Meeting Title: Greater Nottingham Joint

Commissioning Committee Date: 27 March 2019

Paper Title: Thematic Review: Transforming Care For LD&ASD

Paper Reference:

GNJCC/19/051

Sponsor: Nichola Bramhall, Chief Nurse and Director of Quality

Previous Related Papers:

None

Recommendation: Approve ☐ Endorse ☐ Review

☐ Receive/Note for:

Assurance

Information

☒

Summary Purpose of Paper:

The purpose of this paper is to provide information to the Joint Commissioning Committee on the delivery of the planned care sections of the Operational Plan and delivery against national standards and targets. It is intended to assure the committee of the work being undertaken to deliver the local Transforming Care Programme, against the nationally agreed inpatient targets. The paper is accompanied by patient stories. The report is structured as follows: Section 1: Patient stories Section 2: Context, National Strategy Section 3: Section 4:

Local Strategy Update on Performance against National Standards

Section 5: Current Performance and Key Challenges

If paper is for Approval/Endorsement, have the following impact assessments been completed?

Equality / Quality Impact Assessment

Yes

No

N/A

☒

☐

☐

Data Protection Impact Assessment

Yes

No

N/A

☐

☐

☒

Conflicts of Interest: Recommended action to be agreed by the Chair at the beginning of the item.

☒ No conflict identified

☐ Conflict noted, conflicted party can participate in discussion but not decision

☐ Conflict noted, conflicted party can remain but not participate

☐ Conflicted party is excluded from discussion

Have All Relevant Implications Been Considered? (please tick where relevant)

Clinical Engagement ☒ Patient and Public Involvement ☒

Quality Improvement ☒

Equality, Diversity and Human Rights

☒

Integration ☒ Innovation / Research ☐

Improving Health Outcomes / Reducing Health Inequalities

☒ Patient Choice / Shared Decision Making

☒

Financial Management ☒ Corporate Governance ☒

Is the Information in this paper confidential? Yes ☐ No ☒

If yes, please state reason why:

Risk: (briefly explain any risks associated with

the paper) N/A

Recommendation:

The Joint Commissioning Committee is asked to:

ACKNOWLEDGE the patient’s story

ACKNOWLEDGE the paper which provides information on the changes made and impact had to date, as well as the key challenged faced

NOTE the governance and mechanisms in place to deliver the national targets in relation to LD/ASD inpatient care

ACKNOWLEDGE the conflict of priority which needs to be managed, between national targets and ensuring that discharges from hospital are both safe and sustainable

1

Thematic Review: Transforming Care for People with Learning Disability

(LD) & Autistic Spectrum Disorder (ASD)

Introduction

The purpose of this paper is to provide assurance to the Joint Commissioning Committee on the

delivery of the ‘Transforming Care’ section of the Operational Plan, as well as providing a detailed

up-date on delivery against national standards and targets. It is intended to provide an update on

the work of the Nottinghamshire Transforming Care Partnership (TCP), as it implements its

programme of transformation of services for people with learning disabilities and/or autism who

may display behaviours that challenge, and to assure the Committee that relevant processes and

metrics are in place in relation to the delivery of key performance targets, with mitigating actions in

place where there are risks to delivery.

The report is structured as follows:

Table of Contents

Section One: Patient stories – Discharges from Long Stay Hospitals .............................................. 1

Section Two: Context ...................................................................................................................... 2

i) National Strategy ...................................................................................................................... 2

ii) Local impact and performance targets……………………………………………………………….4 Section Three: Local Strategy………………………………………………………………………………5 Section Four: Update on performance against national standards .................................................. 8

Section Five: Current Performance and Key Challenges............................................................... 12

1

Section One: Patient Stories – Discharges from Long Stay Hospitals

Names have been changed to protect patient confidentiality.

