Hampshire County Council

Social Care Policy and Review Committee

May 31^st 2002

Options Report for the Best Value Review of Adult Mental Health Residential Services.

Mental Health Service

Report of the Director of Social Services

1

SUMMARY

1.1

Introduction

This report identifies progress to date with the Best Value Review of Mental Health Residential, Nursing and Accommodation Services for adults. It reports on the findings from the four C's of Consult, Challenge, Compare and Compete, and identifies options for future service delivery. There were three principle sources of information for this review:

1. A report by ROCC, a voluntary sector Housing organisation.

2. Activity and financial information, including regional and national benchmark information.

3. Work in progress as part of the implementation of the mental health National Service Framework (NSF).

1.2

Consult and Challenge

The principle findings were:

1. A need for consistent and holistic care coordination from community mental health teams, who are provided with adequate information and support on housing issues.

2. Wide variations in the provision and quality of service provided.

3. No (district) local authority has the full range of provision, or a plan to develop it.

4. Lack of specialist accommodation in all areas.

5. Inappropriate use of some accommodation, e.g. hostels.

6. Need for improved interagency working at both strategic and operational levels.

7. A need for effective consultation processes for users and carers.

8. Improved financial and management information and practice.

1.3

Comparison

1. There are significant service gaps, lack of equity of housing provision and inequality of investment in community services across Hampshire with low investment resulting in high residential costs.

2. A steady rise in costs of residential care is apparent as services focus on more dependent groups of service users, with history of detention under Section 3 of the Mental Health Act.

3. Mental Health service costs are lower than other adult groups.

4. Hampshire is average or above average in relation to national performance measures looking at cost and number of users helped to lived independently.

5. Twenty six percent of placements are Out of County, with the vast majority living in neighbouring authorities, within a few miles of home. However, any out of County placements result in a degree of uncoordinated care as the placing social services authority retains responsibility for care, whilst the new area assumes NHS responsibilities.

6. The Hampshire rate is met for approximately fifty percent of placements, the remainder being above this rate.

1.4

Compete

1. Hampshire Social Services Department does not directly provide any Residential care or Housing with Support Services. A range of services are commissioned from the private and voluntary sector, either on a spot purchase or contract basis.

2. The identified inequity in Housing provision has to be addressed by working with District Councils.

3. Specialist provision to meet complex needs which incurs high cost should be developed jointly with the NHS. This provision should be located in County to ensure continuation and coordination of care and rehabilitation.

4. Mental Health residential spend is a relatively small proportion of overall Departmental budget, and of care budget.

5. Few providers are available, and less still who can meet specialist needs.

6. Significant cost variation which reflects high need and local market conditions.

1.5

Options

The recommendations of the ROCC report (Appendix 1) have been developed into a draft action plan (Appendix 2). The key outcomes required are:

1. Development of a range of residential care and housing with support in each locality informed by the needs analysis in the ROCC report.

2. Development of integrated planning processes incorporating the NSF and Supporting People agendas

3. Development of robust joint financial and management information

4. Improved housing practice in mental health services through joint training

5. Services are responsive to specialist needs

6. There is effective user and carer involvement

7. Revenue and capital resources are maximised across agencies to meet need and promote independence

8. Services have clear, jointly owned and published care standards

There are essentially two options emerging from this review (Appendix 1). The first is to maintain current practice, introducing incremental change as and when resources allow. This can be justified on the grounds that on a range of comparator information Hampshire performs relatively well on a range of indicators. It does not however meet the requirement of the NSF, and also leave a number of people with severe mental illness and high needs with inadequate care.

The second option consists of three parts:

(i) An option to develop a mixed economy of residential care through capital investment. This would best be achieved as a joint venture with the NHS.

(ii) Increased investment in community services to meet the requirements of the NSF.

(iii) Joint commissioning of a range of residential and rehabilitation services with the NHS, including the option of pooled budgets, but without capital investment by the County Council.

1.6

Contents

1. Summary

2. Introduction

3. Consultation and Challenge

4. Comparison

5. Competition

6. Conclusion

7. Options

8. Recommendations

9. Appendices

Page 1

Page 4

Page 8

Page 13

Page 23

Page 27

Page 29

Page 30

Page 31

Appendix 1

Appendix 2

Appendix 3

Appendix 4

Appendix 5a / 5b

Appendix 6

Appendix 7

Appendix 8

Appendix 9

Appendix 10a

Appendix 10b

Appendix 11

Appendix 12

ROCC Report, Executive Summary

Draft Action Plan based on ROCC Report

List of information available upon request

Gap Analysis by Area

Residential Budget compared to outturn 2000/01 (actuals and percentages)

Prevalence rates of severely mentally ill adults by area

Percentage spend on Residential / Day / Domiciliary care by area

Locations of Out of County Residential placements by area

Comparator weekly unit cost of support mentally ill adults in Residential and Nursing care, 2000/01

Analysis of Providers of Registered care by type and area

Analysis of Providers of Non Registered care by type and area

Glossary

Option Appraisal

2

INTRODUCTION

2.1

This report outlines details of the progress to date in the Best Value Review of Residential, Nursing and Accommodation Services for Mental Health and identifies options for service development. The Mental Health residential care review is one of three separate but linked reviews of residential services for adults (the others being people with disabilities and older people). The scope for the mental health review includes residential and nursing home provision funded by the County Council, housing with support, and adult placement for adults aged 18-64 with mental health problems. Services for people who abuse alcohol and drugs were excluded from this review as these are subject to a separate review in 2002-03. A glossary of abbreviations used in this review is found in Appendix 11.

