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Transforming Care in Ealing – 18th March 2016

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Joint transformation planning template

Ealing

1. Mobilise communities

Governance and stakeholder arrangements

The health and care economy covered by the plan The plan covers the London Borough of Ealing which is the 3rd largest borough in London. The Plan will be overseen by the Ealing Health and Wellbeing Board which is chaired by the Leader of the Council and which includes representation from Adults’ Services, Children’s Services, Housing & Public Health. The Plan will also be presented to the Health and Adults’ Services Scrutiny Panel to ensure good oversight of health and social care services. Adults The commissioning of care and support services for adults with Learning Disability in Ealing is governed by a section 75 agreement, and the CCG delegates this role to the local authority. The Community Team for People with Learning Disabilities is a joint team provided by Ealing Council Adults’ Services and London North West Healthcare NHS Trust. Psychiatry is provided by Central and North West London NHS Trust (CNWL) Ealing has a diverse provider landscape with the vast majority of services being provided by the voluntary and independent sector. There has been a recent drive to outsource services previously provided by directly by Ealing Council which has resulted in the re-provision of supported living, outreach and day opportunities. The main providers of supported living in Ealing are Certitude and Yarrow Housing. West London Mental Health Trust (WLMHT) provide both inpatient and community treatment in Ealing (including assertive outreach, home treatment, court diversion scheme and IAPT). There are no specialist LD or autism Assessment and Treatment inpatient services in Ealing and these placements are spot purchased outside our borough boundaries. The Kingswood Centre in Brent is the most local LD service, and Cygnet in Harrow provides the nearest specialist autism inpatient service Children and Young People Ealing Council and Ealing CCG are committed, through a Section 75 agreement, to joint commissioning of services for children with additional needs. There is an integrated front line service for children with additional needs comprising SEN, specialist child health and social care. It is commissioned by Ealing Council and Ealing CCG and delivered by the Council and London North West Healthcare NHS Trust (LNWHT).


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Specialist child health services are provided by LNWHT and are funded by the CCG (all types of specialist child health services) and the Council (SLT and OT only). CAMHS/LD services are commissioned by both the Council and the CCG and provided by WLMHT. Services include an innovative project designed to prevent children becoming looked after/residential boarding schools, by supporting carers, schools and other carers in managing children with challenging behaviour. There are six stated funded day special schools in Ealing and 8 (6 at primary and 2 at high school level) and additionally resourced provisions (ARPs) within mainstream high schools. Two more high school based ARPs are being considered. The special schools are expanding in respond to increased demand. The Borough also utilises day and residential non maintained independent sector provision to help meet specialist needs. Ealing Council works with 8 other boroughs through the West London Alliance to help support this commissioning activity. Other services include domiciliary care (both at home and to support community based activities) commissioned via an approved list. There is also a range of short breaks provision, both residential and day, located in the borough or in nearby area. The CCG and the Council commission the impartial information advice and guidance service that is delivered by Family Action and also commission short breaks and family support services from Mencap, Contact Family and a local short breaks provider Log Cabin. Mencap also provide a transition and Connexions project for young people with additional needs. Early Bird and Early Bird Plus are multi-agency programmes designed to provide training and support to families and carers of pre-school and school age children with autism. The programmes are supported by the Local Authority and delivered in collaboration with LNWHT. Current members of the Early Bird team offer educational psychology, occupational therapy and, speech and language therapy.

The governance arrangements for this transformation programme Ealing has a Learning Disabilities Partnership Board and an Autism Partnership Board who report to the Health and Wellbeing Board and oversee the borough’s strategies to meet these needs. The Children with Additional Needs Board is a sub-group of the Children and Young People’s Partnership Board, which also reports to the Health and Wellbeing Board. The purpose of the Adult Learning Disabilities Partnership Board is set by the national ‘Valuing People Now’ agenda and the Ealing Health and Wellbeing Strategy. The Board oversees strategic planning and the implementation of service development and ensures that people with learning disabilities and carers are at the centre of all planning and service delivery. A Learning Disabilities Provider Forum also feeds into the Learning Disabilities Partnership Board.


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The North West London Transforming Care Partnership Board provides leadership and assurance on the delivery of the TCP plan and will oversee progress of all the agreed work streams. The Transformation Board is chaired by the Senior Responsible Owner (SRO), Jan Norman, Director of Quality and Safety, Brent, Harrow and Hillingdon (BHH) CCGs Federation. The Deputy SRO is Jonathan Webster, Director of Quality, Nursing and Patient Safety for Central London, West London, Hammersmith and Fulham, Hounslow and Ealing (CWHHE) CCGs. The Strategic Financial Governance will be provided by Neil Ferrelly, the Chief Financial Officer across BHH Membership includes senior commissioning representation from learning disability, mental health, and children’s commissioners from local authorities and CCGs. In addition to NHS Specialised Commissioner, Local public health and Department of Justice.