Sarah’s Story

Sarah is in her 40s and has a moderate learning disability as well as autism. She experienced a placement

breakdown in the community when she was in her late 20s and was admitted to an assessment and

treatment unit (ATU). The ATU struggled to meet her needs and from there she was transferred to a variety

of hospitals before being placed in a low secure hospital in Staffordshire. Whilst there she found it hard to

tolerate being in a shared environment, and mixing with both staff and fellow patients. She exhibited a high

degree of challenging behaviour, leading to her being placed into a seclusion suite within the hospital where

she remained for 8 years. The inpatient staff stated that they could not release her from the seclusion area

and much of the contact with staff took place by interacting through a hatch in the wall. Sarah struggled to

allow or accept even very familiar staff to enter her area, and was deemed to have self-isolated. She was

described for many years as ‘too dangerous to discharge’ from an inpatient setting. Following 2 years of

planning, the responsible CCG and Local Authority commissioned a bespoke placement for Sarah consisting

of a single person apartment with dedicated staffing in Nottinghamshire where she has resided for the past 3

years. Despite the challenges that have been faced both by Sarah and her staff team since she moved into

her apartment, the number and severity of incidents have reduced dramatically. Staff have adopted a

‘withdrawal’ policy of leaving the accommodation when it appears necessary to do so, and as an

individualised package, allow Sarah to make decisions about what she wants to do, when she feels ready

and able to engage in activity. This has included Sarah deciding to leave her apartment to walk in the local

area, or accessing local shops/amenities via secure transport at her own pace, and with a familiar staff

supporting her discretely. Sarah having free access to her whole apartment, having greater control over her

daily and weekly routine, and successfully entering public spaces and choosing how to spend her own

money, have for her been huge successes which had for much of her life seemed impossible goals to reach.

Statutory agencies involved in her case such as NHSE regional team, the CQC and her Responsible

Authority have concluded that her levels of functioning and quality of life have improved dramatically since

discharge from hospital.

Andrew’s Story

Andrew entered the hospital system when in his teens and was moved around a variety of hospitals and

levels of security. He was diagnosed as having a mild learning disability and emotionally unstable personality

disorder. Inpatient settings observed Andrew to exhibit various forms of deliberate self-harm, leading to him

being nursed on close observations, and numerous admissions to general hospital settings. Now in his 30s,

and following extensive planning, a community placement was identified for Andrew where he would have his

own accommodation within a core and cluster setting and a dedicated staff support team. Prior to discharge

Andrew’s capacity was assessed by the Local Authority in order to determine if his care plans could be

delivered under Deprivation of Liberty (DoL) legislation under the Mental Capacity Act, but he was assessed

as having capacity and so the necessary care plans and levels of restriction could not legally be applied in

the community setting. Following his discharge in September 2018, the community provider struggled to

manage the behaviour and levels of challenge that Andrew exhibited and his incidents of self-harm appeared

to increase. It was unclear to what extent his care and environment could be restricted and several incidents

resulted in admissions to general hospital settings. In January 2019, following a series of incidents, a Care

and Treatment Review (CTR) was held that concluded that his safety and wellbeing could not be safely

managed in the current setting and it was necessary to readmit him to hospital under the Mental Health Act.

The professionals and agencies involved have reflected that there is an inherent issue with managing risk

and the use of legislation such as DoL, in order to ensure that care and support is delivered through an

appropriate legal framework, but as well as this there is a lack of appropriately staffed and skilled providers

within the community.

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Section Two: Context

National Strategy

Following the publication of the Department of Health’s report ‘Transforming Care: A national

response to Winterbourne View Hospital’ 1 in December 2012, and subsequent reports

including the Bubb Report in November 2014, ‘Transforming Care for People with Learning

Disabilities – Next Steps’ 2 in January 2015, a significant amount of work has been

undertaken to make improvements in the care and services available for people with

learning disabilities and/or autism spectrum disorders. However, nationally there is a view

that more needs to be done. Simon Stevens, Chief Executive of NHS England, said on 3

June 2015: “We have not finished the job. We need a closure programme for long stay

institutions, with more power in the hands of families.”

NHS England, the Local Government Association and Association of Directors of Adult

Social Services announced on 12 June 2015 that five ‘fast track’ areas were being

established that would be the forerunners of transformation of services for people with a

learning disability and/or autism and challenging behaviours, or a mental health condition.

The fast track areas were asked to submit a transformation plan by 7 September 2015 which

described how they would strengthen community services, reduce reliance on in-patient

beds (non-secure, low and medium secure) and close some in-patient facilities.