2.2

2.2.1

2.2.2

2.2.3

2.2.4

The Mental Health National Service Framework

The development of mental health services is subject to the ten year Modernising Mental Health Services national strategy, the key components being a National Service Framework (NSF), a proposed new Mental Health Act, (including Community Treatment Orders) and additional investment. The NSF consists of seven standards for services with accompanying evidence based models, plus supporting strategies to provide the infrastructure:

Standard 1: Promoting mental health and combating discrimination

Standards 2 & 3: Services in Primary Care

Standards 4 & 5: Services for people with severe mental illness

Standard 6: Services for carers

Standard 7: Suicide prevention

There are supporting strategies covering workforce, information, finance, research and development, plus organisational requirements for the establishment of specialist mental health trusts, and integrated working with social services.

The NSF reflects the complexity and diversity of people with mental health problems, and the need for a multi-disciplinary and multi-agency approach to deliver quality services, manage risk, and combat discrimination against people with mental health problems, in the context of historically low investment in services.

The current national priorities for service development include the establishment of assertive outreach, crisis resolution and home treatment, and early intervention services, plus development of the workforce, joint information systems, and joint organisational arrangements for service delivery. Sound assessment and care planning is an essential part of the process to enable people with mental health problems to receive the services they need. All people under the care of mental health services should have a care plan under the Care Programme Approach (CPA) that includes an assessment of housing, benefits and employment needs (plus a risk assessment and crisis plan). The information needs to be on an electronic information system (e-CPA).

2.2.5

The Government announced an additional seventy five million pounds nationally in "earmarked" mental health funds for NSF priorities in 2002/03. However, it currently appears as if little of this funding will be invested in new service developments. This is explored further under Section 6 and a consideration of options for service development.

2.3

2.3.1

2.3.2

Aims of Service

The aim of the service is to commission a range of residential care and housing with support to meet the assessed needs of people with severe and enduring mental health problems, in partnership with local health and housing agencies.

Safe, high quality housing with care, which promotes maximum independence consistent with the safety of service users and others is needed as part of a range of provision to enable people with mental health problems to live and work in the community. Similarly, provision of suitable residential care for people for whom housing with support is inappropriate, should be available "as close to home as possible, and in the least restrictive environment consistent with the need to protect them and the public, to ensure in policy terms services achieve optimum quality of life and help reduce suicide and demands on mental health services including inpatient beds." (Standard 5, Mental Health NSF)

2.4

Objectives of the Service

1. Ensure effective arrangements are in place for strategic planning and operational delivery that engages all relevant stake holders, users and carers.

2. Ensure equality of access to a range of residential and housing with support schemes in accordance with local needs and priority and within available resources.

3. Ensure that the service provided conforms to National standards.

4. To maximise resources through effective collaboration with partner agencies.

2.5

Aim of Review

1. To carry out a fundamental review of residential and accommodation services by July 2002 in order to meet current and future needs effectively, efficiently and economically.

2. To provide residential and accommodation services that maximise independence, in partnership with other agencies and organisations, and in accordance with the National agendas (e.g. National Service Framework, National Care Standards Act).

2.6

Review Objectives

(i) To identify the current and future demand for residential services.

(ii) To implement effective, efficient and economic methods of service delivery.

(iii) To evaluate the financial performance of services in appropriate comparison with other Authorities and other organisations.

(iv) To review and clarify quality standards taking account of stakeholder views.

(v) To measure performance against these quality standards and identify options for addressing potential shortfalls.

2.7

Partnership

1. Partnership will have an impact on the progress of this Best Value Review. Members' preferred options and the action plan will need to be jointly agreed with the Health and Housing services if the implementation requirements of Supporting People and NSF for mental health are to be realised.

2. Local Implementation Teams (LIT) are the key vehicle to develop the Mental Health National Service Framework at a local level. The LITs are based on Primary Care Trust (PCT) areas, and in line with government requirements include local stakeholders, users and carers.

2.8

Work Undertaken

The work referred to in this review can be divided into three areas:

(i) ROCC Report and related work

(ii) Financial and Activity Mapping

(iii) A range of other work in progress related to NSF implementation

The ROCC Report, and related work

The mental health review aimed to build on a number of pieces of work that had either been completed or were in progress during the lifetime of the review. These included:

1. An analysis of Housing need across Hampshire Districts of people with severe mental illness (The Mary Rose Tarpey Report, 1996).

