review of arrangements for COUNTY COUNCIL AND HEALTH services FOR people with learning disabilities in hertfordshire

modelling of DEMAND AND future costs
2006/07 – 2015/16

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Review of County Council and Health Services for People with Learning Disabilities in Hertfordshire

TABLE OF CONTENTS

1...... EXECUTIVE SUMMARY

2 BUDGET ISSUES AND TASKS TO BE COMPLETED

3 METHODOLOGY

4...... background and context

5 ELIGIBILITY, ASSESSMENT, CASE MANAGEMENT
AND COMMISSIONING

6...... REVIEW OF DATA

7 RECOMMENDATIONS AND THE FINANCIAL MODEL

APPENDIX 1 KEY STAFF INTERVIEWED

APPENDIX 2 policies, strategies AND procedures examined

APPENDIX 3 valuing people

APPENDIX 4 CLIENT STUDY

APPENDIX 5 FINANCIAL MODEL…………………………….BOUND SEPARATELY

Please note that in this report where we refer to a chapter, this refers to a specific section of this report. Where we refer to a section, except where a piece of legislation is referred to, we are referring to a section of the financial model.
1EXECUTIVE SUMMARY

1.1Budget Issues and Tasks to be Completed (Chapter 2 of this report): Hertfordshire commissioned PriceWaterhouseCoopers (PWC) consultants in 1999 to assess demand for services for people with learning disabilities. This work concluded that demand was high and would continue to increase. Based on this a programme of investment in residential and nursing care services was agreed.

1.2Despite this considerable investment, the county council and health service continues to have demand above the levels anticipated with considerable overspending. These are detailed in paragraph 2.6.

1.3Consequently CareandHealth consultants were commissioned to review the original PWC work and revise this in light of the experience since 1999. The aims of the work are set out in paragraph 2.7.

1.4Methodology (Chapter 3): We undertook the tasks set out in the brief through a variety of methods outlined inChapter 3 of the report. In particular we examined case files, interviewed key staff, reviewed key strategic documents, analysed data about services in Hertfordshire and in similar authorities, and then modelled the financial effects we estimated for future demand and some offsetting economies.

1.5Background and Context (Chapter 4): The national context for services for people with learning disabilities includes significant changes and improvements required through the Valuing People guidance. These requirements are set out in Appendix 3. Although the changes have not been adequately funded by central government, Hertfordshire CC and its NHS partners have made significant efforts to deliver the changes. We were impressed by these and the progress made against the Valuing People agenda.

1.6PWC found that demands for services for people with learning disabilities in Hertfordshire were high. Demand for services is increasing due to a number of factors including increased life expectancy for people with learning disabilities who now survive childhood or middle age where previously they would not. These are shown in paragraph 4.9 of the report.

1.7Additional funding pressures are also occurring due to increased expectations of service users and carers, higher regulatory demands on providers, lack of competition among providers, increased health needs and centrally determined criteria for eligibility. More detail on these is provided in paragraph4.10.

1.8Eligibility, Assessment, Case Management and Commissioning (Chapter 5): We found that Hertfordshire’s criteria for eligibility: -

  • Are in line with other authorities.
  • Were consistently applied.
  • Could not be tightened as they were set at the most stringent level acceptable to central government.
  • Could not be relaxed without considerable additional (and probably unaffordable) costs.

1.9Demands for services have increased due to the effects of the Fair Access to Care Services(FACS) regulations. These mean many people are now eligible for learning disability services due to their vulnerability, not their level of learning disability, who would previously have been outside the eligibility criteria. Some of these cases are very costly.

1.10The assessments, care plans and risk assessments we examined were good or excellent. The vast majority of care plans were in our view proportionate to the need.There may be opportunities for fuller use of nursing staff in CLDTs. The work of the Accommodation Panel was successful and proportionate in its challenge to the plans proposed by staff.

1.11Commissioning of services was less successful. We found a number of areas where methods could be improved with potential significant savings to offset some of the increased costs due to increased demand. These responses are set out in Chapter 7 of the report.

1.12Review of Data (Chapter 6): We considered the experience of Hertfordshire and other counties since 1999 when PWC reported.

1.13The number of residential, nursing and other group based housing and support services needed had increased broadly in line with the estimates provided by PWC.

1.14We found that demand for community based services (not considered by PWC) had also increased and that the responses provided were now more complex given the needs of these service users.

1.15Budgets had increased in Hertfordshire significantly. This increase was however lees than the average of similar counties. Hertfordshire’s budget per capita was amongst the highest. Its SSA was the highest and had risen in line with other authorities. Other councils tended to overspend their budget allocation for learning disability services in 2003/04, whereas Hertfordshire underspent by 1.3%.

1.16Unit costs had risen significantly in Hertfordshire, although by less than the average in similar authorities. These had been high in 1999 and remained high compared to similar counties

1.17We also found that Hertfordshire may be at a disadvantage, as the number of registered nursing and residential beds available in the county, was lower than in other counties.