The areas were chosen based on the numbers of in-patient beds that they had within their

area in order to make the biggest impact and effect the biggest change. The areas chosen

were as follows

Arden, Herefordshire and Worcestershire

Cumbria and the North East

Greater Manchester and Lancashire

Hertfordshire

Nottinghamshire (including Bassetlaw)

As part of transformation plans, fast track areas were invited to bid for a share of a £10

million transformation fund to help accelerate service redesign and shape the new national

approach to transforming learning disability services and services for those with autism

spectrum disorders more widely across England to embed more sustainable change.

Obtaining a share of the national monies was conditional on CCG’s match funding the

contribution.

1

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/213215/final-report.pdf 2 https://www.england.nhs.uk/wp-content/uploads/2015/01/transform-care-nxt-stps.pdf

3

A national service model for those with learning disabilities and/or autism spectrum disorders

was published at the end of October 2015 3 which includes national planning assumptions

for re-designing services, and numbers of patients to be receiving inpatient based care.

3 https://www.england.nhs.uk/wp-content/uploads/2017/02/model-service-spec-2017.pdf

4 https://www.england.nhs.uk/wp-content/uploads/2015/10/ld-nat-imp-plan-oct15.pdf

‘Building the Right Support’ 4 is a national plan to develop community services and reduce the use of inpatient facilities for people with a learning disability and/or autism who display behaviour that challenges, including those with a mental health condition . Implementing this model is intended to give citizens affected by these conditions, greater power over the services they use, and should result in a significantly reduced need for inpatient care. The national planning assumptions set out in this paper set the targets for reduction in inpatient usage that each area is to achieve: “We expect that as a minimum, in three years’ time no area will need capacity for more than 10-15 inpatients per million population in clinical commissioning group (CCG) commissioned beds (such as assessment and treatment units), and 20-25 inpatients per million population in NHS England-commissioned beds (such as low-, medium- or high-secure services). “ These planning assumptions set out in 2015 aimed to achieve 45 – 65% reduction of CCG-commissioned inpatient capacity, and 25 – 40% reduction of NHS England-commissioned capacity, with the bulk of change in secure care expected to occur in low-secure provision. Overall, 35% - 50% of inpatient provision was to close nationally, with alternative care provided in the community. The changes have more impact in those areas of the country currently more reliant on inpatient care. Over the three years 2016-2019, the expectation was to need hospital care for only 1,300-1,700 people compared to the starting position of 2,600. The intention being to free up money which can then be reinvested into community services, following upfront investment.

4

Local Impact and Performance Targets In April 2016 all TCPs submitted trajectories for both CCG and NHS England (1 April 2016 to 31 March 2019). A process was developed to ensure that all TCPs have the opportunity to review their trajectories for 2017/18 and 2018/19 and amend them whilst ensuring that by 31 March 2019 they are still within the national planning assumptions laid out above

Transforming Care Partnership Learning Disability Inpatient Projections (including all patients originating from within the TCP, both NHS England- and CCG- commissioned)

Year 0 (2015/

16) Year 1 (2016/17) Year 2 (2017/18) Year 3 (2018/19)

31/03/16

30/06/16

30/09/16

31/12/16

31/03/17

30/06/17

30/09/17

31/12/17

31/03/18

30/06/18

30/09/18

31/12/18

31/03/19

NHS England commissioned inpatients

42 42 40 38 36 35 33 31 29 28 26 24 23

Inpatient Rate per Million GP Registered Population NHS England commissioned***

45.09 45.0

9 42.9

4 40.8

0 38.6

5 37.5

8 35.4

3 33.2

8 31.1

3 30.0

6 27.91

25.77

24.69

CCG commissioned inpatients

31 31 31 31 29 28 26 25 24 23 20 17 13

Inpatient Rate per Million GP Registered Population CCG commissioned***

33.28 33.2

8 33.2

8 33.2

8 31.1

3 30.0

6 27.9

1 26.8

4 25.7

7 24.6

9 21.47

18.25

13.96

Total No. of Inpatients with learning disabilities and/or autism* (TCP level; and by TCP of origin)**

