Agenda item
Update on Transforming Care Programme: Learning Disabilities
- Meeting of Community and Wellbeing Scrutiny Committee, Wednesday 17 April 2019 6.00 pm (Item 6.)
- View the declarations of interest for item 6.
This report provides the background to why the Transforming Care programme was developed and an update on Brent’s progress against national and regional requirements and/or priorities, and confirms the priorities for this year agreed at the Health and Wellbeing Board in January 2019.
Minutes:
Councillor Farah (Lead Member Adult Social Care) introduced the report and advised that Helen Woodland (Operational Director Social Care) and Helen Duncan-Turnbull (Head of Service, Complex Care) were present to help address members’ queries. Helen Duncan-Turnbull highlighted that the report updated the committee on the progress achieved with respect to the delivery of the transforming care plan (TCP). It was explained that the TCP aimed to reduce inpatient admissions for people with learning disabilities, ensuring that there was sufficient support available in community settings, with the ultimate aim of improving quality of care and quality of life. The report outlined Brent’s progress against the national and regional requirements and set out the priorities for the current year as agreed at the Brent Health and Wellbeing Board in January 2019.
To achieve the national TCP, Brent had four work streams in place: Market Development; Reduction in the number of NHSE and CCG in-patients; Integration of the Health and Social Care Learning Disability teams; and, Transitions. Drawing the committee’s attention to the progress made against the key milestones for each of these priorities, Helen Duncan-Turnbull advised that all of these had been met and were being monitored both by the North West London Steering Group and at a local level. Furthermore, Brent had exceeded the milestone relating to accommodation for people with Learning Disabilities due to the council’s New Accommodation for Independent Living (NAIL) project. A key area of challenge related to the support for those individuals with complex needs. Brent currently had ten people in specialist commissioned beds and currently, forensic support was lacking across North West London, with particular concern for outlying boroughs such as Brent. A further area of challenge was the potential financial pressures relating to individuals with complex needs who had been in-patients for less than five years. The NHSE provided funding for those who had been in-patients for five years or more to support discharge plans and community provision; however, seven of the ten individuals were not eligible for such funding, representing a financial pressure for the CCG or local authority going forward.
In concluding her introduction, Helen Duncan-Turnbull highlighted next steps and priorities for the coming year, which included the establishment of an Autism Board and the further development of specialist accommodation via the NAIL project, with a particular focus on the complex support needs of the ten individuals previously referred to. It was noted that the 0-25 Disabilities Team and the Integrated Health and Social Care Team had now been established. With regard to the later work would focus on improving the cohesion of the team, with a service review due later in the year to monitor progress.
Duncan Ambrose (Assistant Director, Brent CCG) outlined the practical monitoring arrangements supporting the work of the TCP. The committee was advised that a weekly monitoring call was held to discuss each in-patient with Learning Disabilities and consideration given to how their discharge could be accelerated. A risk register was maintained for those at risk of becoming in-patients, with consideration given to what support could be put in place to prevent escalation.
The Chair thanked colleagues for the introduction to the report and invited questions from members of the committee.
The committee questioned what actions were taken to mitigate the challenges highlighted in the report. Further details were sought regarding the monitoring arrangements for providers and it was questioned how the council and CCG was ensured that the needs of individuals within these provisions were being met. Members subsequently sought particular comment on the operational challenges posed by the integration of Health and Social Care Learning Disabilities teams and the creation of the 0-25 Disabilities Team. Concern was expressed that the lack of funding transfer agreements for seven individuals in specially commissioned in-patient provision could act as a disincentive in supporting their discharge to community based services. Several queries were raised regarding workforce development, with members seeking assurance that the training programmes detailed in the report had been successful in addressing the issues raised via the Winterbourne View scandal, and questioning the breadth of coverage across the workforce. Members subsequently questioned how the council and CCG ensured that independence was promoted and that a hospital environment was not simply being recreated in the community.