2. Review of Alton and Aldershot Mental Health residential spend, January 2001. This internal review was commissioned due to concern about the perceived high use and cost of residential care in this locality in comparison with other parts of Hampshire.

3. Challenge and Change: Developing a Mental Health Housing Strategy for Hampshire County Council November 2001 (The ROCC Report).

ROCC is an umbrella agency for supported housing in Hampshire and the Isle of Wight. They were commissioned by the Social Services Department in 2000 to develop a housing strategy for mental health service users in Hampshire,

building on the findings of the Mary Rose Tarpey report, and to assist in preparations for the introduction of the Supporting People initiative.

It was subsequently agreed that this work should form the basis of the Best Value Review, supplemented by an extension of the Alton and Aldershot Residential care review to other parts of Hampshire, and other work being conducted at the same time as the Best Value Review. A summary of the key points is found in Appendix 1. A draft Action Plan has been developed based on the recommendations of the ROCC Report, see Appendix 2.

2.9

The work that has been undertaken so far is summarised in terms of challenge, consultation, comparison and competition and the preferred options are outlined. Supporting evidence to back up work undertaken and findings are found in appendices. Further evidence, listed in appendix 4, is available upon request.

3

CONSULTATION AND CHALLENGE

Consultation and Challenge were undertaken as described below. A Challenge Group for all three Best Value reviews posed a series of challenge questions to each review at the beginning of the process:

(i) Should Hampshire County Council be providing residential care at all?

(ii) If so, how many homes should Hampshire County Council have and should they compete with or compliment the independent sector?

(iii) Is accommodation in the right place, as close to home as possible?

(iv) Is it socially inclusive?

(v) Does it meet a diverse range of needs, including those of people from black and minority ethnic cultures?

(vi) Does it meet the needs for specialist provision, for example for those with complex needs?

(vii) Does it encourage independence and resettlement into the community?

(viii) What is the disparity in unit cost between provided and purchased care?

(ix) How can greater consistency and equity of service for users across the County be achieved?

(x) How can the gap between the demand for and supply of beds in the market place be closed?

(xi) What should the "Hampshire rate" (at which care is purchased from the independent sector) to ensure an acceptable quality of care is delivered?

(xii) How can the recruitment and retention of care staff be improved?

(xiii) Are services effective in contributing to performance requirements such as the Performance Assessment Framework, National Service Frameworks and new are commission standards?

3.1

Consultation Undertaken

o ROCC Report.

o Service User Consultation.

o Best Value Team Meetings.

o Feedback from Stakeholders.

o Challenge Event, January 2002.

o Follow-up Stakeholder Event, June 2002.

o Local Implementation Teams.

o Staff Consultation.

o NHS Trust Configuration.

o Forensic Services.

o Supporting People.

o Workforce.

o Literature survey of research.

3.2

Findings

The key findings for this section are summarised in the ROCC Report summary findings. The key message is that maximum opportunity should be taken to move towards using non-registered provision.

Provision of Residential Care

One of the key challenge questions for the Best Value Review is: Should Hampshire County Council be providing residential care at all? The vast majority of people with mental health problems live in their own accommodation with family or friends or in supported housing and therefore the question to be addressed concerns what added value is Residential Care providing and is it necessary.

A small minority of people with severe and enduring mental illness have highly complex and diverse needs, often including dual diagnosis and which results in a high level of risk, both for the person themselves and others. This multiplicity of need and management of risk requires a high level of skilled multidisciplinary staff which could be more effective and efficient if concentrated in one place, i.e. a Residential or Nursing Home. For this small group of people residential care is probably necessary, however, work could be undertaken to develop and promote independence in these care settings.

3.2.1

ROCC Report summary findings

1. Need for more consistent and holistically focussed Care Coordination (assessment and care management) practice with sufficient information and training available to staff on specific housing practice, needs and related finances.

2. Range of provision and quality of service showed wide variations:

(i) Inequality in the number of units of supported housing.

(ii) No local authority has the full range of provision, or a plan for provision and development

(iii) No service was available in some specialist categories e.g. specialist floating support, specialist lodgings, services for women only, or particular ethnic groups

(iv) Scarcity of specialist services for challenging behaviour and dual diagnosis (mental health / learning disability; or mental health / substance misuse), adult placements, accommodation in rural areas

(v) Inappropriate use of some accommodation, hostels, night shelter and non-specialist crisis accommodation

(vi) Many Care Homes registered inappropriately for people under age 60 with mental health problems

3. Need for improved multi-agency working at both strategic and operational levels

4. Need for effective consultation process to involve users and carers in the planning and development processes both in statutory and independent agencies.

5. Improved financial management through better financial information and use of partnership arrangements including Health Act flexibilities to maximise new developments.

(See appendix 1, ROCC Report Executive Summary)

3.2.2

Service User Feedback

1. ROCC Report

The ROCC Report research team contacted service users and carers both individually and at consultation events, which included a specific Users Involvement event. Also, the effectiveness of existing mechanisms for involving users and carers was scrutinised resulting in a number of overall issues, including: the need to develop an identified network of user groups; the need for funding to ensure effective consultation is carried out; need for consistent approach to county wide consultation.