73 73 71 69 65 63 59 56 53 51 46 41 36

Total Inpatient Rate per Million GP Registered Population ***

78.37 78.3

7 76.2

3 74.0

8 69.7

8 67.6

4 63.3

4 60.1

2 56.9

0 54.7

5 49.39

44.02

38.65

5

Section Three: Local Strategy

The Nottinghamshire TCP Area covers the populations of the City of Nottingham and

Nottinghamshire County including Bassetlaw. There are two Local Authorities, seven

Clinical Commissioning Groups (CCGs) and NHS England Specialised Commissioning

Hub. Care is delivered by a range of providers from both the NHS and the Independent

Sector.

The County and District boundaries within the Nottinghamshire area are shown in the

diagram below:

We have involved all the commissioning organisations noted above in the development

of this plan as well as other stakeholders, including Nottinghamshire Healthcare NHS

Foundation Trust (NHT), Health Education East Midlands, Positive Behavioural

Support Consultancy, Challenging Behaviour Foundation and the NHS England National

Team for Learning Disabilities. They have endorsed the submission of this plan via the

Transforming Care Board.

There are other key partners who will also need to be engaged with the work and our

plans for the future, for example Nottinghamshire Police and CCGs outside of the area

who may place individuals within Nottinghamshire. This is in addition to people with

learning disabilities and/or autism, their families and carers as well as wider

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communities within Nottinghamshire

Robust structures were put in place by the TCP in order to oversee the governance,

accountability and effective delivery of the programme to include the Transforming Care

Board, chaired by the Director of Quality and Personalisation for NHS Nottingham City and

six work-streams that undertake key deliverables within the programme:

Admissions and Prevention

Strategic Commissioning

Operational Commissioning

Workforce Planning and Development

Integrated Care and Support

Communication and Engagement.

Between September 2015 and April 2016 the Transforming Care Partnership undertook the planning cycle of the programme in order to complete key preparatory tasks such as defining the Nottinghamshire population that would be affected by the programme, refining data to understand and agree the partnership’s inpatient population and set this as a baseline figure, agreeing how the transformation plan could be operationalised, agreeing a plan of prioritisation for service model changes, and demonstrating how the necessary finance would be re-modelled, to shift from inpatient to community - based care. Our new model of care and support in Nottinghamshire is focused on enabling access to mainstream universal and community support with enhanced specialist, specialist and

7

targeted community based support only provided when mainstream services cannot provide the support required or people are identified as being at risk of their needs and behaviours escalating and/or deteriorating. Inpatient settings are only used to complement community services e.g. short breaks, crisis, or where inpatient settings are mandated. Commissioning these new-style services will reduce the demand on hospital placements which are disempowering and unsettling for individuals and their families. This will allow the amount of in- patient beds to be reduced over time. Support and care in Nottinghamshire is to be orientated around the person and their family, friends and informal support networks. It has six levels of services around the person as illustrated in the diagram below:

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Section Four: Update on Performance against National Standards

The TCP has commissioned a range of services to meet the needs of people who are both being discharged from hospital, or who live in the community and are at risk of admission to hospital including development of a new community forensic LD/ASD team, an expansion of the community intensive support team, a residential unplanned care respite facility, and new specialist residential and supported living ‘step down’ services. The data below shows how the numbers of inpatients has been impacted by the new model. The numbers of CCG inpatients has been either slightly above or slightly below target throughout the programme, but has been reduced significantly from 31 in April 2016 to 16 patients in February 2019. The NHSE specialised commissioned inpatient numbers have remained significantly above target and have not been significantly affected by the programme. These include patients who are in nationally recognised levels of security including high, medium and low secure and include a high number of people who are on restricted and criminal justice related sections of the mental health act.

