To consider proposals for the development of high-performing health and social care services by 2012 to meet the expected future needs of 18-64 year-olds in Herefordshire with mental health problems and physical disabilities.

The Committee considered proposals for the development of high-performing health and social care services by 2012 to meet the expected future needs of 18-64 year-olds in Herefordshire with mental health problems and physical disabilities. The Chairman expressed some general reservations about the robustness of the data upon which the reports were based.

The Corporate Policy & Research Manager concurred: the reports themselves identified the deficiencies in the available data both locally and nationally and recommended action to address the local elements, as well as a further review of the levels of need for services by 2012 in the light of the better data that should be available by that time.  These were not matters that were unique to Herefordshire, as similar issues existed across many local and health authorities.  It was, nonetheless, possible to regard the estimates of need to 2012, which was the time-horizon for the recommended improvements in services, to be reasonably robust. What was clear, from the comparisons that had been made with high-performing areas similar to Herefordshire, was the nature and broad extent of the service improvements that were needed.   He emphasised that the report had been prepared under the direction of a steering group involving a range of partners and had been quality assured by two national expert advisers, whose qualifications for the role were outlined in Appendix 3 of the report.

He first presented the section of the report on the future care needs and services for 18-64 year olds with mental health problems.  He based his remarks on Appendix 1, the summary of the report, on pages 9 and 10.

He went on to say that Herefordshire spent far more on secure and high-dependency residential nursing care than the other authorities that had been used as comparators in this study.  The County also provided less support for users and carers than the comparators. Whilst there was a feeling in these groups that services had improved, they still left a lot to be desired, including in respect of communication issues between users and staff and between different groups of professional staff.  Direct access to secondary services as well as more training and work opportunities had also been highlighted as being of concern to users and carers.

He said that the report found it reasonable to conclude that the aggregate level of spending by the Council and the PCT in 2006-07 (including the overspend of £1.3 million against budget) was the minimum necessary recurrent funding to meet the needs of those with the most serious and the most common mental health problems up to 2012.  This conclusion should be reviewed by 2012 in the light of better data, including the actual demand for fully modernised services.  Since it was not possible to stop current provision before more efficient and effective services had been put in place, non-recurrent bridging funding would be required.  The transformation plans to bring about the new pattern of services should be fully integrated with the steps taken to manage current in-year over-spending against budget.  Cabinet had recommended to Council that the funding should be made available.

He added that the new services would only work if all those caring for and supporting people with mental health problems were developed to have the right skills and behaviours. This would need to be done as part of the introduction of the streamlined processes and ICT-based systems which were now being put in place.

Mr Hemming concurred with the previous comments that accurate data for all key aspects of were difficult to obtain at this juncture.  He went on to say that improvements had been made at the Stonebow Unit, which included a suite to assess those arrested under Mental Health Act powers rather than the use of police cells, as well as the piloting of a single consultant working closely with the crisis team over admissions.  This had reduced the length of stay on wards, which was to the benefit of patients, as shorter admission periods undoubtedly aided recovery. 

He reported that the PCT was also good at managing people who had to be sent to psychiatric care units out of the County.  A review was underway which was considering rehabilitation and recovery of patients, as well as the housing of users.  This would help every Hereford patient currently out of county, and would reduce costs to the PCT.  Staff were being offered additional training, and a postgraduate training was being provided for drug workers in association with the University of Worcester.  Changes were also being put in hand to consider ways to improve the eating disorders services: a pilot project to treat people at home.   The number of middle grade doctors was also being increased from three to five. 

He went on to say that, with regard to users and carers, integrated operational management groups were being put in place.  Work was being undertaken with user groups where the PCT would have the responsibility for operational feedback.  In addition to these advances, work had taken place that had reduced the waiting lists for those undergoing methadone treatment. 

In the ensuing discussion, the following points were made:

·            A number of depressive illnesses were under reported, as those who could afford it tended to have such problems treated privately in order to avoid the possibility that their employer might access medical records. 

·            The Corporate Policy & Research Manager concurred, and noted that, wherever possible, these issues had been considered and taken into account in the report.  He added that there was a problem of identifying all cases early onset dementia, as it was difficult to obtain reliable data regarding those who had been diagnosed.