1.18Recommendations and the Financial Model (Chapter 7): Finally we modelled the financial effects of the increased demand for services and the potential for off-setting savings. These are set out in Chapter 7 and appendix 5. This does not include demands for continuing care where we are aware that work is being undertaken by other consultants for the PCTs. This modelling indicates that additional investment will be required due to year on year net increase in the numbers of service users as follows:

1.19For example on current trends, funding for an additional 270 residential care places will be required in the next 10 years.The financial effects of this growth and changes to funding available from central government sources are summarised in the table below.

1.20We also identified a number of areas of possible savings. These included:

  • Additional Provision in Hertfordshire
  • Reduction in Duplicate Placements
  • Reduction in Voids in Block Purchased Beds
  • Arrangements for Micro-Contracting and Purchasing
  • Review Arrangements
  • Specialist Aspergers Team
  • Transitions Worker
  • Crisis Intervention Team
  • Charging

These are set out fully in Chapter7.

1.21The benefits of these proposals would not all be available in the first year. Some we consider would take several years to implement fully. We have estimated the benefits on what we consider to be a reasonable timescale for effective implementation. The effect of these proposals together with the growth required is set out below

1.22Even with the possible savings, it is clear that considerable additional financial demands will be experienced in coming years. Actual demand may be slightly less with growth estimated at likely maximum levels, while savings we have estimated conservatively. We believe it would be unwise to budget at levels lower than those indicated.

SUMMARY OF RECOMMENDATIONS

  1. Using the Financial Model - In using the model we recommend that you monitor the actual net change in numbers of placements against these projections annually in relation to underlying rates and any bulges in demand in relation to transition of young people from children to adult services, or other areas.
  2. Inflation - We also recommend that you monitor the actual inflation in costs for each type of placement generally, and specifically for young people in transition and for those aged over 50.
  3. Additional Provision in Hertfordshire(Section 12 of the financial model) – We recommend that you explore the possibilities of expanding the residential provision for people with learning disabilities in Hertfordshire in partnership with one or two partner providers. A particular area that this housing and support might focus on would be to meet the needs of people requiring semi-secure accommodation; for people with challenging behaviours; and for people with high level autism and aspergers syndrome.
  4. Reduction in Duplicate Placements(Section 13) - We recommend that the continuation of the funding of a duplicate placement should only continue after one month with the authorisation of the accommodation panel. After two months it should only continue in very exceptional circumstances.
  5. Reduction in Voids in Block Purchased Beds(Section 14) – We recommend that the contract arrangements are re-negotiated to take account of this situation in particular where the likelihood of upstairs rooms not being used at all is apparent.
  6. Arrangements for Micro-Contracting and Purchasing(Section 15) - We recommend: -

aContinuing the work on a regional basis to develop an agreed approach to contracting and a more united approach on contract negotiation and cost control.

bDeveloping a cost model for placements to assist those purchasing to achieve consistency in costs for placements. This will need to take into account factors including the level of need and challenging behaviour, staffing requirements including 1:1 staffing and waking night staff, differing property costs across the county.

cCreating a specialist function, which we consider will be most effective if positioned externally to the assessment teams possibly with the contracts team, to undertake the purchasing of placements

  1. Review Arrangements(Section 16) - We recommend that a programme of reviews is developed to ensure that the services provided and costs of all cases are reviewed at least annually. After a move to residential accommodation, there should be at least one review in the first six months.
  2. Specialist Aspergers Team(Section 17) – We recommend the creation of a specialist team to deal with the needs of people with Aspergers Syndrome to ensure that these needs are fully met by specialist staff. This development will need to be joint between the county council and the health service.
  3. Transitions Worker(Section 18) - We recommend a specialist post to co-ordinate this process ensuring that involvement with the young person and their family is planned from an early stage.
  4. Crisis Intervention Team(Section 19) - We recommend the creation of a team to provide additional support to residents or people living in their own homes who are in difficulty.
  5. Charging(Section 20) – We recommend you consider the introduction of charges for some services as part of the process of ensuring that people with learning disabilities live as normal a life as possible.

2BUDGET ISSUES AND TASKS TO BE COMPLETED

2.1PriceWaterhouseCoopers (1999) concluded that Hertfordshire had high demand for services for people with a learning disability. To meet the needs identified in their demographic study would require a programme of on-going investment in the service.

2.2Consequently, the Council agreed to fund an additional40 units of housing and support a year by investing £1m annually together with the on-going costs of previous year placements. For 2005/6 the new investment was £1.8m.

2.3A partnership agreement established Joint Commissioning Arrangements and a pooled budget for the service. Currently, the Joint Commissioning Team allocate

£49.7m to Adult Care Services to provide direct services and block and spot contracts to purchase services from the private and voluntary sectors.

£26.435m to A.C.S. for the purchase of social care for people who would otherwise be the responsibility of the N.H.S. and including people resettled from hospital under the provision of Section 28a N.H.S. Act 1990.

£8.647m to Hertfordshire Partnership Trust for assessment and treatment services and as a provider of housing and support.

2.4The 8 Primary Care Trusts have pooled their resources to provide a budget of £5.732m to provide for the continuing care needs of people with a Learning Disability.