The recommendations from service users include blocks to user involvement as well as drivers for it and ideas for improvement. The ROCC Report details recommendations (page 44 - 48) which include:

_ Need to provide "ordinary" homes/housing

_ Improved multi-agency working

_ Resettlement workers and specialist support for vulnerable groups, e.g. services for women with children need developing

_ Need for more information about housing

_ Need for better trained staff

2. Sainsbury Centre for Mental Health "Working for Inclusion" 2002

User led research supports local findings reported by the Sainsbury Centre for Mental Health. The work is based on the issues considered important by mental health service users and survivors and is carried out by service users and survivors. The main findings with regard to housing issues include the need to:

_ Improve provision for people with multiple needs, such as those with drug or alcohol problems and mentally ill offenders, people in crisis and those with episodic high care needs.

_ Improve provision of intensive support and 24 hour supervision.

_ Improve active programmes of skill development and rehabilitation.

_ Reduce the number of large residential care homes and increase supported housing.

_ Plan housing and support services together to create a comprehensive and effective service.

3.2.3

Feedback from stakeholders

The Challenge Event showed a general agreement with the findings and draft recommendations of the ROCC Report and comments from this and other sources can be found in documents listed in Appendix 4.

3.2.4

Feedback from Local Implementation Teams (LITs)

Five targets for LITs have been identified as outcomes necessary for the implementation of an effective mental health Residential and Housing Strategy and Service.

(i) LITs to update mapping, validate and identify priorities for their area

(ii) LITs to consider Best Value Review options and feedback comments

(iii) Each LIT to identify a Housing Champion

(iv) Each LIT to access training and information about Supporting People

(v) User / carer involvement in strategic planning and specific housing development through membership of LITs.

A general finding is that LITs are actively involved in the Housing agenda at different levels. Work will be needed to monitor strategies to identify gaps and inequalities.

3.2.5

Feedback from Social Services Managers across the County

Priority areas which need addressing at strategic and operational level include:

(i) Out of County placements

(ii) Contracting

(iii) Planning mechanisms

(iv) Assessment and review of need

(v) Crisis care

(vi) Challenging behaviour resources

3.2.6

NHS Trust Consultation

West Hampshire Trust have commissioned three reviews in order to develop services to respond to the needs and strengths of service users.

1. Review of NHS 24 hour Nursed Care (Covering Southampton, New Forest, Eastleigh / Test Valley South, and Mid Hampshire) 2001

2. Sainsbury Centre review - Building Better Mental Health Services Together, February 2002.

3. The Mental Health Rehabilitation Service Consultation 2002 builds on the previous two pieces of work.

A similar review in currently underway with Surrey Hampshire Borders NHS Trust.

The Social Services Department's initial response to the West Hampshire Trust work is to welcome proposals seeking to address poor quality NHS accommodation which is less than satisfactory. However, this may result in a cost shunt to the County Council unless specific measures are in place to prevent this. Proposals also need to be considered alongside the Supporting People framework and incorporated in local housing strategies.

3.2.7

Forensic Services

Recommendations following consultation by the Sainsbury Centre for Mental Health and the ROCC Report (drawing on work by the Wessex Consortium) conclude that the accommodation needs of most Mentally Disordered offenders can be met in the community with the appropriate level of flexible support.

3.2.8

Supporting People

The main recommendations of the ROCC Report and related joint developments, e.g. with the WHT, have been identified as the key priorities to the Supporting People Team, and the Supporting People Strategy, and will be incorporated within.

4

COMPARISON

Comparison work looked at the range and quality of services across Hampshire, activity and financial information, and national performance information.

4.1

Work Undertaken

· Mary Rose Tarpey Housing Analysis 1996.

· ROCC Report accommodation Mapping.

· Analysis of budgets.

· Review Alton Aldershot Residential Spend 2000/01.

· Internal area by area comparison of Activity / Spend / Community Resources 2001.

· Costs above "Hampshire Rate" analysis.

· Neighbouring and comparator local authorities analysis in terms of places, placement and cost.

· National Performance Information.

4.2

Findings

Key Messages:

1. There are significant service gaps, lack of equity of housing provision and inequality of investment in community services across Hampshire with low investment resulting in high residential costs.

2. A steady rise in costs of residential care is apparent as services focus on more dependent groups of service users, with history of detention under Section 3 of the Mental Health Act.

3. Mental Health service costs are lower than other adult groups.

4. Hampshire is average or above average in relation to national performance measures looking at cost and number of users helped to lived independently.

5. Twenty six percent of placements are Out of County, with the vast majority living in neighbouring authorities, within a few miles of home. However, any out of County placements result in a degree of uncoordinated care as the placing social services authority retains responsibility for care, whilst the new area assumes NHS responsibilities.