Ealing Health & Wellbeing Board

Children & Young People's

Partnership Board

Transition Board

Children with Additional Needs

Board

Adults Learning Disabilities

Partnership Board

Health Sub-Group

Learning Disabilities

Provider Forum

Autism Board - All Age


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In addition to the Partnership Board, a working group has being developed to drive implementation with fortnightly meetings scheduled. This will feed into the Partnership Board. The North West London TCP Board is established as a strategic commissioning forum – with agreed routes for wider engagement across our provider base outside of the Board. The TCP Board reports to the North West London Mental Health and Wellbeing Transformation Board which has the senior executive and clinical leads from key partner organisations – including representatives from the West London Alliance from Directors of Adults' Services, Directors of Children’s Services and Directors of Public Health. We welcome the membership of NHSE as a full partner and member of the Board.

Stakeholder engagement arrangements Empowerment, and putting the person at the heart of all we do, is fundamental to our vision and approach. People with a Learning Disability (PLD) and / or autism and their family carers are routinely involved in service planning via partnership board, strategy consultations, and the subgroups. There are a number of groups that support stakeholder engagement - Power Group (peer advocacy group), Carers Centre, Provider Forum, and a Parents’ Forum which is self organised by parents of children with additional needs and funded by the Council as required under the Special Educational Needs and Disability (SEND) reforms. The Big Health Check is held annually and gathers feedback from people with learning disabilities and their families about their experiences of using local health services. This information is used to inform the action plan for the Health Subgroup. Commissioners consult PLD and their families as part of procurement exercises.

Providers in Ealing use a variety of mechanisms to promote involvement e.g. quality

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Mental Health and Wellbeing Transformation Board

Borough Councils

W K&C H&F H E B H H

CCG Governing Bodies (and Collaboration Board)

Workforce

Enablers

C W H&F H E B H H

Loca

l De

live

ry

Loca

l In

no

vati

on

Mental HealthTrusts

CNWL WL

North West London Transforming Care Partnership Governance

Chair: Dr Fiona Butler Members:NWL CCG Chairs, NWL Local Authority (DASS, DCS and 2 x Public Health), CNWL CEO, WLMHT CEO, CWHHE AO, BHH AO, Dir S&T, Dep Dir MH S&T, WLMHT and CNWL Commissioning Leads, NHS England representative for MH/Specialist commissioning, Met Police representative, Lay Partners, 3rd Sector, Healthwatch, ICHP,Public Health England, GP Federation, HE NWL

Chair: Matt Hannant (SRO), Members: SRO, CRO, CEO, (WLMHT), CEO, (CNWL), Director Public Health rep

Chair: Jan Norman Deputy Chair : Jonathon WebsterClinical Lead to be confirmed Strategic Finance: Neil FerrleyMembers:Senior CCG LD Commissioner Leads, Senior LA commissioner Leads. NHS England Specialised Commissioner , Health Education North West London, public health

Provide views

Line of accountability

Key

Provider Trusts

Health & Wellbeing Boards

London Mental Health Partnership Board

Joint Overview & Scrutiny Committee

Other Key Stakeholders

Steering Committee Transforming Care Partnership Board Meeting

Programme Executive

Information

Payments

Estates

Serious and Long Term

Mental Health Needs

Common Mental Health Needs

Children and

Young People

Wellbeing &

Prevention

Whole Systems Integrated Care Finance & InformaticsWorking Group

Learning Disabilities

/TCP


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assurance boards, service user parliaments, conferences, satisfaction surveys,

Working Together for Change, person centred recruitment, planning and co-delivery

of LD and autism awareness training, quality checking, co-delivery of training.

Describe how the plan has been co-produced with children, young people and adults with a learning disability and/or autism and families/carers Our plans are based on the knowledge built up from the Joint Strategic Needs Assessment and the views received through the continuing involvement of people with learning disabilities and their families as described above. We recognised that a variety of mechanisms will need to be used to ensure that people with complex needs are able to be meaningfully engaged. We therefore arranged large scale interactive event on 21 March for people with learning disabilities and autism and their carers as well as some smaller scale sessions including a coffee morning for family carers and some focused 1:1 sessions with people with challenging needs who have had previous experience of being in hospital. Ealing has arranged a Building the Right Support stakeholder workshop in March to which professionals from WLMHT, LNWHT, Ealing CCG, Ealing Council and the LD and autism provider market will be invited and given the opportunity to contribute to our plan. We will ensure that people with LD and or autism and their families are involved in reviewing and monitoring the delivery of our plan and in the development of new services.

Please go to the ‘LD Patient Projections’ tab of the Transforming Care Activity and Finance Template (document 5 in the delivery pack) and select the CCG areas covered by your Transforming Care Partnership

Any additional information The projected usage of inpatient beds over the next 3 years will need to be regularly reviewed against actual activity and spend data and our ability to support individuals outside patient settings. We will continue to interrogate the data and refine our implementation plan in light of changes.

2.Understanding the status quo

Baseline assessment of needs and services

Detail of the population / demographics There were 930 adults with LD known to the Ealing Council in 2014/15; 91% of people are within 18 – 64 age range and 60% are males. The largest group of people are in age range of 25-34 age range – 25%. 3% of adults with LD (26 people) are parents. In Ealing, the figures are likely to be an underestimate. One of the reasons for this could be due to a large BAME community and reluctance of some groups to seek help. Of the 930 people with Learning Disabilities known to the local authority, 217 live outside the Borough of Ealing Source: Adults Performance & Management Team, 2015


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23% (217) of people with LD known to services live outside of the borough. Southall has the largest population of people with LD – 19% and Perivale has the smallest population - 5%.

