NHS BOURNEMOUTH AND POOLE
NHS DORSET
DORSETHEALTHCAREUNIVERSITY NHS FOUNDATION TRUST
Re-commissioning mental health services for older people
in Bournemouth, Poole and Dorset
Joint Scrutiny briefing – October 2011
- EXECUTIVE SUMMARY
1.1.There are approximately 750,000 people living with dementia in the UK and this number is expected to almost double within 30 years, with the estimated cost of care rising to £35 billion by 2026. Much of this cost occurs at a late stage, on more expensive services, while earlier interventions can improve the quality of life for people and be more cost effective.
1.2.People with dementia tend to stay in hospital for longer than people who were admitted for the same condition but who do not have dementia, and up to 70% of hospital beds are currently occupied by older people, with up to half of these thought to be people with cognitive impairment. Better management of dementia in hospitals can reduce the length of time that people stay in hospital, and help them to return home earlier.
1.3.The proportion of the population aged 65 years and over in Bournemouth (19.04%), Dorset (25.64%) and Poole (21.18%) is above the UK average of 16.55%. Projections indicate numbers will rise significantly, particularly in Dorset and Poole and in parts of Dorset the proportion of people aged 65 years and over will approach 40% by 2030. It is also estimated that within this population, approximately 70% of people diagnosed with a mental impairment will have dementia.
1.4.The pattern of care in Bournemouth, Dorset and Pooleis currently reliant on inpatient and specialist services, however there is the opportunity to reshape services to provide care in community-based settings, offering more choice to patients.
1.5.Most people with dementia live at home but up to one third of people with dementia live in care homes. People living with dementia also need access to mainstream services, however it is necessary to ensure that providers have specialist advice, training and support to raise their awareness of the needs of dementia sufferers and their carers.
1.6.Previous engagement with stakeholders has informed the implementation of the transforming community services strategy, the development of the mental health strategy and a vision for mental health services for older people. The consensus of all those involved is the need to develop enhanced community-based care and to incorporate flexibility of response in order to better meet the specific requirements of individual service users and their families.
1.7.Collectively the PCTs and local authorities spend approximately £45 million annually on mental health services for older people. This includes all the community and hospital services, day care, home care and care home services, but excludes the increased cost of stays in acute hospitals exacerbated by mental illness.
1.8.To ensure the health service can met the needs of dementia sufferers and their carers in the future, it is necessary to re-shape existing community mental health teams for older people and the inpatient/hospital-based services into a new model of service delivery incorporating:
A memory assessment and early diagnosis service
An intensive dementia community support service
Age-appropriate urgent and inpatient care
Specialist support for the wider provision of care for older people with mental impairment by primary care, community care teams and care homes.
1.9.Whilst the final shape of services remains to be determined, it is anticipated that proposals will provide an extended range of community services to offer earlier diagnosis and treatment for people with dementia, earlier access to information and support for carers, a dedicated rapid response service to address urgent need at home for people with dementia and their carers, and a re-configured inpatient service focused on a more limited number of centres of excellence across the county.
1.10.A joint project plan with Dorset HealthCare University NHS Foundation Trust is under development, incorporating a communications and engagement plan, with the expectation that more detailed proposals on the revised services couldbe brought to the Joint Overview and Scrutiny Committee meeting on 5th December. Capital funding is available this financial year to undertake any necessary upgrades or extension to service facilities and the Joint Overview and Scrutiny Committee will be kept updated as the proposals develop so that appropriate investment decisions can be reached.
2.BACKGROUND – THE CASE FOR CHANGE
2.1.The National Dementia Strategy (2009), the National Institute for Health and Clinical Excellence (NICE) Dementia Quality Standard (2010), and updated strategies for local dementia care in Bournemouth, Dorset andPoole identify four main aims:
Early diagnosis and early interventions
Better care for people at home and in care homes
Better care in hospital
Reducing inappropriate use of anti-psychotic medication
All of these aims are underpinned by better support for carers.
2.2.Following extensive consultation with health and social care experts, including people with dementia and their carers, in July 2011 the Department of Health published a Dementia Commissioning Pack, which sets out a joint health and social care approach to improving services for people with dementia.
