To review the services commissioned by the council and the clinical commissioning group for adults with learning disabilities in Herefordshire.

A presentation was given by the senior commissioning officer, Herefordshire Council and the community learning disability team service manager, 2gether NHS Foundation Trust. It was noted that the presentation was a brief tour of the service, which provided long-term work covering each person’s life span, all health needs and all aspects of daily living.  

The presentation highlighted the following key points:

·         Although statistics could not be relied upon, it was estimated that 2.32% of the county’s population had a learning disability diagnosis, and this covered a wide spectrum of needs.  This figure broadly fitted national demographics; however it was noted that the county had a good reputation for the care of people with a learning disability which resulted in people moving here to access services

·         In terms of funding, learning disability services represented 30% of the adult social care budget, supporting 550 people, which was broadly equivalent of 25% of council tax income, and which was typical of national picture.

·         As shown in the adults and wellbeing blueprint, there was a move towards mainstreaming peoples’ experience and accessing universal services rather than looking to adult social care, which represented significant culture change. 

·         Work on developing access to information and improving the “front door” would help people know where to access information and support. Success in achieving changes to the pathway was facilitated by community brokers, in getting more consistent and richer information, and all information was being linked into WISH online which was starting to show success.

·         In terms of health provision, providers and commissioners were working together to ensure contracts were directed in the right way and meeting long term needs. The focus was on making sure reasonable adjustments were made so that people could routinely go straight to the service they needed.  This was supported, for example, in acute care by acute liaison nurses. Herefordshire had been successful in limiting the use of out of area placements for people with learning disabilities, and those people who were out of county were on planned return. This was an excellent position as continuing healthcare for this small cohort was known to present a challenge, and the intention was to bring everyone home to the county.  Service provision cost around £250k per person annually, so a possible way to support this outcome was to develop specialised services shared with neighbouring authorities.

·         Access to the community learning disability team was supported by a multi-disciplinary approach and an open referral system. The aim of the service was to provide person-centred support for people to access mainstream services whilst recognising the need for some specialist support.

·         The service was supporting access to annual health checks and there was a lead nurse providing training for GPs to increase access which was currently around 60%. Take-up of health checks was lower than in the general population, so this was being promoted with input from the Clinical Commissioning Group and the council. This was a critical area of focus as someone with a learning disability could have a life expectancy of 20 years less compared with other people.

·         Feedback on service provision was always sought. There was an effective user engagement process and it was recognised that there was still work to do around addressing lack choice of where to live, access to work and training. The council needed to lead by example and there were opportunities to offer employment and meaningful training.  Health inequalities remained, and there were not enough opportunities to demonstrate social value.  Too few people had choice or control over life decisions and access to advocacy.

·         A new strategy was in development and this would put greater emphasis on delivering changes to have meaningful impact. 

The chairman noted the lack of robust data and asked why this might be.  The commissioning officer explained that it was a complex picture and that people were within a spectrum of learning disability, some of whom were not always identified because of lifestyle or level of need, so it could be possible for someone to present as an adult who had been previously unknown to services.

The chairman asked what employment opportunities had been explored.

It was explained that there were some good examples of support into employment but more could be done. Supermarkets, for example, had done well and understood what peoples’ support needs were, and so there was learning to take from them and provide opportunities. The council, for example, had contractors which could be accessed for employment and training, and this level of support added value across the sector because people were seen in a valid role. 

A member noted the variety of needs of people with a learning disability. In the context of a learning disability not being immediately apparent and the limited time GPs had for consultations which did not provide time to identify someone with particular needs, people could fall through the gap, and so alternative ways of addressing this needed to be identified.  

The commissioning officer commented that it was important to give GPs the tools to support people and that practice nurses could be involved more in this respect.  He added that the annual health check was so important, with appropriate help, in establishing a picture of a person to enable their ongoing good health. The service manager added that in providing training to the whole practice, practice nurses or healthcare assistants would be enabled to conduct pre-assessments before someone sees the GP.

The chairman asked about the prevalence of the learning disability nursing speciality. The service manager confirmed that this was still offered and the service took some specialist nurses who were coming through that line of training, although this was a small cohort.

A member commented on the importance of employment opportunities in supporting peoples’ integration. She referred to a recent visit by committee members to a local service provider’s centre which was found to be inspirational and forward thinking.  The member noted that there had been a shortage of speech and language therapists and asked if this had been addressed. 

The service manager explained that there remained a national shortage, and it had been a challenge to recruit a speech and language therapist to the team. However, a newly qualified therapist had been appointed and they had been inducted alongside an experienced mentor, which meant that there was now a highly specialised speech and language therapist in the team, although there was just one. 

A Healthwatch representative welcomed reasonable adjustments within universal services as this had been recognised by Healthwatch as an issue for people with additional needs. 

The Healthwatch representative also enquired about whether the learning disability strategy would be presented to the committee for scrutiny. 

On the point of reasonable adjustments, the commissioning officer explained that there would be an incremental process to ensure that services understand what support someone needed and making sure the referral process was right.  This would enable better use of specialist services if they could support mainstream services and have clear referral pathways. The new strategy would demonstrate how services would interact.  The commissioning officer commended 2gether NHS Foundation Trust for the training they provided and for working across the sector.

As regards the strategy, this was being developed and was at the stage of incorporating comments from the engagement process to ensure it was meaningful. It was noted that timing of the decision to be taken by Cabinet was prior to the next scrutiny committee.  

The assistant director, operations and support commented on the paternalistic nature of the current culture, and that if people could move away from this and manage risk, opportunities would be realised. The adult social care model challenged the level of risk for people in communities and people needed to embrace this by starting conversations earlier in life with parents. It was important to get this right to achieve what people with learning disabilities wanted the strategy to achieve.

The chairman commented on the low number of people noted on GP records as having a learning disability and asked if the Clinical Commissioning Group could promote recording.  The CCG’s assistant director commented on the learning disability spectrum and issues around choice as factors influencing the level of recording, but confirmed a commitment to work with primary care to support people. She added that recording was critical as it linked to outcomes and the CCG was working with primary care to establish attempts to improve peoples’ outcomes. 

In answer to a further question from the Chairman regarding people with multiple needs including dementia, the CCG assistant director confirmed that a joint pathway was being developed as this was identified as a key area of growth and that it was also essential to engage with families on such matters.

RESOLVED

That

a)    The service overview be noted; and

b)    Further information on the implementation of the joint learning disability strategy be awaited