6. The Hampshire rate is met for approximately fifty percent of placements, the remainder being above this rate.

4.2.1

The Mary Rose Tarpey Report

The report in 1996 mapped housing need for people with mental health problems across Hampshire by District Council. It includes a number of key findings which support the need to extend the Housing provision to meet specialised client need, e.g. crisis beds, provision for younger people and increased support assistance to promote independence. Information from this report is included in the ROCC Report.

4.2.2

ROCC Report Mapping

Information about provision was gathered from written sources and a range of staff interviews and mapped against District Council boundaries (which are not coterminous with Hampshire Social Services, except for Basingstoke). The mapping for each District Council concludes, as far as possible, with both a quantitative and qualitative estimate of housing need. See 3.2.2 and gap analysis in Appendix 4.

4.2.3

Budget Issues

The total Mental Health Budget for 2000/2001 was £8,580,000, with a gross Residential budget of £2,561,000 and a net outturn of £1,582,000.

1. Analysis of Budget Outturns, 2000/2001

o Area comparisons of net budget against net actuals indicates considerable variance, from 15% underspend in the New Forest, to 47% overspend in Alton / Aldershot, and 62% overspend in Basingstoke. (See appendix 6a & 6b).

o Budget allocation has followed an historical pattern, not taking into account the variation in population or prevalence of mental illness across areas.

Area

WAP

(Working Age Population)

Prevalence Rate SMI

(Severely Mentally Ill)

Alton / Aldershot

156,000

6,240

Basingstoke

102,000

4,080

(See Appendix 7)

o Budget allocation per capita varies from £8.63 (Alton / Aldershot) to £13.43 (Basingstoke). Allocation based on population figures for 2002 and 2003 indicates the size of the under and over allocation per area and the readjustments needed to ensure equity of allocation (see below). Annual readjustments would also need to take place as population changes occur.

o Full analysis requires examination of NHS investment and prevelance rates of mental illness. This began in the NSF monitoring but is currently not on a consistent basis to allow comparison. Primary Care Trusts (PCTs) who have funding responsibility will not transfer funds to neighbouring PCTs so achieving equitable distribution of mental health resources will remain a significant challenge.

Estimates for 2002 based on cash limit as 31st October

Population 2002

Percentage of total population

Allocation based on population

Per Capita

Current Allocations

Per Capita

(Under) / over allocation

%

£

£

£

£

£

North and Mid Hants

Alton / Aldershot

156785

19.91

1,697,566

10.83

1,352,300

8.63

(345,266)

Basingstoke

103579

13.15

1,121,195

10.82

1,391,300

13.43

270,105

Winchester / Andover

103059

13.09

1,116,080

10.83

1,336,000

12.96

219,920

Sub Total

363423

46.15

3,934,841

10.83

4,079,600

11.23

144,759

South West

Eastleigh / Romsey

101,740

12.92

1,101,585

10.83

882,900

8.68

(218,685)

New Forest

101,132

12.84

1,094,764

10.83

1,257,700

12.44

162,936

Sub Total

202,872

25.76

2,196,349

10.83

2,140,600

10.55

(55,749)

South East

Fareham & Gosport

116,757

14.83

1,264,436

10.83

1,077,400

9.23

(187,l036)

Havant & Petersfield

104,440

13.26

1,130,574

10.83

1,228,600

11.76

98,026

Sub Total

221,197

28.09

2,395,010

10.83

2,306,000

10.43

(89,010)

Total

787,492

100.00

8,526,200

10.83

8,526,200

10.83

0

Estimates for 2003 based on cash limit as 31st October

Population 2002

Percentage of total population

Allocation based on population

Per Capita

Current Allocations

Per Capita

(Under) / over allocation

%

£

£

£

£

£

North and Mid Hants

Alton / Aldershot

157,780

19.87

1,694,156

10.74

1,328,300

8.42

(365,856)

Basingstoke

105,001

13.23

1,128,016

10.74

1,400,300

13.34

272,284

Winchester / Andover

103,829

13.08

1,115,227

10.74

1,351,000

13.01

235,773

Sub Total

366,610

46.18

3,937,399

10.74

4,079,600

11.13

142,201

South West

Eastleigh / Romsey

102,532

12.91

1,100,732

10.74

882,900

8.61

(217,832)

New Forest

102,219

12.88

1,098,175

10.74

1,257,700

12.30

159,525

Sub Total

204,751

25.79

2,198,907

10.74

2,140,600

10.45

(58,307)

South East

Fareham & Gosport

117,914

14.85

1,266,141

10.74

1,077,400

9.14

(188,741)

Havant & Petersfield

104,636

13.18

1,123,753

10.74

1,228,600

11.74

104,847

Sub Total

222,550

28.03

2,389,894

10.74

2,306,000

10.36

(83,894)

Total

793,911

100.00

8,526,200

10.74

8,526,200

10.74

0

2. Section 117 (aftercare) Mental Health Act 1983

People detained under Section 3 or 37 of the Mental Health Act 1983 are entitled to Section 117 aftercare once the period of compulsory detention has ended. It is illegal for local authorities to charge for services provided under this section, and though currently subject to an appeal to the House of Lords, it appears likely that this position will be upheld (some local authorities have continued to charge for residential care and have unsuccessfully argued that they are providing residential care under alternative legislation). Hampshire has operated a non-charging policy for services provided under Section 117 since 1995.