2.3.There are approximately 750,000 people living with dementia in the UK and this number is expected to almost double within 30 years. The estimated cost of providing care for people with dementia will have risen to £35 billion by 2026. Much of this cost occurs at a late stage, on necessarily more expensive services, while earlier interventions that are known to be cost effective and to improve the quality of life for people with dementia and their carers are not widely available.
2.4.Part of the reason is that many people with dementia do not receive a diagnosis, or, where a diagnosis is made, it is often late in the illness when it is too late for those living with dementia to make choices. Improving diagnosis, and in particular early diagnosis, provides a gateway for more effective care and support and helps to improve the quality of life for people with dementia and their families.
2.5.Most people with dementia live at home but up to one third of people with dementia live in care homes. They all require ongoing care managed by their GP but the complex physical and mental health needs of this patient group means that at times GPs require access to specialist advice. People living with dementia are also likely to need access to a range of mainstream community-based services, but often these services do not respond well to the specific needs of people with dementia and their carers. It is necessary therefore to ensure that specialist advice, training and support is available to assist care-givers and to ensure that the full range of community-services is “dementia-friendly”.
2.6.Up to 70% of hospital beds are currently occupied by older people, and up to half of these may be people with cognitive impairment, including dementia and delirium. People with dementia tend to stay in hospital for longer than people who were admitted for the same condition but who do not have dementia. Better management of dementia in hospitals will therefore reduce the length of time that people with dementia stay in hospital, and help them to return home earlier.
2.7.The development of behavioral and psychological difficulties is common in dementia. Help can be given through anti-psychotic medication but often alternative non-pharmacological treatments can be more appropriate.
2.8.In comparison to some other parts of the country, dementia care in Bournemouth, Dorset and Poole is good. But analysis shows that the incidence of dementia is under-diagnosed, and that older people are admitted to hospital for unplanned care more frequently and for longer than in many other places. Whilst expenditure on anti-psychotic medication for people with dementia in Bournemouth, Dorset and Poole is relatively low compared with most other areas, guidance suggests that inappropriate prescribing could be reduced.
2.9.Further, the proportion of the population aged 65 years and over in Bournemouth (19.04%), Dorset (25.64%) and Poole (21.18%) is well above the UK average of 16.55%. Population projections indicate that the proportion of elderly and very elderly people locally will rise significantly, particularly in Dorset and Poole. In parts of Dorset the proportion of people aged 65 years and over will approach 40% by 2030.
2.10.Within this ageing population, approximately 70% of people diagnosed with a mental impairment will have dementia.
2.11.The pattern of care in Bournemouth, Dorset and Poole is heavily reliant on inpatient and specialist services, and there is the opportunity to reshape services to provide care more effectively through a service more focused on providing choice and care in community-based settings.
3.DEVELOPING PROPOSALS FOR CHANGE
3.1.In Marchand June 2011 the two primary care trusts facilitated a series of three interactive half-day workshops at Merley House, Wimborne involving a wide range of local stakeholders including representatives of local authorities, hospital and community services providers, GPs, carers and third sector organisations. The aim was to establish a vision for mental health services for older people which clearly identifies and addresses the preferences of local service users and their carers whilst also incorporating the service characteristics and standards defined in national guidance. There was consensus on the need to develop enhanced community-based care and to incorporate flexibility of response in order to better meet the specific requirements of individual service users and their families.
3.2.Members will recognise that these outcomes are entirely consistent with the earlier extensive consultation that was undertaken on Transforming Community Services, and the Service Strategies for Mental Health and for Older People where there was widespread support for bringing care closer to home by offering a wider range of services in the community.
3.3.A further key outcome of these workshops was the agreement with providers of a service user care pathway which will help to define how services should be configured in the future.
3.4.Collectively the PCTs and local authorities spend approximately £45 million annually on mental health services for older people. This includes all the community and hospital services for older people provided by Dorset Healthcare University NHS Foundation Trust (DHUFT) and the day care, home care and care home services provided and commissioned by the local authorities, but it excludes the increased cost of stays in acute hospitals exacerbated by mental illness.
