Agenda item

The West Berkshire Health & Wellbeing Board is asked to acknowledge, understand and endorse the Transforming Care Plan.

The Board considered a report (Agenda Item 3) concerning the Transforming Care Plan, which had been jointly developed with the six local Berkshire authorities and the seven Clinical Commissioning Groups (CCGs) across Berkshire West.

Sarita Rakhra, Carers/Voluntary Sector/Mental Health and Learning Disability Commissioning Manager for NHS Berkshire West CGs, introduced the report which set out how services would be transformed for people of all ages with a learning disability (LD) and/or autism who displayed behaviour that challenged, including those with a mental health condition.

In 2012 a BBC Panorama programme had revealed abuse of vulnerable people at Winterbourne View. This provoked the Department of Health to conduct a Review all CCGs and local authorities were required to submit a joint strategic plan to show how people with LD would be supported out of the Assessment and Treatment units.  A joint Berkshire strategic plan was developed in 2013 and a Winterbourne Project Board lead service re-design work and developed key elements of a Positive Living Model. The Review concluded that in-patient provision should be scaled back with a stronger focus on community based support. A target was set for 50% of in-patient beds to be moved by June 2014 and not all Berkshire patients were moved within this timeline due to complex care needs that could not be met in appropriate community placements.

A concordat was signed between the Local Government Association (LGA), Association of Directors of Adult Social Services (ADASS) and NHS England to improve the lives of people with learning disabilities and/or autism and mental health problems.

The Berkshire Transforming Care Plan was aligned to the national plan, Building the Right Support, to strengthen community services and close 50% of the inpatient facilities by March 2019. The shared Berkshire vision was to improve the pathway for people with learning disabilities and challenging behaviour by reducing reliance on in-patient beds through increasing access to intensive specialist community services.

There was a national process to support discharge from the Access and Treatment Units (ATUs) and CCGs were required to chair and facilitate multidisciplinary Care and Treatment reviews that drew up recommendations and action plans to support timely and effective moves from in-patient beds into the community.

NHS England commissioned the forensic pathway, such as at Rampton Secure Hospital. There was one patient who had been accommodated there for 14 years and could be considered to be institutionalised; a stepped change would be required to resettle that individual into the community. Commissioners were working with national leads to ensure people were effectively supported for life in the community.

In Berkshire, the Berkshire Transforming Care Partnership Board (TCPB) had been lead by Gabrielle Alford, Director of Commissioning for Berkshire West CCGs, and Alan Sinclair, Interim Director of Adult Social Services and the Deputy Senior Responsible Officer. The TCPB has worked with CCGs, Local Authorities, and the Learning Disabilities Partnership Boards in developing the Plan. The TCP had been due for submission in July 2016 but NHS England had moved the timeline for submission forward to May 2016, hence a Special Health and Wellbeing Board meeting being called to review the Plan.

The Berkshire plan was built on agreed values and principles, and identified specific actions to ensure that all services were planned through clinical engagement and accountability, commissioned and provided in line with national plan and the regional ‘Positive Living Model’ for people whose behaviour might challenge. At present, 16 beds were commissioned by Berkshire Healthcare Foundation Trust (BHFT) and the proposal was that by March 2019 the reliance on these would be reduced by 50%. The Board were asked to support Berkshire’s vision to close down 50% of the in-patient provision hrough developing an Intensive Intervention Service in the community thus reducing the reliance on Assessment and Treatment units to support people with a learning disability and/or autism and mental health conditions.

This service would also entrench a system of person-led planning, to put the person with a learning disability and/or autism and mental health conditions and their families or carers at the centre of decision making and formulating their own Care Plans.

The Transforming Care Partnership Board held a planning workshop and drew representation from a wide range of stakeholders that included representatives of the 7 CCGs, 6 local authorities (LASs), LDPBs, local Advocacy groups, Primary care clinical lead (champion), Children's services, and the Autism Board.

The attendees at this workshop ranged from those in operational positions through to Directors of Social Services, commissioning and Provider organisations. The main focus of this workshop was to agree and align a Berkshire vision to bring together shared aspirations.

This planning workshop confirmed the asset base, shared the perceived obstacles and planned 7 key work streams to deliver a county wide vision for people with a learning disabilities and /or autism whose behaviour challenges. These were:

Joint commissioning: Joint commissioning and health and social care integration would continue to be a priority. At present, alignment of commissioning between local authorities and the CCGs was over reliant on a matrix tool and opportunities for collective decisions should be taken. The TCP also brought opportunities to develop pooled budgets. At present, providers were largely in control of prices and collective action on market development could assist price control to come under the CCGs and local authorities.

Additionally, NHS England had invited bids from voluntary sector organisations, housing associations and local authorities in the South and Central region for £8.6m in capital investment to adapt properties to meet the needs of people with learning disabilities and /or autism. This fund had been created by an underspend from northern regions.