Two thirds of the people, 66.7% (620) are receiving community services e.g. supported living, day opportunities, outreach and 22.7% (211) are in residential care. Only 6 were receiving care in nursing settings (0.6%) in 2014/15. Percentage of adults (18-64) with a LD who are known to the council, who are recorded as living in their own home or with their family.

Period Ealing London England

2011/12 61.7 65.7 70.0

2012/13 62.6 68.1 73.5

2013/14 68.6 68.6 74.9

Future Projections Projections of short-term and long-term future prevalence of LD give an indication of future need, but are based on national estimates therefore do not take into account local factors5. In Ealing, the figures are likely to be an underestimate due to a large

5 Emerson, E. and Hatton, C. (2008) Estimating Future Need for Adult Social Care Services for People with

Learning Disabilities. Centre for Disability Research, Lancaster University.


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South Asian community and reluctance of some groups to seek help. In Ealing, the estimates for 2020 indicate that the number of people (aged 18 and over) who have LD will be 6,791; around 1,466 people would have moderate/severe LD and therefore are likely to be in receipt of local services, 357 of those people would have severe LD. It has been estimated that around 108 people in 2020 would display challenging behaviour. Projected estimates have been calculated by applying national estimates to projected population figures The number of young people turning 18 and receiving support from adults services has increased: 2010-11 - 9 2011-12 - 30 2012-13 -19 2014-15 -30 Emergency Admissions In Ealing, the number of emergency admissions to general hospitals of adults with LD in 2013/14 was 4461. This represents 47.5% of the total number of people with LD known by services in Ealing in the same year. This was lower but not significantly different than London (57%) and England (49%) in 2008/09 (no later data available on the Public Health LD Observatory 2013). Employment 9.3% of adults aged 18-64 with LD (80 people) were in paid employment in Ealing in 2013/14. This is a marked decrease from 2010/11 when 13% of adults were in paid employment. However this is better than London (8.8%) and significantly better than England (6.7%) average.

Analysis of inpatient usage by people from Transforming Care Partnership As at the end of March 2016, Ealing CCG commissioned inpatient services for 12 patients with LD / autism. NHS England commissioned secure inpatient services for 2 patients who were registered with an Ealing GP. This total cohort represents less than 1% of the local LD and autism population. Of the total inpatient group, 13 are male, 1 is female. 6 of these patients will be eligible for a dowry. There are currently no children from Ealing in inpatient settings

Responsible Commissioner Name of Unit Location

Distance from borough (in miles)

LOS (days)

Avg bed cost

Purchasing arrangements

NHS England Eric Shepherd Abbots Langley 21 1180 424 Spot

NHS England Cygnet Harrow Harrow 5 1423 424 Spot

Ealing CCG Thors Park Essex 86 1574 574 Spot

Ealing CCG Olive Eden Tottenham 17 3516 574 Spot

1 Source: Ealing SUS Data 2013/14; ICD 10, 2015 Diagnosis codes included: F80 – F89 (disorders of

psychological development, including Autism & Asperger’s Syndrome); Q90 (Down Syndrome)


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Ealing CCG Cygnet, Harrow Harrow 5 3842 574 Spot

Ealing CCG Kingswood Centre Kingsbury 8 897 574 Spot

Ealing CCG Bostal House Abbeywood 25 2512 574 Spot

Ealing CCG Olive Eden Tottenham 17 6013 574 Spot

Ealing CCG Ealing Hospital Ealing 0 73 574 Block

Ealing CCG Kingswood Centre Kingsbury 8 1329 574 Spot

Ealing CCG Kingsley Green Radlett 20 7641 574 Spot

Ealing CCG Kingsley Green Radlett 20 7798 574 Spot

Ealing CCG Cygnet Beckton Beckton 26 334 574 Spot

Ealing CCG St Andrews Northampton 65 916 574 Spot

Two of these placements are in Special Residential Services in a hospital campus. There are some risks associated with discharge planning due to the legal challenge in relation to move on arrangements.

Describe the current system Adults The commissioning of support services for people with Learning Disability in Ealing is governed by a section 75 arrangement between the CCG and the Council. The Community Team for People with Learning Disabilities (CTPLD) is an integrated multi disciplinary service with care management overseen by the Local Authority and all clinical staff with the exception of the psychiatrist overseen by London North West NHS Trust (LNWHT). The psychiatrist is employed by Central and North West London NHS Trust (CNWL). The team work to support adults with learning disabilities in the community to maintain their independence, health and wellbeing. The team consists of care managers, senior practitioners, psychiatrists, psychologists, nurses, therapists and administrative staff. The CTPLD emergency duty team provides social care support 24/7, however the health support is only currently available Mon-Fri 9 -5 pm.

Support needs are identified through a holistic assessment and support planning process. Personalisation is at the heart of this process. An assessment can be offered to: an adult with needs, a carer with needs arising from caring for another adult, young people with care needs, and young carers who are moving towards adulthood. A personal budget is allocated to meet the cost of the services required to meet care and support identified in the support plan. It can be set up as a direct payment, a council managed budget or a mixture of both. Support plans and care packages are agreed at the joint risk panel. Personal health budgets are offered to people who are eligible for continuing healthcare.