TCP Inpatients Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19* Mar-19

Notts CCG - Plan 28 27 26 25 24 23 22 21 20 19 18 17 16 15 13 CCG - current 29 26 26 29 27 26 22 22 18 16 16 18 17 16 - Variance 1 1 0 4 3 3 0 1 2 3 2 1 1 1 -

TCP Inpatients Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19* Mar-19

Notts NHSE – Plan 35 33 31 30 29 28 27 26 26 26 25 24 24 24 23 NHSE - current 44 44 45 42 40 42 40 38 35 34 35 36 37 35 - Variance 9 11 14 12 11 14 13 12 9 8 10 12 13 11 -

9

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

CCG

Admissions 3 2 3 1 0 1 0 0 2 1 0 1 Step downs from secure 2 0 0 0 1 0 0 1 0 0 0 0

Discharges 2 5 4 4 1 5 2 1 0 2 1 1 Actual/Predicted Position 29 26 25 22 22 18 16 16 18 17 16 16

Trajectory 25 24 23 22 21 20 19 18 17 16 15 13 Difference against Trajectory 4 2 2 0 1 -2 -3 -2 1 1 1 3

Recovery Plan 22 21 20 19 18 17 16 15 13 Difference against Recovery Plan 0 1 -2 -3 -2 1 1 1 3

NHSE

Admissions 0 2 2 1 0 0 1 2 1 1 1 1 Step downs to non-secure 2 0 0 0 1 0 0 1 0 0 0 0

Discharges 1 4 1 3 1 3 1 1 0 0 1 0 Actual/Predicted Position 42 40 41 39 37 34 34 34 35 36 36 37

Trajectory 30 29 28 27 26 26 26 25 24 24 24 23 Difference against Trajectory 12 11 13 12 11 8 8 9 11 12 12 14

Recovery Plan 38 37 36 36 35 32 32 31 23 Difference against Recovery Plan 1 0 -2 -2 -1 3 4 5 14

Total

Admissions 3 4 5 2 0 1 1 2 3 2 1 2 Discharges 3 9 5 7 2 8 3 2 0 2 2 1

Actual/Predicted Position 71 66 66 61 59 52 50 50 53 53 52 53 Trajectory 55 53 51 49 47 46 45 43 41 40 39 36

Difference against Trajectory 16 13 15 12 12 6 5 7 12 13 13 17 Recovery Plan 60 58 56 55 53 49 48 46 36

Difference against Recovery Plan 1 1 -4 -5 -3 4 5 6 17

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Section Five: Current performance and key challenges

As of 19th of March 2019 the current performance in relation to inpatients is as follows:

Sept 18 end Q2

Dec 18 end Q3

Feb 19 March 19 Predicted end Q4

CCG inpatients

18 (target 20) 17 (target 17) 16 (target 15) 17 (target 13) 15 (+2)

NHSE Specialised inpatients

34 (target 26) 34 (target 24) 36 (target 24) 36 (target 23) 36 (+13)

TCP Totals 52 51 52 53 51 (+15)

Local Partners have cited a number of provider issues, specific to a small number of key providers

that have contributed to delays in people being able to transition into community placements as

well as cases where people have had to return to hospital settings. The partnership seek to

summarise these issues and their impact, in order to explain why the performance position has

been affected, and to set out what is being done to rectify the provider issues. Partners also seek

to understand how and why a different approach may be necessary moving forward into 2019/20 in

order to reach the new performance targets for the coming year, and to ensure that patients are

transitioned effectively and that re-admission to hospital settings is avoided.

As a result of provider related issues the TCP has seen two patients return to hospital settings, and

6 patients having their discharges delayed leading to a net effect of eight additional patients being

reported. There are 11 placements unoccupied between two providers currently.

Complexity and needs of the patient cohort:

It has been suggested that there has been some naivety on the part of providers, in terms of the

complexity of the service users who are leaving hospitals despite detailed information being shared

prior to referrals being accepted. Providers appeared to struggle to manage complex challenging

behaviour and seemed ill-prepared for the challenges in terms of level of staff skill and experience,

depth of analysis and understanding of challenging behaviour, strong and robust leadership, and

detailed collaborative care planning with external professionals. Both providers appeared to

overestimate the number of people that they could accommodate, running into serious operational

issues well before full occupancy was achieved.

With hindsight it has been suggested that 13 and 8 beds respectively are too large in scale to meet

the needs of the most complex people in the cohort. For future schemes the TCP will work with

providers to develop small schemes of up to 5-6 people, with mixed levels of complexity, and an

emphasis on compatibility. The TCP is working with a provider re a Mansfield development to

accept no more than 5 people initially, and then determine readiness for a 6th person at a later

date. It should be noted that providers can purchase and mobilise new care homes without the

input of commissioners and some sites had been purchased prior to commissioner involvement.