(i) Performance over the last three years in terms of net cash limit compared to net outturns indicates a steady rise in % variance (overspend) from 6.2% in 1998/9 to 22% in 2000/1.

(ii) One factor (the other being the high cost of specialised mental health placements) in this overspend is that 29.2% of mental health service users accessing residential care are subject to Section 117 aftercare regulations which state that services for this group will be free of any charge.

(iii) A project is currently taking place to assess the cost to Hampshire County Council of providing for Section 117 aftercare services across all care groups and the results should be ready for the final report.

(iv) Breakdown by area of loss of income gives Alton / Aldershot (46%) and Eastleigh / Romsey (50%) areas the highest percentage of clients subject to Section 117, and therefore the highest percentage loss of income.

(v) Adjusted figures, for the same period, indicate the following loss of income per annum by area:

Alton / Aldershot

£89,406

Basingstoke

£32,106

Winchester / Andover

£44,840

Fareham / Gosport

£12,800

Havant / Petersfield

£13,400

Eastleigh / Romsey

£25,600

New Forest

£64,000

Total

£281,752

(vi) The £286,000 overspend indicated in Residential outturn 2000/01 is equivalent to the loss of Section 117 income. This needs to be taken into account when setting net income targets for mental health services.

3. Preserved Rights Issue

(i) As from April 2002, Service Users who were previously classed as having "preserved rights", i.e. residential funding commenced prior to April 1993 and was the responsibility of the Benefits Agency, become the responsibility of Social Services departments. There are approximately 35 mental health service users affected by this change.

(ii) The additional demand on the mental health budgets is still being assessed but given the relatively small numbers (there are just over one thousand people who were subject to preserved rights in April 2003) the impact is likely to be slight.

4.2.4

Review of Alton / Aldershot Residential Spend

The review was conducted during April-June 2000 and reported in January 2001. It was commissioned due to a proportionally high budget spend in this area.

Outcomes include - on an area by area comparison:

(i) Alton and Aldershot has highest predicted prevalence rates per head of population of severe and enduring mental illness / hard to engage clients. See appendix 6.

(ii) Alton and Aldershot, whilst not having the highest deprivation scores as a whole (Havant / Petersfield has highest) has pockets of deprivation equal to Havant / Petersfield.

(iii) The three areas with highest number of Residential clients have lowest numbers of Domiciliary clients - the New Forest, Alton and Aldershot, and Fareham and Gosport.

(iv) The two lowest spend areas on Residential Care (Havant / Petersfield & Eastleigh / Romsey) spend more in gross terms on non-residential care, indicating a correlation between high level of community services spend and low numbers of residential placement (Appendix 7).

(v) Comparison of gross and net actual spend on Residential care indicates Fareham and Gosport area having second highest gross spend with one the lowest net spends, showing significant income generated from Health service (due to reprovision of long stay hospital) - (Appendix 5b). This gives Fareham / Gosport a disproportionately low cost Residential spend.

(vi) Average unit cost comparison shows Alton and Aldershot have highest cost for Residential as well as non-Residential indicating generally high cost area in line with the adjacent county Surrey, and proximity to London.

(vii) Basingstoke (neighbouring area) has significantly lower costs for both services and indicates possible improved community and health services and finance from previous reprovision of long stay hospital. Havant / Petersfield with lowest Residential unit cost and fairly low non-Residential and the New Forest with low Residential but high non-Residential cost indicating local variations perhaps due to workforce availability.

(viii) Analysis of average Residential spend per client across old Health Authority areas, shows North and Mid Hampshire higher than South East and South West areas.

Overall Conclusions

(i) Alton and Aldershot has high costs in both Residential and Domiciliary Services.

(ii) Areas with highest number of Residential clients have lowest number of non-Residential clients.

(iii) Past Health reprovision and finance in Fareham/Gosport lead to lower Residential Social Services costs and improved community provision.

4.2.5

Internal Comparison of Activity, Spend and Community Resources, 2001

The area by area comparison undertaken between April and August 2002 indicates the following main findings:

(i) Findings of ROCC Report mapping endorsed.

(ii) A complex picture has emerged across the areas showing a substantial variation in: accommodation provision; spend; community resources; health provision and approach taken by Local Housing forums.

(iii) The main gaps in the service are detailed in point 5.2.3. Needs identified other than accommodation provision include: staff training in housing related issues; culture change within Health and Social Services; increase in accessible transport and employment schemes and rural deprivation schemes.

(iv) Alton / Aldershot area is not funded in line with the high prevalence rate of the severely mentally ill:

· 6,250 people per 100,000 compared to 4,000 - 4,600 per 100,000 in other areas.

