population ages, it is more likely that they will enter treatment and require more services such as detoxification and residential rehabilitation, plus skills for life/reintegration support. Alcohol Misuse Projections based on local evidence suggest that: There are between 38,000 and 55,000 Hazardous Drinkers in Bolton. There are between 11,000 and 17,000 Harmful Drinkers in Bolton. There are between 44,000 and 58,000 Binge Drinkers in Bolton. There are between 5,000 and 10,000 Dependent Drinkers in Bolton. 10% of projected dependent drinkers are known to treatment services. 1% of projected hazardous/harmful drinkers are known to treatment services. There is potentially enormous demand for alcohol related treatment and prevention. Alcohol has been identified as a priority area for Bolton. The Local Alcohol Profile (LAPE) for Bolton shows that the borough to scores worse than the national and regional average across a range of alcohol indicators, many of which maintain a statistically significant difference. When analysed against baseline data from across Greater Manchester, Bolton has the highest percentage of hazardous drinkers within its population at 27%. Increasing risk drinkers account for 23% of the population and 7% of the population drink more than 50 units of alcohol per week. Currently there are 4 people per 1000 population in Alcohol Treatment across Bolton. The number of alcohol related deaths due to circulatory disease increases with age; representing 17% of all deaths, 31% of all deaths, 50% of all deaths, and 74% of all 75+ deaths. This represents a very high number of largely preventable deaths in the borough. A similar pattern is seen for alcohol related high blood pressure and cancers, peaking in the age group. After circulatory diseases, alcoholic liver disease is the most significant in the age group at 22%. The highest alcohol-related mortality is in the most deprived areas of Bolton. A greater proportion of the deaths of this group are due to illnesses associated with excessive alcohol consumption, despite fewer of this population drinking over the sensible weekly limit. This problem crosses a wide range of health and social issues in Bolton. All deprivation levels within Bolton have a similar proportion of severe and problem drinkers. In addition it is also the case that the patterns of drinking are more extreme in more deprived populations so that whilst fewer people overall drink over the recommended limits there is a marked and severe increase to those at high or very high risk levels compared to other areas. Taken together, these explanations reinforce the general conclusion that the severity of the inequalities present in Bolton concerning alcohol is of concern. The World Health Organisation now considers alcohol to be the second biggest cause of preventable death (after smoking) in the UK. Alcohol misuse is a persistent problem that crosses all sectors of health and social care. Bolton- Specialist Care Commissioning Strategy Page 27 of 63

30 Analyse Bolton rates significantly above national levels for most of the indicators in the Local Alcohol Profile, indicating the importance of alcohol related health and harm in the borough. At this stage, the potential impact of the economic downturn on Bolton s drug strategy targets and performance is unknown. Locally, it is expected that there will be an increased number of job losses. This will have impacts including income deprivation and mental illness. These added anxieties for families already experiencing a range of barriers to well-being will have future implications for mental health services, substance misuse services and alcohol treatment services. Services which may be able to provide early identification and support for individuals, will be increasingly significant. Providers and commissioners will need to monitor capacity and demand for these services. There may also be an impact on the efforts of alcohol misusers to recover from their dependencies as they struggle harder to overcome barriers to their re-integration into society in a time of recession. As families in Bolton have less disposable income, then pressure may be put on drinkers to enter treatment and spend less money on alcohol, thereby putting additional strain on the alcohol treatment system. Carers Existing services are only reaching a minority of carers in the borough. Identifying hidden carers is a priority. The number of informal carers is expected to increase. One in four carers has their ability to work affected by caring Half are in poor health Half expect their caring responsibilities to increase over the next five years 25 We recognise that carers are vital to ensuring that vulnerable people receive the care that they need. In more recent years there has been more emphasis on providing support to carers. The culmination of this work has been the development of a comprehensive Carer s strategy supported by a range of service developments. Identifying hidden carers is a priority of this strategy. 25 (Survey of Carers in Households December 2010 NHS Information Centre Bolton- Specialist Care Commissioning Strategy Page 28 of 63

31 Analyse 70 Bolton's Carers by Age Group and Sex to to to to % Total of Age Group % Carers Male % Carers Female Carers in Bolton consistently report higher levels of health problems compared to non-carers 26. Prevalence of pain in carers is higher than it is for Bolton as a whole. As well as differences for physical health, carers also demonstrate a higher prevalence of mental health problems compared to non-carers. In addition carers are more likely to be obese than the general population of Bolton. Numbers and percentage of carers aged 16+ in poor health by number of hours of care provided Total number of carers Total number of carers not in good health % of carers not in good health Number of carers providing 50+ hours of care a week in poor health % of carers providing %0+ hrs a week in poor health % of noncarer population in poor health Bolton 27,813 3, , Carers are also far more likely to experience a severe lack of social support. There is a higher prevalence of fuel poverty amongst carers than in the general population. This is related to the financial difficulties reported by carers; despite a lower rate of unemployment amongst carers than the Bolton average. The number of informal carers is expected to increase significantly in future years as the number of older and disabled people increases. Longer lives, higher rates of survival from illness, accident or disability, and more sophisticated consumer attitudes and behaviour are imposing increasing demands on the care and support system. 26 Bolton Health and Lifestyle Survey 2007 Bolton- Specialist Care Commissioning Strategy Page 29 of 63

32 Analyse The health and social system is reliant on the sustained commitment of families and carers to providing informal care. Unpaid care is the foundation of community care in the Bolton. The bulk of care is provided by family members, partners and friends. It is estimated that there are twice as many unpaid carers as paid staff in the NHS and social care workforce combined 27. Furthermore, the number of carers is predicted to increase by a further 50% by Bolton: People Supported Well by Informal Care Through a combination of the current economic crisis and the ageing population the ratio of people working versus those in retirement will increase from its current level of 3 to 1, to 4 to 1 by Consequently the number of older people with caring responsibilities for people over the current state retirement age is likely to increase. Carers will require support to combine paid work and care, and disabled and older people will require additional support to be active in the labour market. By 2017, we will reach a point where there will be a shortage of care and the probability of placing greater pressures on working age family members will increase Tipping Point For Care: Carers UK Projections from 2001 Census Data 29 Shaping the Future of Care Together, Cm 7673, London: The Stationary Office, Dept. of Health Linda Pickard: Informal care for older people provided by their adult children: projections of supply and demand to 2041 in England. Report to the Strategy Unit and Department of Health (2008). Bolton- Specialist Care Commissioning Strategy Page 30 of 63