Care and support for adults is currently delivered by a range of providers from in-house provider services to a growing number of voluntary and independent sector service providers. The Council currently commissions 14 organisations to provide a range of accommodation based and community services as well as providing a number of services directly including Shared Lives. Just over half of all adults with a LD who receive adult social care live with their parents or family members – hence supporting family carers is a key priority. People living with their families have access to a range of support, including day-opportunities, outreach, support at home, and


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short-breaks (respite)

The main providers of services for people with LD and/or autism with challenging behaviour or mental health conditions in Ealing are Care Management Group, Certitude, Ealing Council, National Autistic Society, Solutions Care and Yarrow Housing Ltd.

Promoting equal access to mainstream services and community facilities is central to improving the lives of people with LD and autism. Ealing Mencap support people with LD to get involved in local and national campaigns (e.g. Hear My Voice). They have worked with the local police and community safety on hate crime issues and continue to work with Transport for London to improve access on public transport for people with disabilities. The CCG and local authority jointly commission Certitude to run the Treat Me Right project to work with local health services to deliver LD and autism awareness training, provide a range of tools to support reasonable adjustments and facilitate a LD champions network. All of the training and tools are co-delivered / produced by people with LD and autism. We have recently agreed to work on a project with Public Health England and our local substance misuse teams to extend this model to identify improvements to practice and reasonable adjustments for people with LD and autism who might benefit from the service

Children and young people Education, Health and Care (EHC) Plans and other planning processes are managed in the main by Ealing Service for Children with Additional Needs (ESCAN) which is an integrated SEN/specialist child health and social care front line service. In addition, children with learning disabilities and/or autism can be seen within CAMHS services. In 2015/16 all NWL CCGs have funded short-term additional staffing capacity to address long waiting times for neuro-developmental assessments. In the remaining years of the five year plan, the majority of CCGs will continue some investment in additional capacity for LD and ND pathways to enable sustained improvements in access and post diagnostic treatment and behaviour management plans. Through the 2015/16 planning work, we anticipate that this pathway will align with transforming pathways in developing a tier free system and developing crisis and urgent care and will form part of the joint Emotional Health and Wellbeing Targeted Service as well as the SPA and developing pathways work across NWL.

What does the current estate look like? What are the key estates challenges, including in relation to housing for individuals? There is a London wide shortage of affordable housing stock. It is especially difficult to identify affordable housing that is suitable for people with challenging needs who require spacious and / or self-contained accommodation. Ealing doesn’t have access to any NHS estate for the purpose of development of housing options for this customer group. In Ealing there are 114 residential care services, providing accommodation for up to 83 people. There are supported living services offering accommodation and support for 119 people through a range of tenures – shared lives, shared ownership, private


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rented, social housing. There are 12 resource centres offering a base for day opportunities programmes; three of these are specifically for people with challenging behaviour. There are two residential respite services; one of these has been developed as a specialist service for people with challenging behaviour. There will be an increase in demand for local housing for people with a range of challenging needs, In addition to expanding our Shared Lives provision, Ealing Council will be working with local support providers to develop a range of affordable housing options including shared housing, self-contained flats with support available on site, and bespoke accommodation e.g. adapted flat for a single person with complex needs. There are currently 6 special schools in Ealing which are expanding to meet increased demand. This includes capital investment in buildings to support increased capacity. Day respite services are provided in school settings, youth centres, and other community settings. Residential short breaks are provided, currently, on an in house basis as well as being purchased externally. The current in house residential provision is located in a building that is not considered to be appropriate to meet current day demands and standards and that, subject to final decision, will be de-commissioned.

What is the case for change? How can the current model of care be improved? The challenges within the current model are:

Widespread recognition that those with a learning disability and/or autism and challenging behaviours are not best served by long term hospitalisation or institutional care.

The ageing population of those with a learning disabilities and or autism requires more proactive support, integrated around co-morbidities which are more common in later life.

The reliance on family and carer support is high and there is a need to ensure that there are both crisis and planned respite services in addition to training and support available to avoid hospitalisation due to carer or family breakdown.

Access to specialist health team is currently only available Mon – Fri, 9 -5 pm

Traditional day services need to be modernised to adopt a more clinically led

evidence based model and implement short-term and long-term clinical

behavioural intervention and support strategies, designed to manage and

minimise challenging behaviour.

Ealing has a lower rate of adults with learning disabilities taking up Annual Health Checks (AHCs) compared to the England and London averages

A recent audit of AHCs highlighted that fewer than 50% of AHCs generated specific health improvements

Ealing has a lower prevalence of LD on the QOF register

There has been a decline in the proportion of people with learning disabilities in paid employment

Please complete the 2015/16 (current state) section of the ‘Finance and Activity’ tab of the Transforming Care Activity and Finance Template (document 5 in the delivery pack)

Any additional information


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The projected usage of inpatient beds over the next 3 years will be regularly reviewed against actual activity and spend data and our ability to support individuals outside patient settings. We will continue to interrogate the data and refine our implementation plan in light of any changes.

