Making the case for a rehabilitation facility: helping rehabilitation psychiatrists to work together with commissioners and senior service managers

Transcription

1 Making the case for a rehabilitation facility: helping rehabilitation psychiatrists to work together with commissioners and senior service managers Faculty report FR/RS/5 Faculty of Rehabilitation & Social Psychiatry November 2010 Tom Edwards, Richard Meier & Helen Killaspy

2 Acknowledgements The authors also wish to thank the following for their contributions:- Dr Charlotte Harrison Dr Frank Holloway Dr Debbie Mountain Dr Tor Pettit Dr Glenn Roberts Dr Alison Rose-Quirie Dr Paul Wolfson

3 Components of the Presentation Introduction Summary of the five types of inpatient rehabilitation facility (from the RCPsych template for rehabilitation services) Preparing the case - what rehabilitation psychiatrists need to know before making the case for a rehabilitation facility Working with Commissioners Elements of an Outline Business Case Looking Ahead Conclusions

4 Introduction 1 Historical Perspective Closure of large mental health hospitals in recent decades Disinvestment in local rehabilitation services Led to an exponential rise in the numbers of patients - whose needs lead them to require longer-term and/or specialist inpatient care - being placed out of area (The Forgotten Need for Rehabilitation in Contemporary Mental Health Services - F Holloway 2005)

5 Introduction 2 Commissioners Held back in ability to stop the growth in out of area placements by a lack of policy guidance relating to rehabilitation services Insufficient suitable step-down accommodation for patients ready to move on from forensic settings Lack of appropriate systems for their care co-ordination and review has further exacerbated the problem

6 Introduction 3 Out of Area Treatments Acknowledging the Range of Provision Complex & specialist nature of some patients needs means that the use of some out of area treatments is clinically justified Most out of area placements are provided by the independent sector Some out of area placements provide highly specialist services commissioned from a number of geographically spread region. This is appropriate & represents an economy of scale not realisable locally due to the low volume of patients with very specialist requirements

7 Introduction 4 Problems with Out of Area Placements Inappropriate use of out of area placements has negative clinical, social & economic consequences Socially dislocated from family, friends & local communities Disaggregated care co-ordination & care management impair timely reviews leading to over-support & institutionalisation Financial impact of this on continuing care & community care budgets is significant Finances released for investment in the local mental health economy by addressing the inappropriate use of out of area treatments (Killaspy, H., Meier, R. A Fair Deal for mental health includes local rehabilitation services. The Psychiatrist 2010)

8 Introduction 5 (Mental health & the economic downturn: National priorities & NHS solutions. 2009) In , OATs cost the NHS 222 million, an increase of 63% on the previous year (Mental Health Strategies, 2005) A freedom of information enquiry to PCTs and local authorities in England found that:- approx. 25% of all residential & nursing placements funded were OATs costing 66% more than local placements with an estimated cost to the NHS & local authorities in of over 300m

9 Introduction 6 New Horizons - Department of Health Had a clear aim to reduce out of area treatments & has been incorporated into the latest QIPP programmes Department of Health. New Horizons: A Shared Vision for Mental Health In Sight and In Mind National Mental Health Development Unit work stream on out of area treatments (incl. Royal College of Psychiatrists) Toolkit for health, social care & housing commissioners aims to:- Limiting the number of people placed inappropriately Reducing the number of people placed at distance from families & social networks Minimising the length of time that people spend in out of area services Maximising & improving care coordination & monitoring of placements Specifying services to actively promote independence Encouraging services to be commissioned on a needs basis, at appropriate costs & within commissioning resources

10 Introduction 7 Clinicians, commissioners & senior service managers can only achieve these working collaboratively New NHS Commissioning Board hold commissioners to account for the provision of a comprehensive healthcare service:- responsibility for commissioning services that can only be provided efficiently and effectively at a national or a regional level central role of the new Board will be to improve patient outcomes, by supporting, developing & performance managing an effective system of clinical commissioning groups Five domains of the proposed Outcomes Framework - Liberating the NHS: Transparency in Outcomes include:- enhancing quality of life for people with long-term conditions helping people to recover from episodes of ill health or following injury ensuring people have a positive experience of care treating and caring for people in a safe environment protecting them from avoidable harm