Current work with providers is focusing on them building confidence and skill with the suggestion

that when unsuspended they begin to work with less complex people, building up to working with

more complex individuals. Given the size of the sites however, it is likely that only a smaller

number of beds will be used for Transforming Care cohort in the near future and possibly longer

term.

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Staff skills/training/impact to local services:

Providers have appeared to underestimate the level of skill and experience required to work with

the patient cohort, and the amount of support registered managers of such services will need. Two

services lost their registered managers soon after opening and were required to put in place acting

managers from other services. Both have reflected that there is need for more deputy management

input on the ground to support the managers as well as more support from senior management

within the organisations. Staff employed within such services need to demonstrate a level of

experience in the field, or a willingness to be trained and to learn how to implement positive

behavioural support strategies on the ground.

Two services has conceded to the fact that their rates of pay may not have been in line with the

level of challenge posed and both have made pay increases for staff in these services. Both

services have been offered access to training in positive behavioural support, and management of

personality disordered behaviour funded by the TCP. One team were also provided with full

management of violence and aggression training, provided by the Healthcare Trust and funded by

the TCP. For new services and for the pipeline service at Mansfield, the partners are asking

assurances from providers about levels of training skill experience and rates of pay for their

workforce, as well as detail of how supervision, training, handovers, de-briefing and staff

support/development generally.

Pressure to meet trajectories:

Throughout Q2 and Q3 of 2018/19 the TCP continued to discharge a steady number of patients

from CCG beds into the community, and remained on trajectory in terms of target inpatient

numbers. Pressure from regional and sub-regional NHSE teams for TCPs to remain on trajectory

and to achieve target discharge dates will have led to pressure on the system to make discharges

happen within timescale. With hindsight, several discharges could have been delayed in order to

allow greater detail regarding care and contingency planning, and to allow for appropriate legal

frameworks to be in place to implement such plans.

There is growing evidence that people moving from both CCG beds and NHSE commissioned

secure beds, who have been accustomed to a full inpatient MDT around them 24 hours a day, will

struggle when discharged to a community setting, and that strong and robust contingency planning

is paramount to make the discharges a success. The level of staff hours that needs to be

commissioned and the costs of community placements are likely to be higher in the initial stages of

transition and in many cases will be higher than the equivalent inpatient cost.

The TCP will need to work closely with the NHSE DCO and regional teams moving forward into

2019/20 to tread a fine line between trying to reach trajectory targets, and trying to ensure that

discharges are safe, realistic and sustainable.

Market engagement and market management:

Local Partners have observed an increasing lack of community placements, for people moving out

of hospitals under ‘Transforming Care’ due to saturation of the local residential and supported

living market. There is a specific need for residential or supported living, core and cluster type

accommodation with nursing and skilled support work input. Providers coming forward with

schemes are quoting fees that are off the scale in terms of existing local frameworks, with

commissioners being unable to influence price, quality or outcomes due to the pressure to utilise

availability.

12

The TCP may benefit from developing a new enhanced framework of providers that specifically

develop services for the TC cohort within pre-set price ranges, using outcome and recovery

focussed models of support. The TCP is taking forward an offer of support from NHSE/LGA to fund

an external consultant to undertake a rapid options appraisal of how this could be developed. This

will need to ensure affordability whilst being attractive enough for providers who can choose to

accept out of area placements should they not wish to work within local parameters.

Recommendation

The Joint Commissioning Committee is asked to:

ACKNOWLEDGE the patient stories

ACKNOWLEDGE the paper which provides information on the changes made and impact had to date, as well as the key challenged faced

NOTE the governance and mechanisms in place to deliver the national targets in relation to LD/ASD inpatient care

ACKNOWLEDGE the conflict of priority which needs to be managed, between national targets and ensuring that discharges from hospital are both safe and sustainable

Theodore Phillips Head of Transforming Care– Greater Nottingham CCGs On behalf of Nottinghamshire Transforming Care Partnership (TCP) March 2019