3.Develop your vision for the future

Vision, strategy and outcomes

Our aspirations for 2018/19 In Ealing, people with a learning disability and/or autism and their families will be able to say:

I have choice and control

I am an equal partner in my care and support

I have a home I can call my own

I feel safe

I am part of my community

I have opportunities to learn and work

I have good health

IMPROVED QUALITY OF CARE

In terms of quality of care, the aspiration is that by 2019 we will have:

Clear and accessible integrated community pathways that focus on prevention and early intervention;

Specialised support services, community-based where appropriate, with a reduced reliance on inpatient facilities;

Timely access to assessment and treatment for learning disability and/or autism;

A well developed and managed provider market of health, social care and third sector providers that delivers high quality personalised support services with a focus on an enablement and developmental approach;

A well developed and managed workforce across health, social care and third sector including succession planning;

Seamless access to mainstream services that make reasonable adjustments to meet the needs of people with a learning disability and/or autism and challenging behaviour;

People with a learning disability and/or autism and challenging behaviour and their families/ carers at the centre of care planning;

A specialist team to address the needs of people who may or have come into contact with the criminal justice system.

IMPROVED QUALITY OF LIFE

In terms of improved quality of life, our aspiration is that by 2019 the support available to people with a learning disability and/or autism who display behaviour that challenges in North West London will:

Enable people to have choice in accommodation that is suitable to their needs and close to their communities and chosen networks;

Meet the needs of people of all ages – not defining support by age but instead responding to care and support needs and reducing the differences in services for children, young people and adults;

Increase the number of people with a learning disability and/or autism and challenging behaviour who utilise a personal budgets;


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Achieve equitable health outcomes for people with a learning disability and/or autism and who display behaviours that challenge that are comparable with the general population;

Be person centred and personalised, including using innovative solutions from the private and voluntary sector.

REDUCED RELIANCE ON INPATIENT CARE

In terms of reduced reliance on inpatient care, by 2019 we will have:

Specialist help available locally, with community support as the first line response;

A safe alternative to hospital for people who, for whatever reason, are not able to remain in their current accommodation and do not need hospital treatment;

Fewer people admitted into NHSE secure hospital provision.

For those that do still require admission, there will be smoother transfers into and out of hospital, high quality assessment and treatment, with shorter lengths of stay, and discharge planning that is commenced as soon as possible.

Fewer children and young people in 52 week residential placements, and where these placements are considered the most appropriate option, placements that are closer to home.

How will improvement against each of these domains be measured? We recognise that one of the best ways to measure success is by talking to people with lived experience and their families about the services and support they receive. In addition to the information routinely captured in reviews, we will use a range of mechanisms to seek feedback. In accordance with the national guidance, we will monitor progress on delivering against the overarching outcomes of the programme using the suggested measures. In addition to these suggested measures, we will also use local measures to monitor progress against our local objectives. Co-production of these measures with people with a learning disability and/or autism and their families and carers will be an important component in the delivery of our Transformation Care programme. QUALITY OF CARE For the aim of improving quality of care, we will use the suggested basket of indicators alongside local measures of success that capture progress against our own KPIs. As a start, this will include (but not be limited to) measuring and developing KPIs on:

Publication of clear local care pathways for people with a learning disability and/or autism who display behaviour that challenges in North West London

Individual service elements for the Community Learning Disabilities team, including numbers of people seen, numbers (and %) of service users with personalised care plans, and patient reported outcome measures;

The number of people who are admitted to inpatient facilities each year, with an agreed trajectory and target for reduction;

Length of stay in inpatient facilities, again with an agreed trajectory and target for reduction;

Readmissions to hospital for people with a learning disability and/or autism;

Referral to assessment times for learning disability and/or autism assessments and treatment;


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Referral to assessment times for new psychiatric referrals for people with a learning disability and/or autism;

Numbers of patients with a care co-ordinator;

Numbers of people with a learning disability and/or autism who display behaviour that challenges with a Care and Treatment Review plan;

Number of organisations across North West London that have implemented the Green Light Toolkit;

Rate of referral, per 1,000 of people with learning disability for adult safeguarding;

Mobilisation of a North West London wide forensic learning disability service. QUALITY OF LIFE For the aim of improving quality of life, we will use measures based on the Health Equality Framework tool. All these measures will be further refined as our plan developed. At present, we have some outline ideas on the quality of life areas we want to assess. These include:

Number of people with a learning disability and/or autism who display behaviour that challenges in residential and/or supporting accommodation in North West London, using settled, unsettled, and inappropriate data sets;

Number and % of people on the learning disabilities ‘at risk’ register;

Number of people utilising personal budgets;

The number (and %) of people receiving social care primarily because of a learning disability who receive direct payments or a personal managed budget;

Proportion of eligible people with an Annual Health check and Health Action Plan;

Proportion of eligible people who take up national screening and vaccination offers;

Rate of people with a learning disability and/or autism who are overweight or obese;

Life expectancy in relation to local, county and national levels;

Proportion of people with a single, integrated, person-centred support plan.