11 Introduction 8 Issue for clinicians, commissioners & service managers Many independent sector providers are also keen to assist in the repatriation of those currently in inappropriate out of area placements Faculty of Rehabilitation and Social Psychiatry of the Royal College of Psychiatrists has described the 5 types of rehabilitation inpatient facility needed to provide a comprehensive rehabilitation service

12 Introduction 9 As well as a range of community services, the 5 types of rehabilitation inpatient facility include:- Community rehabilitation units High dependency rehabilitation units Longer-term complex care Secure rehabilitation units Highly specialist inpatient services Wolfson, P., Holloway, F., Killaspy, H. Enabling Recovery for People for Complex Mental Health Needs: A template for rehabilitation services 2009

13 Community Rehabilitation Unit Patient group & focus: need time to recover from a psychotic episode to optimise medication & reduce side-effects to a minimum focus on engagement, psychological interventions & ADLs Recovery goal: to develop skills & support packages including families/carers, for a successful return to community living with variable degrees of support Site: ideally community-based, with a focus on developing practical ADLs in a domestic environment close to home community Length of admission: usually up to 1 year Functional ability: domestic environments acquiring & utilising activities of daily living skills for community living Risk management: generally low-staffed open units with some specialist risk assessment skills Degree of specialisation: local generic rehabilitation units predominantly for patients with treatment-resistant psychosis for trusts serving a population of around

14 High Dependency Rehabilitation Unit Patient group & focus: highly symptomatic, have several or severe co-morbid conditions significant risk histories, a high proportion are detained, have challenging behaviours & often have had forensic admissions or spent periods of time in psychiatric intensive care units focus is on thorough ongoing assessment, medication, engagement, supporting clients in managing their behaviour & re-engaging with families & communities Recovery goal: usually involves a move on to other facilities in the rehabilitation service before community living or residential care Site: usually hospital-based for support from other units & out-of-hours cover Length of admission: 1 to 3 years Functional ability: domestic services provided by the unit rather than its residents; participation in domestic activities with support encouraged as part of therapeutic programme. Risk management: higher-staffed (often locked/lockable) units able to manage behavioural disturbance Degree of specialisation: serving a population of around to 1 million; has a major role in returning patients from secure services & out-of-area placements

15 Long Term Complex Care Patient group & focus: usually have high levels of disability from complex co-morbid conditions with limited potential for future change associated with significant risk to their own health & safety or to others co-morbidity with serious physical health problems will be common & require monitoring & treatment Recovery goal: other rehabilitation options will usually have been explored the disability & risk issues remain but a more domestic setting that offers a high level of support is practical promotion of personal recovery, improving social & interpersonal functioning Site: usually community-based, sometimes on a hospital campus Length of admission: several years Functional ability: domestic services provided by the unit rather than its residents, although participation in domestic activities with support encouraged as part of therapeutic programme. Risk management: higher staffed units but emphasis on unqualified support staff; risk management based on relational skills and environmental management e.g. low expressed emotion. Degree of specialisation: serving a population of around to 1 million

16 Secure Rehabilitation Unit Patient group & focus: have diverse needs but have all have been involved in offending behaviour all will be detained under the Mental Health Act 1983 and the majority under Part 3 of the Act levels of security will be determined by Ministry of Justice requirements and a key task will be the accurate assessment and management of risk. patients will have varying levels of functional skills & are likely to require therapeutic programmes tailored to their offending behaviour in addition to their mental disorders Recovery goal: to leave hospital with the probability of close supervision by a local community forensic team or assertive outreach team Site: usually a hospital campus Length of admission: 2 years + depending on nature of offending behaviour & psychopathology Functional ability: domestic services provided by the unit rather than its residents; participation in domestic activities with support encouraged as part of therapeutic programme Risk management: higher-staffed units able to manage behavioural disturbance with full range of physical, procedural &relational security & specialist risk assessment /management skills Degree of specialisation: low secure for populations of 1 million plus to high secure for populations of around 15 million