Communications and Engagement: People with lived experience and their carers would be engaged to develop an easy-to-read version of the TCP. This would involve developing a Berkshire wide TCP communications plan.

Workforce Development and culture: It was recognised that cultural shift would take a significant amount of time to achieve. A cultural audit of the workforce would be undertaken by a questionnaire and the results would be used to grow a cultural change programme. People with lived experience would be involved in interviews for providers and staff, to continue their role at the centre of decision making.

Families, Children & Young people: Gaps had been identified in the TCP. Education services would need to be included in work on this area, to support children to continue to be supported in the community rather than in residential placements out of area. The Transforming Care Partnership Board would be engaging a Director of Children’s Commissioning, nominated by the local authorities to develop joint ways of working. Sally Murray, Head of Children’s Commissioning for the Berkshire West CCGs would support understanding of how Educational Health and Care Plans (EHCPs) and Special Educational Needs (SEN) Plans would link in to this work.

Autism: NHS England identified gaps in the TCP for people with autism and at a workshop it was decided that, the six autism strategies would be linked into the Transforming Care Plan. People with autism were sometimes viewed as outside the learning disability arena and this would enable services to provide joined-up support to people with an array of needs.

Service reconfiguration: Some in-patient beds would be retained to provide therapeutic Inpatient support for planned and emergency day and overnight services to individuals for whom it was clinically indicated. A specialist multi- disciplinary team would assess needs, design and implement therapeutic programmes of care that required the physical environment a building based unit could offer. A therapeutic inpatient unit would also act as a resource hub for the intensive intervention service and sessional activity, such as Sensory Integration, could be provided.

Risks: A programme management approach would be utilised to mitigate the financial risks. NHS England had provided £38k funding to appoint a programme manager to lead the work and set a timeline for delivery by March 2019.

Councillor Graham Jones expressed the view that the Transforming Care Plan to reduce the number of in-patient beds and provide community-based care was laudable and enquired why the target was a 50% reduction. Sarita Rakhra advised that the target was set by NHS England and there would be implications to underachieving against the target. She further explained that in Berkshire the aim was to overachieve against the target and reduce the number of beds to 11 by 2019.

Shairoz Claridge enquired how West Berkshire’s numbers of in-patient beds compared to other areas. Sarita Rakhra answered that northern regions have much higher numbers but in the south there were more people who had been at an ATU for a longer period.

Councillor Hillary Cole commended how the Transforming Care Plan aligned with the new way of working in adult social care in West Berkshire which got people more involved in their care. She also stressed the need already identified in the TCP to support children via the education service and engage families early in order to make the transition from provision for children and young people to adults easier.  Councillor Cole commented that involving the person in the process was important as often families wanted different things and families needed to be managed. Regarding the funding for the plan, Councillor Cole asked whether local authorities would also be expected to contribute.

Sarita Rakhra clarified that the CCG would be reducing the in-patient contract and re-investing the funds to develop the Intensive Intervention Service. Berkshire Healthcare Foundation Trust (BHFT) had indicted they would support this. At the TCPB, local authorities had expressed concerns that they would be placed under pressure to provide community services and these had been fed back to NHS England. The idea was for a whole system change and the CCGs would engage with local authorities on how to use the funding.

Responding to Councillor Cole’s point regarding families and carers, Sarita Rakhra advised that they would be involved in the Positive Living Model. She agreed that sometimes carers were an obstacle to achieve the person’s wishes and cited a case example of one person who had moved out of an ATU back to Reading, and the family had raised safety concerns. This had helped to secure the environment and safeguard their family member. The programme manager would be expected to develop a system for good engagement with families and carers in decision making.

Councillor Cole expressed the view that the local authority needed to send a clear message to the NHS that they were facing severe financial challenges and whilst she supported the initiative, she would expect to receive the funding to achieve the outcomes of the plan. Shairoz Claridge commented that the whole system was under financial pressure. Sarita Rakhra agreed with this view and reported that NHS England had been informed already of that view. Already, high cost placements were being reviewed to ensure that the most cost effective services were being provided. Councillor Cole reiterated that any savings that the TCP achieved must be invested back into the project and improve people’s quality of life rather than offsetting overspends in other budgets.

Andrew Sharp disputed that families caused a problem and advised they had an important role in highlighting issues for a person with limited mental capacity. In the Winterbourne View example, patients’ families had trusted the view of the professional and were let down. What the person with the learning disability wanted was not always safe or realistic. Shairoz Claridge agreed that a balance was required between the person’s human rights, their families and carers wishes and their care. Sarita Rakhra commented that carers had been engaged in developing the Positive Living Model and their feedback was positive.

Councillor Lynne Doherty referred to the gap that had been identified for children and young people and enquired when the Joint Strategic Needs Assessment (JSNA) would be updated. Lesley Wyman advised that it was difficult to compile the JSNA because the NHS and local authority collected different data. Some limited data had been received from the shared team.