REDUCING THE RELIANCE ON INPATIENT SERVICES

For the aim of reducing reliance on inpatient services, we will use the Assuring Transformation Plan data set to monitor progress. This will include defining baselines and setting KPI trajectories and end states in collaboration with our providers and service users for the following:

The number of people who are admitted to inpatient facilities each year, with an agreed trajectory and target for reduction;

Length of stay in inpatient facilities, again with an agreed trajectory and target for reduction;

Readmissions to hospital for people with a learning disability and/or autism;

Number of readmissions to hospital generating a root cause analysis;

Number of patients admitted who were not on ‘at risk of admission’ registers prior to admission;

Number of patients with a planned transfer date;

Numbers of patients transferred out of inpatient care with a relapse prevention


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plan;

Numbers of children and young people in residential schools placements, with an agreed trajectory and target for reduction;

Number of children and young people in residential schools placements outside of London, with an agreed trajectory and target for reduction;

Awareness of Local Authority to up-coming transfers from Criminal Justice system;

Number of people with a learning disability and/or autism who display behaviour that challenges with an independently appointed Advocate (family member, independent person, formal Independent Mental Capacity advocate (IMCA))..

Our principles in offering care and support to people with a learning disability and/or autism who display behaviour that challenges. To deliver on this agenda, all key stakeholders will work to a set of overarching principles:

People are treated with dignity and respect;

People are supported to have a good and meaningful everyday life and relationships through access to community based activities and services such as education, employment, social and sports/leisure;

Support is provided to promote maximum independence; not doing things for people but helping people to do things for themselves, adopting the principles of “Active Support”

Promote equality; respecting people, families and staff irrespective of their beliefs and practices in relation to their race, ethnicity, religion, gender identity, disability, age or sexual identity.

Focus on person centred, family -centred, planned and pro-active support to meet the specific and changing needs of individuals;

Support and promote individual choice and control to assist people to realise their potential and aspirations;

Be preventative and proactive; responding to emerging problems and preventing them from escalating;

People who use services and their families are actively engaged as equal and valued partners in the co-design, development and delivery of support.

Achieve a balanced approach to risk which gives individuals control and the right to make mistakes without serious implications for their security and safety;

Support to access universal services including health services to promote physical and emotional wellbeing

Parents/carers of children and young people and adults are supported in their caring role

Please complete the Year 1, Year 2 and Year 3 sections of the ‘Finance and Activity’ tab and the ‘LD Patient Projections’ tab of the Transforming Care Activity and Finance Template (document 5 in the delivery pack)

Any additional information We will interrogate the data and refine our implementation plan on an ongoing basis

4.Implementation planning

Proposed service changes (incl. pathway redesign and resettlement plans for


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long stay patients)

Overview of our new model of care The new service model in Ealing will emphasise the shift from inpatient to community settings and focus on prevention and early intervention. The success of the model will be dependent on all stakeholders (including people with LD, autism and their families) working together as equal partners to develop services that are based on current good practice, and reflect relevant specialist and clinical guidance. People will have access to specialist health multi-disciplinary health team in the community on an intensive 7 day a week basis. For people with a mild learning disability, this will include access to generic mental health and forensic services We also recognise that we need to develop the skill base of our local providers (e.g. of residential and supported living services, and day opportunities) to ensure that care is delivered consistently in line with existing care plans and behavioural support plans. Support Providers will need to be able to respond to the changing needs of individuals during different chapters of their life e.g. transition into adulthood, moving into old age and supporting people during a time of crisis or ill health. People will have good access to universal health services including primary care, health screening, mental health services, liaison and diversion schemes, and substance misuse. Family carers will have access to support including respite, information and advice and training e.g. PBS, autism. People with LD/autism will have access to day opportunities 7 days a week that promote learning, independence, employment, healthy lifestyles and access to the community People will have timely access to inpatient care that is close to home if their treatment can’t be delivered in the community.

What new services will we commission? Ealing has identified the need to commission additional autism provision for adults and young people. We propose to invest in the development of a multi-disciplinary transition team to support young people with autism and their families. We propose to expand both residential and non-residential short breaks provision for people with challenging behaviour - for both adults and children and young people – to prevent breakdown and unnecessary admissions to inpatient care. We have already agreed to commission additional clinical support for people living in the community. We also propose to develop an enhanced 7 day a week specialist health offer from local Community Team for People with LD (LNW integrated team with Ealing Council), including additional clinical posts to provide intensive support to people with challenging behaviour and mental health needs . We propose to explore opportunities to develop a NWL service for people with LD/autism who have a forensic history.


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We propose to develop additional local housing options for people with LD and/or autism who have challenging needs, including the provision of short term accommodation for people who need crisis intervention and are at risk of placement breakdown We propose to develop additional peer to peer quality checkers service to capture the views and experiences of children and adults with LD and autism about the services and support they receive. We intend to remodel existing day opportunities for people with challenging behaviour. We are currently working with local providers to de-register some local residential services to provide supported living.

What services will we stop commissioning, or commission less of? We aim to reduce the usage of assessment and treatment inpatient beds by 30% and reduce inpatient bed spot purchasing – either by number of admission or reducing length of stay. This needs to be set against increasing population and demand and dependent on community service development, so will not necessarily result in savings but will contribute to the sustainability of the services. We intend to commission less residential care services counterbalanced by additional supported housing. We have already reduced our usage of residential school placements and the plan would be to reduce this even further.