17 Highly Specialist Services Patient group & focus: have very particular needs e.g. acquired brain damage, severe personality disorder, co-morbid autism-spectrum disorder with psychological approaches to treatment & management predominate often, nearby step-down units will be required that allow people to move on but maintain contact with the specialist expertise they require very active liaison with referrers is an essential aspect of these services Recovery goal: to move on to more independent settings often with complex care packages developed with advice of the specialist service Site: within hospital complexes or in stand-alone units Length of admission: 1 to 3 years, but highly variable depending on nature of the conditions & specialist treatment programmes Functional ability: variable, but hopefully covering a range from full domestic services to high levels of patient participation in ADLs Risk management: varies with risk profile and treatment needs Degree of specialisation: highly specialist facilities for specific conditions & complex co-morbidities for populations of several million

18 Preparing the case - what rehabilitation psychiatrists need to know before making the case for a rehabilitation facility 1 Who They Need To Persuade Senior management within the provider organisation Emphasis on potentially improving the wider care pathway e.g. by providing for patients stuck in acute wards Enhancing the current rehabilitation care pathway (where it exists) Include some description of the pathway beyond the proposed facility e.g. to supported accommodation

19 Preparing the case - what rehabilitation psychiatrists need to know before making the case for a rehabilitation facility 2 What the Strengths of the Different Sectors Involved Are and How They Can Collaborate Effectively Independent sector providers are increasingly developing rehabilitative care pathways - though often still located out of area (e.g. step down facilities & CTO s) Greater collaboration between:- local NHS commissioners providers independent & third sector providers can lead to mutually beneficial partnerships to provide appropriate care pathways locally

20 Preparing the case - what rehabilitation psychiatrists need to know before making the case for a rehabilitation facility 3 What the Strengths of the Different Sectors Involved Are and How They Can Collaborate Effectively (contd.) Independent sector can develop services at greater speed & with greater flexibility to meet changing patient needs than the NHS through its access to capital Voluntary sector has enormous experience in the provision of supported accommodation & facilitation of service users engagement in meaningful occupation An understanding any potential collaborations with the 3rd sector can be of great importance in the preparation for the proposed rehabilitation facility

21 Preparing the case - what rehabilitation psychiatrists need to know before making the case for a rehabilitation facility 4 What the Level of Need for the Proposed Service is (or Existing One if its Continuation is Under Threat) This will need to include:- numbers of patients placed out of area their clinical profile length of stay whether the number of suitable patients is large enough to justify the particular type & size of rehabilitation unit or service proposed Some NHS Trusts & PCTs employ dedicated staff to review all patients in out of area treatments which:- facilitates comprehensive clinical & social needs assessments identifies how many patients could be repatriated to existing/proposed rehabilitation services or supported accommodation in the local area Many rehabilitation psychiatrists also aware of :- the no. of patients placed out of area their clinical needs & associated costs

22 Preparing the case - what rehabilitation psychiatrists need to know before making the case for a rehabilitation facility 5 What the Range of Current Provision is, and How Any Proposed Service Would Complement This What type of rehabilitation service is proposed How this will reduce the need in the future for individuals with complex mental health needs to be transferred to out of area placements Allow appropriate flows of patients through the care pathway & reduce pressures elsewhere within the local service system The five types of rehabilitation inpatient facility (as described previously) The location of any proposed service (e.g. rural/urban) will have a bearing on the proposal & may present additional challenges in terms of the logistical & demographic characteristics

23 Preparing the case - what rehabilitation psychiatrists need to know before making the case for a rehabilitation facility 6 What Size the Potential Financial Flows from the Proposal is Some estimation of the potential financial flows that could result from the provision (or re-provision) of the proposed facility or service Understanding of how these could be reinvested locally Could be in partnership with independent &/or third sector providers, to develop local rehabilitation & supported accommodation services A Comparison of service users out of their local area and local rehabilitation service users in Islington (Killaspy et al 2009). The outcomes were:- 51 service users identified & 40 reviewed in 1 st 30 months of the plan 25 assessed as suitable to move 13 relocated - all to more independent accommodation associated financial flows reinvested into new local highly supported flats

24 Preparing the case - what rehabilitation psychiatrists need to know before making the case for a rehabilitation facility 7 Who the Competition is NHS providers increasingly have to compete for investment from commissioners finite budgets The independent sector is:- able to move into niche areas of specialist mental health service provision not constrained by serving a particular geographical area in the same way as NHS providers able to make appropriate economies of scale for very specialist care where the local demand would clearly not justify local investment Independent sector & voluntary sector have a longer history than NHS providers in attracting investment through competition