2.5The Councils in Hertfordshire spend £4.75m of Supporting People Grant on the provision of housing support for people with a Learning Disability. This services 897 people in group homes and supported living and a further 173 people with secondary support needs.

2.6These budgets are under severe pressure. As examples:

  • In December 2004, the pooled budget was overspent by £1.688m. Through projecting known demand for accommodation the Council expect that this overspend could exceed £5m in the foreseeable future.
  • The Continuing Care budget has increased by £1.75m in the last year to meet increased demand for N.H.S. care and services.
  • Central Government has reduced the Supporting People Grant by 5%. This will need to be replaced if current housing support services are to be maintained.
  • The J.C.T. face a loss of £1.47m because of the Central Government claw back of those Section 28a monies for people deemed as old long stay patients and resettled before 1972. Their funding reverts to the Learning Disability Development Fund (LDDF) for national re-allocation to PCTs for re-allocation to prescribed categories of expenditure. Hertfordshire receives back only about 30-35% of the clawed back funding. Although this funding is “ring-fenced” at present, this may not continue. At this point PCTs could reallocate the funds away from learning disability services.
  • CareandHealth has been commissioned to analyse current and future demand, to identify the consequent budget pressures and to identify options for managing demand and expenditure. This is to be achieved by:
  • Estimating future (10 years) demand for services by client group and to include new groups such as Aspergers and adults who are deemed vulnerable. Previously these people would not have received services funded by the Joint Commissioning Board. They are now eligible because of the introduction of the Fair Access to Care Services (FACS) regulations introduced by the Department of Health.
  • Identifying demand against the current criteria for eligibility and against the statutory minimum criteria if that is different.
  • Analysing current eligibility criteria to determine that it meets statutory requirements and how it compares with the criteria set in other authorities.
  • Considering if current practice in assessing for and delivering packages of care reflects the eligibility criteria and provides value for money.
  • Evaluating the appropriateness of care commissioned at both a strategic and an individual case basis.
  • Comparing activity, expenditure and performance in Hertfordshire against comparable County Councils in England.
  • Identifying options to manage future demand.
  • Estimating the shortfall in funding to meet the service requirements.
  • Additionally, and beyond the initial brief, it became evident during the course of our work that, for completeness, we should consider how changes in care management, review, commissioning and contracting could help to manage demand.

3 METHODOLOGY

3.1We held interviews with key officers from all partners to gather their views on the challenges they were facing and to allow us to test out findings and options with them.(Appendix 1 – List of Interviewees)

3.2We undertook a case file analysis to examine:

  • the interpretation and implementation of Fair Access to Care (FACS),
  • the standard of risk assessments,
  • the proportionality of care plans,
  • that those care plans reflect the aims and objectives set locally and of Valuing People,
  • that costs for the purchase of care are reasonable, and
  • that reviews are carried out to assess if care plans remain relevant and proportionate.

3.3We contracted to examine 40 case files. However, in order to get a representative sample across the county, we extended the exercise to include:

  • 70 client files (10 from each CLDT) made up of
  • 4 clients with critical or substantial needs,
  • 4 clients with a moderate learning disability but eligible for a service, and
  • 2 clients with Aspergers from each locality.
  • 71 applications to the Placement Panel including
  • 18 clients in transition,
  • 15 clients in hospital,
  • 10 clients where there is an urgent need for a placement,
  • 22 clients where changes in family circumstances will require a new or changed placement in the foreseeable future, and
  • 6 clients where existing services are over-provided.

In particular, we examined if requests for placement were proportionate, how the panel ensures that placements meet assessed need and provide value for money, if the panel is challenging in its approach and if the challenges made were appropriate.

3.4We conducted a literature search to identify research which will help to determine future patterns of need.

3.5We examined and analysed key strategies, policies, procedures and eligibility criteria. We then “benchmarked” these against statutory requirements and Valuing People.

3.6We undertook a desk top exercise to examine FACS guidelines in 30 local authorities.

3.7We conducted an examination and analysis of activity, performance, commissioning and contracting data and benchmark against other authorities.

3.8We undertook a desk top search for example of good practice elsewhere in England to manage demographic and resource pressures.

3.9We considered the PWC Report (1999) to determine its current relevance.

3.10We estimated demand for the next 10 years by reference to:

  • Council data on children with disabilities and adults using residential and community care services
  • Aspergers research project
  • Assessment and Care Management Process
  • Clients known to the placement panel
  • Incidence of client deaths
  • Outstanding resettlement activity
  • National and academic research on the incidence of learning disability in the wider population
  • Action for Health – potential consequences on demand.
  • We formulated recommendations to suggest how demand and expenditure may be controlled by making changes to care management, review, commissioning and contracting processes.
  • We undertook financial modelling of likely expenditure against:
  • Current policy, practice and procedures
  • Recommended changes.

4background and context

4.1The Government White Paper, Valuing People (March 2001) establishes a national agenda for improving and modernising services and opportunities for people with a learning disability. It is recognised that this group of people are amongst the most socially excluded and vulnerable people in Britain. Few have a home of their own, a job, real choice in how they live their lives and few friends outside their families, people who care for them and their peer groups whom they meet in segregated service provision.