What existing services will change or operate in a different way? We will remodel current day and outreach services for people with challenging behaviour to offer a clinically led model that reflects NICE guidance. We will re-specify community team outreach and development links to inpatient and crisis response. We will work closely with mainstream service providers and the local community to raise LD awareness and to ensure that information and services are reasonably adjusted for people with LD, particularly alcohol and substance misuse and mental health services, but also staff working in urgent care and Accident and Emergency Departments. We will expand the provision of respite for adults with LD and challenging behaviour to include age 16+. We will reduce the waiting times for specialist Child and Adolescent Mental Health Services (CAMHS), to ensure that a crisis and intensive support service is in place in each borough, develop a comprehensive learning disability (LD) service for children with challenging behaviour and autism, and improve access to community eating disorder services.


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We will develop an autism team within the care management team for people with disabilities.

Describe how areas will encourage the uptake of more personalised support packages Personalisation is at the heart of social care within Ealing Council, is embedded into the assessment and support planning process and is very much business as usual. The local authority has offered to manage personal health budgets on behalf of the CCG. We will continue to ensure that people have choice and control over how their health and social care needs are met by offering personal budgets and personal health budgets with access to information, advice and support to help people understand the choices available to them. For children and young people, this will be supported through Education, Health and Care planning processes.

What will care pathways look like? It is envisaged that there will be a number of care pathways for the 5 cohorts identified in Building the Right Support at different life stages. Part of this work will involve re-designing these pathways. Our care pathways will be:

Planned, in collaboration with the person with a learning disability and/or autism and their family and carers;

Based on current good practice, and reflect relevant specialist and clinical guidance.

Proactive, considering future care and support needs as well as the current situation;

Co-ordinated, linking up health, social care, education and the voluntary sector to provide a joined up approach to support that meets the range of needs of the person.

How will people be fully supported to make the transition from children’s services to adult services? The planning process during transition is led by the transition social work team. There is a virtual multi-disciplinary team that meets weekly to discuss individual cases. EHC planning processes cover this up to age 25. There is significant joint working across children’s and adults’ services (health and social care) with input from the psychologists (adults) who provide in-reach support into schools. A transition protocol is currently being developed to support transition from child to adult psychiatric services. Mencap also provides a transition and Connexions project for young people with additional needs. The intention is to commission a multi-disciplinary Transition Team to work with young people with autism (age 14 – 25) to support the move into adulthood.

How will you commission services differently? Most services will be commissioned individually via personal budgets. The Council

and CCG are carrying out a procurement exercise with participating boroughs in the


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West London Alliance to develop an approved list of accommodation based services

through a Dynamic Purchasing System (DPS) and an e-brokerage platform.

Assessment and treatment services will continue to be spot purchased.

Further work needs to be carried out to determine commissioning arrangements for additional clinical support. Depending on the scale of the services, some services (e.g. specialist LD forensic service) may be commissioned collaboratively with neighbouring boroughs and may be put out to tender.

For children and young people, domiciliary care and short breaks residential provision will be commissioned via Dynamic Purchasing Systems.

How will your local estate/housing base need to change? We need to have access to more local housing, for example through increasing nominations to social housing and seeking new build within housing developments. One option is to obtain capital through the Transforming Care Programme to convert some existing sheltered housing units. We will work with the Council’s housing and property teams to identify opportunities to increasing housing availability. As part of the procurement DPS, Ealing Council is seeking to develop the market and purchase supported living placements from support providers who are able to offer a range of affordable housing options via established links with housing providers for example: • Shared housing • Core and cluster – self-contained flats with support available on site • Network – small networks of people living in close proximity to each other • Bespoke accommodation e.g. adapted flat for a single person with complex needs In addition to local housing, there is a need to build respite capacity. We estimate that £40,000 capital monies are needed to adapt local provision to increase bed capacity.

Alongside service redesign (e.g. investing in prevention/early intervention/community services), transformation in some areas will involve ‘resettling’ people who have been in hospital for many years. What will this look like and how will it be managed? Each resettlement plan will be unique, person centred and will vary depending on the needs and circumstances of the individual. We are currently working with two people in hospital campus provision. Their circumstances are complex and subject to a legal challenge. We have held care and treatment reviews and will continue to work with these patients and their families. Both patients have lived in hospital settings for most of their lives and any move on plans will need to be in the best interest of the individuals.

How does this transformation plan fit with other plans and models to form a collective system response? The aims and values of this transformation plan fits with the local Transforming Care


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delivery plan, the wider LD Strategy and the Autism Board’s delivery plan

5.Delivery

Plans need to include key milestone dates and a risk register

What are the programmes of change/work streams needed to implement this plan?

Housing / Estates

Workforce planning – staff availability, skills and quality of care

Market development/provider development

Pathways and protocols

Green light agenda – people with mild LD and autism should be able to use all services without special service for people with LD

Access to primary care

Inclusion

Education/public health/awareness/understanding

Who is leading the delivery of each of these programmes, and what is the supporting team The programme will be lead by the jointly appointed commissioners for adults and children’s services who will build on existing networks to establish a transformation team to deliver the programme. There is already a good network of relationships between commissioners and providers, statutory and voluntary agencies, service users and families and friends and these will be drawn upon to champion and drive implementation. Some programmes will be borough specific and others involve a number of boroughs and CCGs, or the whole TCP area. Once this has been agreed, detailed delivery plans with milestones and leads can be confirmed.

What are the key milestones – including milestones for when particular services will open/close?