25 Working With Commissioners 1 Timing of Involvement of Commissioners The point at which commissioners become involved in any proposal may well be critical to its chances of success Rather than presenting PCT or GP consortia commissioners with an exhaustive business case, it is more advisable to involve them earlier in the process Give them the opportunity to develop an outline business case in collaboration with clinicians and service managers

26 Working With Commissioners 2 Clinical Case Also Needs to be Made Clinicians in the best position to do this - stressing issues of equity of, & access to, high quality clinical care addressing needs of local population Need to stress:- advantage of geographical proximity for service users to keep in touch with their family, friends & local community continuity of clinical care provided by local services that allows effective monitoring of progress care co-ordinator's & rehabilitation practitioner s knowledge of local appropriate & available move-on facilities in making suitable discharge plans for the service user in a timely fashion lack of financial disincentives to service user move-on within a local rehabilitation system benefits to the service user of increased autonomy through accessing treatment more locally

27 Elements of an Outline Business Case 1 Introduction Needs to provide adequate detail concerning areas such as the strategic context & potential financial advantages of the project, while being sufficiently succinct to communicate the salient points for a full business case to be sanctioned subsequently What is the proposal about? a new facility such as an inpatient rehabilitation unit reprovision of an existing facility reconfiguration of rehabilitation services across an area Are there any potential collaborative partnerships across providers? Are there any competitors? what are their strengths & weaknesses in comparison to the local proposal?

28 Elements of an Outline Business Case 2 Introduction (contd.) A brief statement regarding rehabilitation services & their importance (depending knowledge/expertise/interest which the commissioners being sought to influence have about rehabilitation services: e.g. general definition of rehabilitation services, and/or a description of their purpose) Indication whether this is an options paper or outline business case for one particular proposal (containing explicit justification regarding choice of site for the proposed unit) Brief statement about the need for the proposed change:- detail what benefits the proposed change would bring, and for whom e.g. a typical patient that a rehabilitation service might help

29 Elements of an Outline Business Case 1 The Case for Change An outline of current service provision & implications of the status quo Analysis of whether adaptations could be made to existing facilities to obviate the need to build, purchase or lease new sites An explanation of how the proposals might help the PCT/GP Consortium provide a more comprehensive suite of care five types of rehabilitation inpatient facility - Recovery for People for Complex Mental Health Needs: A template for rehabilitation services 2009 (as described previously)

30 Elements of an Outline Business Case 2 The Case for Change (contd.) Service delivery benefits of how the proposal might include:- enhance the whole system of local care pathways? make for more accessible, locally based services? enable care co-ordinators to be better able to monitor the progress of their patients? negate the future requirement for patients having to be transferred out of area? help repatriate those already in such placements? Highlighting vulnerable groups for whom the impact/benefits might accrue from the proposal which the local PCT/GP consortia have identified as:- disadvantaged or a priority especially socially-excluded

31 Elements of an Outline Business Case 3 Proposed Service Model(s) Description of the proposed model reference to the five types of inpatient rehabilitation facility Evidence of the model s efficacy in clinical terms:- Enabling recovery; the principles and practice of rehabilitation psychiatry. Gaskell, London. Roberts, G., Davenport, S., Holloway, F., Tatton, T. (2006) Principles and Practice of Psychiatric Rehabilitation: (2009) by Patrick W. Corrigan et al Recovery from Disability: Manual of Psychiatric Recovery (2008) Robert Liberman An analysis of risk for each of the options regarding:- the clinical risks e.g. level of clinical risk & support in a psychiatric emergency? the health & safety risks e.g. proposed building layout fit for purpose? of current provision versus the options outlined in the case the reputation of all the organisations involved if a collaborative venture with neighbouring Trusts/other providers is being proposed

32 Elements of an Outline Business Case 4 Community Involvement and Support Acknowledgement of the potential sensitivities which various options may have including any findings from, or plans for:- consultations with service users & carers the wider public e.g. use of an existent building may need planning permission for a significant change of use with the plans