·            The Head of Service - Adult Social Care reported that the delivery of services within the County was complex.  Some of the services were provided, on behalf of the Council and the PCT, by the PCT’s provider-arm through joint teams and services. However, there were a number of people in residential accommodation, and some of these services were bought in by the Council from other providers.  Consequently there were a number of choices that would need to be made over who was best placed to provide services in developing the County-wide services in the future.

·            In reply to a question on how the out of county patient care costs could be reduced, the Corporate Policy & Research Manager directed the Committee’s attention to page 31 of the report.  He said that in the absence of adequate local, community-based services, the trend towards increased numbers of placements and higher costs would continue.  Detailed modelling had shown, however, that should the appropriate care and support be provided locally the net effect would that it ought to be possible to provide the aggregate proposed new pattern of services within the current level of expenditure. There would, however, always be some specialised care that would need to be provided out of County.

·            In reply to a question regarding out of county costs on specialist care, Mr Hemming said that some patients would always have to go to specialist units or high security hospitals, but that there were other patients in out of county placements at the moment whose needs could not presently be addressed within the County.  The PCT and Council did have the capacity to increase the available range of services so that more of these individuals could be treated at home.  A repatriation programme was in hand.

·            There was clearly an expanding need for carers in the home, and this was not only true of the mental health arena.   It was not clear from this report, however, that this was necessarily being provided.  The increase in resources that was being considered seemed to be financial and there was no indication that additional staff would be employed.  The Head of Service - Adult Social Care replied that this was both a local and national problem as it was difficult to recruit people into social care.  A national campaign to encourage young people to choose this career path had been launched by the government.  There were particular issues in Herefordshire, which were common to all rural counties.  Ways of further encouraging recruitment and retention were being considered. 

·            In reply to a question regarding the mental health of migrant workers, Mr Hemming said that few members of these communities came into the Council and PCT’s services.  Acute cases were dealt with at the Stonebow Unit.  This would seem to signal that people from these groups either did not know where or how to seek help, or were concerned how they would be treated if they came forward.  There was a budget for 1.5 community development workers, and the PCT would need to consider how best to connect with these communities.

·            The issue was raised of the increasing local and national problem of returning Armed Service personnel with mental health issues who were trying to re-integrate into civilian life and find employment.  Mr Hemming said that the Services provided treatment for those who continued to serve, but once they had been discharged, follow up care was provided by the PCT.  In general, there was an insufficient number of staff trained in the appropriate psychological therapies required to deal with the post-traumatic stress syndromes which these patients presented.

Assessments of 18–64 Year-Olds’ Future Needs and Services: Physical Disabilities

The Corporate Policy & Research Manager went on to report on the future care needs and services for 18-64 year-olds in Herefordshire with physical disabilities.  He drew the Committee’s attention to the summary at pages 93 and 94 of the report and said that currently many thousands of people within the County drew invalidity benefits, but a relatively small proportion actually accessed available services.  There were an estimated 4,600 people with moderate disabilities who are likely to require care at some time, a number which was expected to increase by about 5% by 2012 and 8% by 2021.  An estimated 950 currently had serious disabilities and were likely to require care at some time; a the number that was expected to increase by a maximum of 5% by 2012, but not further by 2021.   Overall, the report concluded that it would appear appropriate to plan to provide care and other support for an additional 5% of people by 2012.

Users and carers had expressed broadly similar concerns to those with mental health problems.  In particular, they wanted better communications with staff; more consistent support from social workers and occupational therapists, and a reduction in waiting times.  They were also keen to see the extension of direct payments and personalised budgets.  The Corporate Policy & Research Manager went on to say that, in order to achieve high-performing, cost effective services by 2012, Herefordshire would need to do more to support people, including those with intensive care needs, in their own homes and communities, together with other measures to give more control to users and carers.  Appendix 6 of the report, pages 105 to 108, outlined in detail the improvements that would be required to existing services. 