(v) High rate of staff vacancies in Basingstoke and Alton / Aldershot areas.

(vi) High cost of placements in Alton / Aldershot.

(vii) High number of Out of County placements in New Forest, i.e. 13 from a total of 25.

(viii) Difficulty in accessing robust and accurate data from the existing systems leads to inaccurate information for budget management and financial longer term planning. In this review it has resulted in a significant amount of project time devoted to manual gathering of information.

4.2.6

Costs above Hampshire rate

A comparison has been undertaken of the cost to the Service of Out of County placements above the Hampshire County Council rate compared to the cost of In County placements above the Hampshire County Council rate, based on service mapping April - August 2001.

Cost

There were 38 out of County placements and 107 in County placements from a total of 145 (2000/01).

Out of County placements

Within HCC rate

Over HCC rate

38

18

20 excess funding = £153,800

Plus 6 part-funded by Health with Social Services contribution at HCC rate.

In County placements

Within HCC rate

Over HCC rate

107

49

58 excess funding = £357,600

Plus 6 part-funded by Health with Social Services contribution at HCC rate.

Out of County

In County

Total no. of Res. placements

Area

No. out of County placements

No. above HCC rate ( ) indicate cases with Social Services costs

Cost to Social Services (only) above HCC rate

No. in County placements

No. above HCC rate

Cost to Social Services above HCC rate

16

WA

9

8 (7)

51.6k

7

1

4.5k

25

NF

13

6 (1)

1.6k

12

5

12k

26

AA

5

5

75.8k

21

14

161.4k

15

B

2

1

£800

13

5

43k

37

FG

2

2

11k

35

19

94k

17

HP

4

2

12k

13

11

37.5k

9

ER

3

2

£1000

6

3

5.3k

145

Totals

38

20

£153,800

Totals

107

58

£357,600

Average cost

£7,690

Average cost

£6,165

Outcomes

(i) Out of County placements = 26% of total number of Residential placements.

(ii) Both out of County and in County placements have similar number of "HCC rate" and "over HCC rate" costs.

(iii) Both have 6 placements part funded by Health not included in calculations.

(iv) Wide local variations in costs above the Hampshire rate both out of and in County.

(v) Alton / Aldershot and Winchester / Andover have significantly higher costs above the Hampshire rate for Out of County placements.

(vi) Very wide variations in placements in County above the Hampshire rate particularly Alton / Aldershot, but also Fareham / Gosport, Basingstoke, and Havant / Petersfield.

(vii) Average extra cost of "above HCC rate" out of County placements is £7,690 per annum compared to In County average extra cost at £6,160 per placement.

(viii) Fareham / Gosport - high number of placements is due to 9 Health funded placements following long stay hospital reprovision.

However:

(i) Theoretically a saving of £153,000 could be made if Service Users were found placements in County at HCC rate.

(ii) These placements do not presently exist.

(iii) The overarching problem is the high cost of care for people with complex mental health needs.

(iv) Consideration should be given to developing a new model of mixed economy of care within County, which in partnership with Health may be more cost effective and meet needs locally.

Location

Although there are in total 38 Out of County placements, (26% of total placements), given the geographical size of Hampshire and the recent Local Government reorganisation, the vast majority of placements are as "close to home as possible" and therefore could be seen to meet the NSF requirement, e.g. Alton clients placed in Surrey, New Forest clients placed in Bournemouth. (Appendix 8)

However, as previously stated, it is desirable for successful care coordination and prevention/management of risk, plus quality of life in retaining links with family and employment, for placements to be located in County where both Hampshire County Council and Health responsibilities coexist.

The majority of out of County placements, 30 out of a total of 38, are located in neighbouring authorities, several within a few miles of Hampshire and Service

Users normal residence:

Neighbouring Authorities

Remaining Placements

Surrey

Wiltshire

Southampton

Portsmouth

Bournemouth

Total

6

6

7

4

7

30

Devon

Somerset

Gloucestershire

Portsmouth

Bournemouth

Total

3

1

1

1

2

8

4.2.7

Comparator and Neighbouring Local Authority Analysis

1. Comparison with other local Authority areas in terms of places, placement and cost. (note: a number of different comparator groups are used in this section drawn from different sources).

Places

o There has been a National year on year overall drop in the number of Residential Care Homes and places for people with Mental Illness since 1997. (Community Care Statistics 2001, Residential Personal Social Services for Adults, England (figures include elderly mentally infirm but general trend applicable).)

o A comparison of number of places in Hampshire with counties in the South East and South West shows Hampshire having:

· Fourth lowest number of places in South East out of total of seven.

· Seventh lowest number of places in South East and South West out of fourteen.

Placements

Hampshire has been relatively successful in 2000/1 in preventing admission to mental health Residential care (National Statistics publication, 2000/1, Number of supported residents (by Local Authority))

In terms of placements, Hampshire has the second lowest number of placements in a range of nine neighbouring and comparator authorities.