33 Elements of an Outline Business Case 5 Risks Acknowledgment of the financial risks (e.g. if the proposal were to include financial flows from reconfiguration/sale of another facility that did not deliver the projected surplus) The planning risks (i.e. if the proposal requires planning permission that may be rejected for any reason) The market risk (e.g. if the estimated number of patients who could potentially relocate to the new facility is not achieved/sufficient referrals are not forthcoming) Acknowledgment of any risks resulting from doing nothing

34 Elements of an Outline Business Case 6 The Strategic Case Are there any CQUIN (Commissioning for Quality & Innovation) targets which the proposal might help local providers to meet? the CQUIN payment framework is a national framework for locally agreed quality improvement schemes makes a proportion of provider income conditional on the achievement of ambitious quality improvement goals & innovations agreed between Commissioner and Provider, with active clinical engagement includes goals in the three domains of quality - safety, effectiveness and patient experience (and to reflect innovation) Are there any regional strategies? e.g. does the proposal fit in with the PCT s or GP consortium s strategic plan?

35 Elements of an Outline Business Case 7 The Strategic Case (contd.) Is there a national policy? NMHDU document (March 2011) - toolkit for health, social care & housing commissioners Royal College of Psychiatrists report in Mental health & the economic downturn: National priorities & NHS solutions. (2009 Department of Health. New Horizons: A Shared Vision for Mental Health Reported the plan to reduce the use of out-of-area placements by ensuring sufficient high-quality local services

36 Elements of an Outline Business Case 8 The Commercial Case A financial model that shows phased start-up and cash-flow requirements An estimate of financial issues/benefits may generate increasing income over a period of time as the service reaches full capacity & steady state, rather than being at full operational capacity from the start potentially a facility/service to the PCT/local GP consortia to reinvest funds into the local health economy rather than spending them outside the borough on out of area treatments

37 Elements of an Outline Business Case 9 The Commercial Case (contd.) Capital costs (brief details, including approximate figures if available), regarding aspects of the proposal such as:- a range of possible sites whether these are leased, already owned for another purpose whether land &/or property would need to be purchased Workforce implications & costs such as:- what staff would be required for the proposed facility/service? are there any costs associated with any proposed movement of existing staff? e.g. medical cover out of hours/banding for nursing staff

38 Elements of an Outline Business Case 10 Managing Change If amendments to an existing service, then might need to refer to: managing the incremental change in the culture of the unit inform referring mental health services work to help current staff adapt as any modified remit and referral criteria begin to take effect If the development of a new rehabilitation facility, then this section might reflect the need for clinicians to: work with the providers to inform the building & service design to ensure best practice engage with, & inform, referring mental health services about the purpose & remit of the new facility to ensure that referrals to the new service are appropriate (work hard at informing the referring team over the reasons as to why a patient has been declined admission to the facility) recruitment drives & redeployment of staff with new facility new team formation issues as the service opens

39 Looking Ahead 1 Plans to send the Making the case for a rehabilitation facility Report to all College Rehabilitation Faculty Psychiatrists & once the GP consortia arrangements are formalised, to all commissioners in England Downloadable version of the Making the case for a rehabilitation facility Report from RCPsych Website at: Downloadable version of NMHDU toolkit (March 2011) In sight and In Mind guide to commissioners and practitioners in the appropriate review of out of area placements at the RCPsych website at:

40 Looking Ahead 2 AIMS Rehab (July 2011) Help demonstrate compliance with the Care Quality Commission s Standards for Better Health & support implementation of NICE guidelines The standards include the following areas:- General Standards Timely and Purposeful Admission Safety Environment & Facilities Therapies & Activities Guide & influence current/future provision of rehabilitation inpatient facilities through these standards Download at the RCPsych website

41 Conclusion Do prepare as much evidence as possible to present the outline business case Be clear of the market forces operating in the area of rehabilitation facility you are considering developing/supporting the continuation of (if under threat) Seek support early from senior management Engage Commissioners early in the project development inform their understanding of the reasons for the business case for the proposed rehabilitation facility Maintain a clear vision of why the rehabilitation facility is needed there will be setbacks/delays/challenges from various sources (both foreseen & unexpected) Continue to be mindful of threats to the rehabilitation facility changes to health strategies/funding issues/market force changes

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