The Head of Service - Adult Social Care reported that the decision to appoint a Joint Director of Integrated Commissioning was designed to make a great deal of difference in the delivery of services.  It was currently sometimes difficult to resolve the needs of different people under the aegis of different organisations with differing priorities.  A temporary officer was in place who would be producing a Joint Commissioning Strategy which would be available later in the year.  She went on to say that the Supporting People Programme was delivering more packages to help people with physical disabilities in ways that would involve the individual, whilst at the same time being more economical in terms of the Council’s resources.  Individualised budgets allowed for an agreement for a budget appropriate to the level of need.  In this way, twelve people with learning difficulties, thirty-six with physical disabilities and forty carers were already being helped.  In addition, a Carers Hub, entitled Herefordshire Carers Support, would be in place from the first week in April.  The number of carers receiving support would be doubled.

In the ensuing discussion, the following points were made:

·            The Head of Service - Adult Social Care went on to say that Herefordshire was, in her experience, the first local authority where the occupational therapists were not employed by the Council.  There was a need to help individuals achieve a better quality of life, and there was concern that therapists employed in a clinical environment tended not to deal with the needs of the person as a whole.  There were also concerns that the assessment process was not as joined-up as it should be, and this would be addressed.  In addition, the particular requirements of young people as a distinct group would be looked at, particularly their needs for employment, housing and leisure. A Member reinforced the importance of the integration of occupational health.

·            That it was important that it should be acknowledged that, without the carers at home, the burden on the Local Authority would be far greater.

·            Concern was expressed that people awaiting direct payments were often those with the most severe disabilities.  The Council was also failing in the area of adaptations in the home, as it was often only clear what an individual required after patients had been admitted to hospital.

·            That there was much talk in the reports of reducing residential care for mentally and physically disabled people.  The biggest resource issue, should the Council continue in this direction, would be the supply of appropriate affordable housing.  The Corporate Policy & Research Manager said that affordable housing was expected to become a top priority for the Council   in its shortly to be approved new Corporate Plan. 

·            The Director of Adult Social Care and Community Services said that the issue had been recognised, and that funding was in place for a dedicated worker in this area.

·            In reply to a query concerning how the new ICT system would help joint working with the PCT, the Head of Service - Adult Social Care reported that the first meeting of the ISCS Board had reassured all concerned that the two organisations were moving to a closer integration.  She pointed out that, at the moment, staff in the mental health services were required to input data into three different systems, which was clearly inefficient. 

RESOLVED:

That;  

(a)   The Committee believes that the recommendations to improve both Mental Health and Physical Disabilities are sound, although it remains concerned that some of the conclusions are based on data that is far from robust.   Herefordshire Council and the Primary Care Trust (PCT) need to ensure that, as a matter of urgency, better systems of data collection and analysis are in place, so that future improvement plans are more securely evidenced-based.  (The Committee understands that new systems for Herefordshire Council’s social care services will be installed in the Autumn, which should greatly improve both assessments and data collection.  It is hoped that the PCT will make similar improvements.)  The Committee intends to focus on key outcomes, and will therefore require regular reports to the Committee on the success of achieving the reports’ recommendations;

(b)   The Committee supports Recommendation B as outlined in the paper before it, but believes that joint commissioning and provision between the Council and the PCT should be strengthened (including, for example, in respect of occupational therapy), with absolute clarity about  financial matters .  The Committee was glad to note that recruitment to the post of Director of Integrated Commissioning was imminent.  It was requested that a progress report should be brought to the Committee once the post-holder had been in position for six months, and thereafter on a regular basis;

(c)   The Committee is uncertain whether the total resources proposed will be adequate to deliver the improved services, especially as their introduction might bring increased demand, particularly if services not currently provided (i.e. for personality disorders) are introduced.  This consideration should be taken into account in setting budgets for future years;

(d)   The Committee notes the high dependence on the support of the voluntary sector in the achievement of these improvement plans, and suggests that in order to achieve this they must have the confidence that adequate and secure funding is in place;

(e)   Outside funding sources should be sought as a matter of priority, and internal funding should be made available to support this function;

(f)     A report on action on the workforce improvements necessary to implement the reports’ recommendations, including as regards the training, recruitment and retention of staff, should be made to this Committee in three months’ time;

(g)The importance of the integration of ICT systems between the Council and the PCT be emphasised, and that this matter should therefore be monitored to ensure that the work being undertaken delivers the outcomes required.  A progress report should be provided to the Committee in six months’ time.