3.5.Existing services in Bournemouth, Dorset and Poole, particularly NHS services, seem over-reliant on inpatient and specialist care in contrast to the wider range of home and community-based options identified in the service development workshops and the best practice outlined in national guidance.
3.6.Accordingly a commissioning project team has been established to lead the re-shaping of the existing community mental health teams for older people and the inpatient/hospital-based services into a new model of service delivery incorporating:
A memory assessment and early diagnosis service;
An intensive dementia community support service;
Age-appropriate urgent and inpatient care;
Specialist support for the wider provision of care for older people with mental impairment by primary care, community care teams and care homes.
3.7.DHUFT has agreed to work collaboratively in developing the new service model, although this does not rule out the possibility that some elements of service could be procured externally either under the national Any Qualified Provider scheme or by open market tender.
3.8.Whilst the final configuration of services remains to be determined, it is anticipated that proposals will enable the delivery of an extended range of community services to offer earlier diagnosis and treatment for people with dementia, earlier access to information and support for carers, a dedicated rapid response service to address urgent need at home for people with dementia and their carers, and a re-configured inpatient service focused on a more limited number of centres of excellence across the county. It is anticipated that the reconfiguration will release resources to fund enhanced community service provision and the savings required under the NHS Quality, Innovation, Productivity and Prevention (QIPP) programme.
3.9.A joint project plan is under development, incorporating a communications and engagement plan, with the expectation that more detailed proposals on the revised services couldbe brought to the Joint Overview and Scrutiny Committee meeting on 5th December. Capital funding is available this financial year to undertake any necessary upgrades or extension to service facilities and the Joint Overview and Scrutiny Committee will be kept updated as the proposals develop so that appropriate investment decisions can be reached.
3.10.In the interim, the PCT Cluster has made an additional annual commitment of up to £513k during 2011/12 and 2012/13 to establish a dedicated memory assessment and early diagnosis service. This should improve the diagnosis rate and enable improved access to treatment for people with dementia.
3.11.In parallel Dorset County Council has allocated reablement funding to commission prevention and early intervention services together with community support in the form of a Memory Adviser in each of the six localities in Dorset. In each locality there will be a network of Memory Cafes and “Melodies for Memory” groups. A procurement process is underway, with the expectation that these services will be in place at the latest from 1st January 2012. The Memory Advisers will be employed and managed through a contract with Age Concern and the contract award for provision of Memory Cafes and “Melodies for Memory” groups is expected to be announced shortly. A similar approach is being considered for Bournemouth and Poole.
4.COMMUNICATION AND ENGAGEMENT
4.1.Effective communication and engagement is key to the successful delivery of the change to services which is being sought. The involvement of users, carers, clinicians, staff and other key stakeholders in the development of the mental health services for older people will help to shape the service and ensure that it is relevant, accessible and provides effective and deliverable outcomes.
4.2.The project plan includes a detailed communication and engagement plan, the first draft of which is attached as Appendix 1 to this paper. It identifies the key audiences to engage, the methods and channels of engagement and the process to be followed.
4.3.It is anticipated that the Joint Overview and Scrutiny Committee will be kept updated on the progress of this project at all meetings so they are fully engaged and consulted on any significant service changes resulting from the engagement activity.
5.NEXT STEPS
5.1.The Joint Overview and Scrutiny Committee is asked to note the proposals and the processes anticipated for ensuring improved mental health services for older people in Bournemouth, Dorset and Poole and to provide feedback as appropriate.
5.2.It is also asked to comment on the communication and engagement approach proposed.
5.3.A further update will be brought tothe committee in December.
Graeme Barnell
Deputy Director of Joint Commissioning and Partnerships (Mental Health)
NHS Bournemouth and Poole and NHS Dorset
James Barton
Director of Mental Health
Dorset Healthcare University NHS Foundation Trust
Supporting papers:
National Dementia Strategy (2009), Department of Health
Dementia Quality Standard (2010), National Institute for Health and Clinical Excellence
Dementia Commissioning Pack (2011), Department of Health
Population Estimates (2011), UK National Statistics Publications, Government Statistical Service
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