The CCG has already agreed additional investment in the CTPLD from April 2016 and is working with the other CCGs in the TCP to refine the specifications for CTPLD services and for inpatient LD services at Kingswood Centre for the 2016/17 contract.

Working with the voluntary sector, Ealing intends to commission Mencap to extend and expand the Expect the Best Quality Checker and Peer Support project to strengthen service user and carer involvement in 2016

During 2016/17 a business case for the development of 7 day and out of hours health coverage will be prepared and submitted with a view to implementation from April 2017.


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During 2016/17 the business cases for additional respite provision to be commissioned jointly by the local authority and the CCG will be developed and submitted with a view to implementation from April 2017 if not earlier.

During 2016/17, we will carry out a review of day opportunities for people with challenging behaviour with a view to remodelling in 2017/18 .

During 2016/17 Ealing will develop a programme to develop housing opportunities for people with learning disabilities and/or autism.

What are the risks, assumptions, issues and dependencies? Issues

Timescales and deadlines for submission of TCP plans

Introduction of dowry payments reduced the incentive for the CCG to escalate discharge planning and reduces the amount of money available to invest in specialist community support

Changes to welfare benefits, and the impact of austerity on people with disabilities

Recruitment of care staff is a London- wide issue

Property prices in London restricting availability of services Dependencies

Service redesign for CAMHS

National changes to allow budgets for specialised commissioning to be pooled with CCG budgets for non-forensic services for those with a learning disability and/or autism.

Availability of TCP investment to match local commitments Risks

Reductions in Local Authority funding.

Population growth (overall, but also growth in LD and the number of young people with very complex and challenging needs)

Commissioning and operational capacity

Business as usual – day to day placement and crisis management

Frequent reporting on inpatient cohort significantly reduces the amount of time that can be invested in redesign and transformation work.

Change in CTR guidelines/recommendations will be a pressure – required once every 6 months.

Ministry of justice and tribunals

Inconsistent assessment by Psychiatrists resulting in failure to take clinical responsibility for patients when discharged into the community

Assumptions The following assumptions underpin our Transforming Care plan:

Joint working across sectors and boroughs is achievable and sustainable.

Savings will be released by transferring patients to community care settings, and that these savings will then be invested in community care.


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Additional funding will be provided by NHS England to support transformation, including double running of services during transition and additional investment in commissioning resource.

North West London Transforming Care Plan - Risks and Mitigation:

Risk description Probability (High/Med/ Low)

Impact (High/Med/ Low)

Mitigation

Provider Response: The market does not develop as envisaged. The system may not support new entrant to any market development.

Med High Clear market position statements signalling commissioning intentions Good on-going provider engagement including actively working with providers to invite solutions, resolve issues and concerns.

Workforce skills: required workforce skills and capacity do not develop sufficiently. Staff not available/cannot afford to live in London.

Med High Clear workforce development plans Work with Skills for Care on workforce development models. Sufficient funding to develop workforce skills and recruit appropriate staff.

Mainstream services do not make the reasonable adjustment to accommodate LD/autism needs.

Med Med Senior leadership engaged so mainstream services make adjustments a priority, use contract levers where necessary.

Pooling budgets: nationally changes are not made to allow specialised commissioning spend to be pooled.

High Med Raise nationally as a key issue

Pooling budgets: locally there is still some reluctance to pool health and LA spend.

Med Med Leadership and use of the Better Care Fund and section 75 agreements

CCGs and LA are not able to afford new packages of care in the current financial climate with cuts to existing budgets.

High High Developing the market place and competition would lead to fairer pricing. Develop an effective pricing structure based on the care funding calculator. Consider risk sharing approaches with providers to encourage their investment.

Lack of commissioning High High Provide additional support


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leadership and operational service delivery capacity: business as usual (including CTR guideline recommendation and reporting requirements) takes up everyone’s time and there is no availability to take forward the Transforming Care work.

and capacity via short-term funded posts to cover business-as-usual, allowing experienced staff with local knowledge to get involved in redesign and service development planning.

Population growth: the population of North West London is growing, as is the number of people with a learning disability and/or autism. This will impact on the capacity of services to respond to demand.

High Med Include modelling of population growth into service redesign and business case development. Delivering a community-based model will help mitigate by providing care at a lower cost than inpatient care.

High needs patients: the very high costs of high need patients may negate any savings made by transitioning patients into community settings.

Med High Realistic planning that accepts the non-standard needs of this population. Continued support for high needs patients factored into affordability models.

Culture change: lack of a single vision and aims across all organisations and team

Med Med Effective leadership of the TCP Stakeholder engagement to ensure building of positive and effective relationships.

Earlier discharge may result in more readmissions of patients who were not ready to transition to community.

Low Med Extensive discharge planning, to commence prior to admission, proactive care plans, coproduced with people with LD and/or autism and their carers, and monitoring of readmissions.

Negative publicity regarding the media coverage of closure of inpatient beds.

Med High Effective strategic communications plan which patient stories promoting better outcome for people.

Estates: lack of available, affordable local housing to develop

Med High Consider widest range of solutions including private sector, shared lives etc.


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community in Borough accommodation

What risk mitigations do you have in place? See above

6. Finances

Please complete the activity and finance template to set this out (attached as an annex).

Completed.

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