Councillor Doherty commented that the report was very interesting and enquired whether specialist nurses would be visiting all schools across West Berkshire. Sarita Rakhra recommended speaking to Sally Murray for the detail.

Rachael Wardell firstly sought to welcome the programme of work and the right of people with learning disabilities to live in the community. Secondly, she sought to draw attention to the elements of the pan-Berkshire plan with a particular focus on West Berkshire. Officers at West Berkshire Council had been involved in the process, namely Roz Haines, Karen Felgate and Patrick Leavey. On page 20 and 21 of the agenda, data was presented including projected number of adults with challenging behaviour. Child and Adolescent Mental Health Services (CAMHS) were discussed on page 27 of the agenda, and it was noted that West Berkshire’s Emotional Health Academy supported this work. West Berkshire’s resource centre capacity was extrapolated on page 29 of the agenda and they were full to capacity. Page 46 outlined the local offer and there was an array of West Berkshire focussed content.

Rachael Wardell posed a question to the Board about how it might want to be assured of the risks of the project. There were two red risks; one was to local authority budgets for increased support and housing. The other risk was that the needs of children and adults would not fit together and there would be gaps in provision. The Board might want to receive an update on these risks and community capacity issues. Rachael Wardell noted that the bid for funding due on 26^th May 2016 presented an opportunity.

Councillor Cole responded positively to the opportunity to bid for capital funding and noted that there was a building in West Berkshire which was able to be repurposed and it was hoped that a housing association could take it on. Andrew Sharp queried whether the funding was available solely to provide housing to former inpatients at Access and Treatment Units. Sarita Rakhra advised that it could be used to bespoke housing or make adaptations.

Andrew Sharp raised a further point that the Board needed to be mindful of people with learning disabilities and/or autism living at home with families or carers. Healthwatch had consulted with carers and identified that many carers were reaching old age and there was a risk that people with learning disabilities were reaching similar transition points as they would need to adapt to living without their carer. For example, Andrew Sharp was aware of a carer who was 101 years of age and the person they cared for might go through the same transitional struggles as someone who had been institutionalised. The numbers were known but no action had been taken to assist these people.

Dr Bal Bahia commended the work that had been done, noting that he had been in the Berkshire West 10 Partnership some time ago when the TCPs were first being developed. The collaborative approach had come together well and had a bold ambition to tackle an embedded culture and deal with inequality. Dr Bahia was impressed with the alignment to the Brilliant West Berkshire programme and saw the direction of travel of the TCP as the same as the Health and Wellbeing Board’s vision. It would be the Board’s role to link the various elements together, including the housing elements. Dr Bahia further acknowledged that workforce development and training hubs had been a feature of many plans presented to the Board at its recent meetings and an overarching view of all these areas would be useful.

Andrew Sharp relayed the questions provided to him by Leila Ferguson, who had given her apologies for the meeting. Firstly, she had wanted to know what engagement with voluntary sector organisations had taken place. Sarita Rakhra advised that Learning Disability Partnership Boards had been involved in the process and an engagement plan was being written for involving the wider community, including an easy-to-read version of the TCP.

Andrew Sharp noted that Community Teams for People with a Learning Disability (CTPLD) would not be continuing to work in the same format and asked if these would cause an issue. Rachael Wardell advised that the provision would not be disappearing and the offer to people with multiple needs would be improved by maintaining specialist knowledge and more joint working between professionals with different specialisms.

Andrew Sharp questioned how the number of people with learning disabilities and/ or autism was estimated and forecasted, noting that the Office for National Statistics’ data was at a disparity to those receiving support services. Sarita Rakhra advised that there was work ongoing to align GP registers and various other sources of data. Rachael Wardell also commented that there was a difference between the clinical definitions and the threshold for access to services, for example some measures referred to an IQ lower than 70 whereas people with IQs higher than 70 could still have a learning disability. Dr Bahia further noted that labelling a person was not always helpful and this might impact on the figures.

Andrew Sharp further requested that practitioners be mindful that when considering ‘out of area’ placements, one mile into Wiltshire might be preferable than a person being in Bracknell. He commented that families’ points of view needed to be considered and it was not useful to use local authority boundaries as a guide.

Dr Bahia enquired how residents outside Berkshire boundaries, but within Berkshire GP catchment areas would fit in to the system. Shairoz Claridge explained that these people would be considered on an individual basis

Sarita Rakhra advised that NHS England had also announced funding available for Shared Lives, with a deadline for bids of 31^st May. She noted that West Berkshire had a very successful Shared Lives scheme.

Councillor Jones summated that there had been a good discussion of the TCP and the challenge for the Board would be to make a difference and drive through change.

RESOLVED that the Transforming Care Plan be understood, acknowledged and endorsed by the Health and Wellbeing Board. Further updates on the Transforming Care Plan would be put onto the Forward Plan.