Discussing the success of the NAIL programme, members questioned whether this would support the return of the 84 individuals placed in provision outside of the borough. Further information was sought with respect to the timeframes for the delivery of the NAIL schemes aimed at meeting the needs of people with a learning disability with complex needs. Clarification was sought with regard to the additional beds provided via de-registration or spot-purchase and the role of specialist commissioning was queried. Members sought comment on other housing options which could be considered for this cohort and questioned what support was provided to those cared for within their family homes. With reference to Direct Payments, the committee questioned whether officers were confident that the council had sufficient oversight of the provision being directly commissioned to prevent poor quality provision or financial abuse of those using Direct Payments.
It was noted that the Outcome Based Learning Disabilities team service specification was due to be ratified and the committee questioned who had devised this specification and who had been consulted during its development. Members further questioned how the voice of vulnerable adults was captured with the TCP and commented that future reports should include feedback from those affected. The committee asked when advocates were used to support individuals in making their voices heard. In concluding their questioning, Members sought comment on whether there was any concern amongst officers that there were individuals with unidentified needs who remained unsupported by the council.
Responding to the queries raised, Helen Woodland (Operational Director Social Care) emphasised that the intent behind the transforming care agenda was to move people into community settings where there could be a greater assurance with regard to safeguarding and the quality of care received. Every individual with a social care package of support had an annual review to ensure that the care they received remained appropriate for their needs. In addition, contract monitoring with providers, safeguarding visits and close working with the CCG and Integrated Health and Social Care team all contributed to the safeguarding structures in place.
Helen Woodland advised that integrated teams provided better outcomes for service users. Commenting on the integration of the Health and Social Care Learning Disability Teams, Helen Woodland advised that the challenges had been both practical and cultural: the former included issues such as where the team should be located and how the different IT systems worked together; the latter, the understanding the different eligibility criteria for services and the different risk structures in place. It had been important to invest time to allow a protected learning environment to develop and to support techniques such as reflective practice sessions to encourage different perspectives to be shared. A service review was scheduled for later in the year to ensure that the work that had been undertaken had been effective and that the expected outcomes were being achieved. Duncan Ambrose emphasised that prior to the integration of the services, it had been the service user who had experienced these tensions between the services.
Helen Duncan-Turnbull outlined the challenges experienced in the creation of the 0-25 Disabilities Team, which combined the children’s team and the transitions team. It was highlighted that there were different legislative requirements for children and adults and the approach taken had been to ‘buddy up’ workers from the respective teams to ensure the necessary mix of experience and knowledge. This approach helped to build supportive relationships between team members and was reinforced by a programme of formal learning and quarterly reviews.
The committee was assured by Helen Duncan-Turnbull that the lack of a funding transfer agreement did not act as a disincentive for the council or CCG in supporting the discharge of a patient – this would be unlawful. Rather it would be necessary to assess the support needs of the individual being discharged from inpatient care, determine which of these fell within health or social care services and to arrange for funding to be agreed between the council and CCG as necessary. Duncan Ambrose added that the transfer funding agreements provided by NHSE were to aid in the acceleration of inpatient discharge for those who had been in-patients for a long time and would not be a disincentive for normal processes.
Addressing Members’ queries on workforce development, Helen Duncan-Turnbull advised that a number of the staff training programmes referred to in the report had been identified as necessary to implement the Transforming Care agenda, both at a North West London and local level. Many of these programmes were therefore, specifically targeted to address particular issues of concern. A range of training around positive behaviours support had for example, been commissioned to help staff better support people with complex needs and challenging behaviours. The contract monitoring teams also created workforce development plans for the local authority and providers. These plans were reviewed annually to account for emerging needs or issues identified via contract monitoring. It was confirmed that not all staff would have received the training to date and that this could take approximately 18 months. Helen Woodland emphasised the importance of the workforce development plans established via contract monitoring, noting that as a commissioner of these services, the council had a responsibility to ensure that ongoing training needs were being addressed. This was particularly important given continual changes in the provider market and staff turnover for individual providers. The council had to work continually to ensure that provision that had been rated as good, remained so. The work of the Safeguarding Concerns Sub Group was particularly important in this process, allowing the council to identify issues early on and target support as needed.
The committee was further informed by Helen Woodland that outcome frameworks were being built into the annual reviews of individuals’ support needs to better capture people’s perceptions of their care and wellbeing. Developing a better service user led view of services also helped ensure independence was being promoted and the NAIL programme meant that individuals were less likely to be placed in residential or nursing care. Furthermore, the council was reviewing the procurement of its home care services to ensure that all providers had an enablement or reablement focus. This was not something that was currently present in the provider market and the council was working with those companies to support their staff to achieve this focus. There was currently a lot more work to be done before this goal was achieved for home care, though many residential providers and supported living providers were very good at promoting independence.
Helen Woodland further advised that part of the approach of the NAIL programme was to create accommodation around cohorts, for example those with similar interests or age, and designing those developments with input from those who would be living there and their network of family and friends. With regard to the 84 individuals currently placed out of borough, it would depend on the individual circumstances as to whether it was appropriate or beneficial to change their existing arrangements. The number of out of borough placements was likely to fall over time as circumstances were reviewed but members were advised that sometimes it was entirely appropriate to place someone out-of-borough. It was clarified that the NAIL schemes listed in the report were Learning Disabilities specific. There was an ongoing forward plan to develop NAIL accommodation in line with future need. Helen Woodland clarified that the provision of additional beds via de-registration meant that the council worked with an existing care home to convert their registration to a supported living provider, requiring de-registration with the Care Quality Commission. With regard to spot purchasing, this was a method of purchasing using a West London Alliance framework of rates for which a bed was only paid for when used. Spot purchasing had been used for specialist provision and in some cases the package of care was very expensive due to the complexity of needs.
Helen Woodland highlighted to the committee that not all Brent residents with a Learning Disability would qualify for housing support, but strong links were maintained with the housing team to provide support where appropriate. It was further clarified that if an individual was cared for in a family setting, the carer would be entitled to an assessment and where needed support could be provided to aid independence, identify housing solutions, or provide respite care. Addressing concerns expressed regarding direct payments, Helen Woodland advised that there was an element of risk with direct payments but it was suitable to allow those adults the freedom to commission their own services. The council had monthly contact with individuals using direct payments and had oversight of the services being received. A peer review would be held in Brent in June 2019 and this was one amongst a number of safeguarding mechanisms that contributed to the council’s safeguarding framework.
Helen Duncan-Turnbull advised that the Outcome Based Learning Disabilities team service specification had been developed at a North West London Level in line with best practice and agreed for use across all partners including the local authority and CCG. It was confirmed that the voice of adults with learning disabilities was fed into the Transforming Care Programme via the Learning Disabilities Partnership Board, which was co-chaired by a service user. This group and the Health Sub-Group were good at engaging their peers and representing those views to the council and partners. Helen Woodland clarified that advocacy would only be used for individuals who were unable to speak for themselves, support in all other cases would be provided by a social worker. Family members were engaged wherever possible.
Helen Woodland advised that the council was likely to know of individuals who needed support, often via the health service. The eligibility criteria for social care support was more stringent than it had been and there were no longer as many services for people to access. A key issue for those who were not supported by the council was safeguarding. A lot of work had been undertaken with partner agencies to raise the profile of reporting safeguarding concerns and positively, Brent had a significantly higher rate of reporting than other boroughs.
At the invitation of the Chair, Ian Niven (Brent Healthwatch) advised that Brent Healthwatch had been closely involved in the TCP and the process had been very positive. Ian Niven explained that he had been struck by the genuine commitment and professional approach taken to solving complex problems. Commenting on the voice of service users, Ian Niven highlighted that the CCG had commissioned an advocate which worked with relevant groups around this and helped to ensure engagement in the decision making processes regarding the Integrated Health and Social Care Team.
The Chair thanked everyone for their contribution to the meeting.
RECOMMENDED:
i) That the measures already in place to support the TCP cohort in the borough and the further actions planned as part of the TCP programme be noted;
ii) That the progress made against key milestones and the areas that require further development be noted.
iii) That future reports on the TCP include the voice of the service user;
iv) That a further report on the progress made in relation to the TCP be presented to the committee at an appropriate time, following the service review;
Supporting documents:
- Transforming Care Programme, item 6. PDF 235 KB
- Appendix 1 - Building the Right Support, item 6. PDF 2 MB
- Appendix 2 - Transforming Care - A National Response to Winterbourne, item 6. PDF 302 KB