Norm for % of Mental Health Placement

England

4.3%

South East Region

3.6%

Shire Counties in S.E. Region

3.3%

Hampshire

2.8%

Kent, Surrey, West Sussex, Portsmouth, Southampton, Reading, West Berks, Wokingham

8.7% - 2.7%

Cost

Comparison with the official comparator group of fifteen Shire counties in 2000/01 regarding the weekly unit cost of supporting mentally ill adults in Residential and Nursing care (Personal Social Services expenditure and unit cost: England 2000/1):

o England - £412

o Hampshire fifth lowest unit cost out of 15 Shire Counties (Appendix 9).

o Hampshire unit cost is £372.04 in range of £205.74 - £639.58.

o In the previous year, Hampshire was the second lowest place at £268.43, thus indicating the pressure on current budgets as prices rise, or more accurate information.

The Hampshire unit cost of £372.04 is well above the Hampshire rate of £248 per week. These factors need to be taken into account:

1. When the numbers of people in Residential care drops, as more people are accommodated in supported housing in the community, the unit cost of residential care will rise.

2. The needs of people with severe and enduring mental health problems are complex and often require specialised residential units which are costly.

3. The cost of residential and nursing care for adults with mental health problems is substantially lower than that for adults with a learning or physical disability.

4.2.8

PAF Indicators

The PAF returns relating to mental health performance are:

A6 - psychiatric readmission rates

B15 - unit cost of residential and nursing care

C31 - number of people helped to stay in own home (per 100,000 population)

C27 - number of people admitted to residential care (per 100,000 population)

Performance is shown in terms of ●'s, with one ● = investigate urgently, and five ● ● ● ● ● = very good performance.

The returns for 1999-2000 and 2000-2001 indicate:

o B15 - GOOD. Hampshire Residential placement costs although slightly higher in 2000-1 than previously still remains acceptable and within the bottom two fifth of comparator Counties. Band ● ● ● ● - good performance.

NOTE - However, within Hampshire there is significant variation in costs per area with Winchester/Andover, Basingstoke and Alton/Aldershot showing significantly higher than other areas in both gross and net terms. Also, there is a relationship between cost and quality which needs to be balanced to achieve high standards together with efficient use of resources.

o C27 - GOOD. Hampshire is shown as successful in keeping people out of residential care with a rating of ● ● ● ● - good performance 1999/0 and 2000/1.

o C31 - GOOD. Hampshire has improved significantly in 2000/01, the indicator moving from ● ● -low performance at 1.0, to ● ● ● ● - good performance at 2.8. This commitment to improving community resources will be one of the most important factors in lowering the admission rate to residential care.

o A6 - This indicator is in the Health domain and data is collected for the three (previous) Health Authorities covering Hampshire. In 1999/0 only Portsmouth and South East Hampshire HA were rated ● ● ● ● - good performance, with Southampton and South West Hampshire HA and North and Mid Hampshire HA rated ● ● - question performance.

5

COMPETITION

Key Messages:

1. Hampshire Social Services Department does not directly provide any Residential care or Housing with Support Services. A range of services are commissioned from the private and voluntary sector, either on a spot purchase or contract basis.

2. The identified inequity in Housing provision has to be addressed by working with District Councils.

3. Specialist provision to meet complex needs which incurs high cost should be developed jointly with the NHS. This provision should be located in County to ensure continuation and coordination of care and rehabilitation.

4. Mental Health residential spend is a relatively small proportion of overall Departmental budget, and of care budget.

5. Few providers are available, and less still who can meet specialist needs.

6. Significant cost variation which reflects high need and local market conditions.

5.1

Work Undertaken

· Mapping and analysis of Registered Residential care providers within Hampshire and in external Local Authority areas (Out of County).

· Mapping of Non Registered Housing with Support Services and an analysis of deregistration agenda.

· Identification of gaps in service provision by area.

· Identification of other Local Authority provision, in house.

5.2

Findings

5.2.1

Current Provision

(i) Hampshire Social Services Department does not directly provide any Residential care or Housing with Support Services. A range of provision is commissioned from the private and voluntary sector, either on a spot purchase or contract basis.

(ii) Health provision is available in terms of some 24 hour nursed care, high level supported housing and crisis accommodation in varying amounts across the county (Mental Health Service Mapping October 2000), with some areas e.g. Eastleigh / Romsey having no Health provision. There is a current move in Health to reconfigure services using the rationale of rehabilitation or "move on", which may have implications for Social Services.

(iii) The service has not been the subject of compulsory or voluntary competitive tender. There is a seriously restricted market, with few providers available, not able to meet present need. For example, 34% of current provision is out of County. The risk of inflating costs in a limited market may indicate that statutory services should develop and manage these services.

(iv) Contracts with Providers take the form of individual Service user care plans within the framework of the Care Programme Approach (CPA - assessment and care planning mechanism for mental health). Staff from both Health and Social Services (Care Coordinators) purchase care from providers who may be located within Hampshire or in other Local Authorities. This individual approach hinders comparison between providers and further complicates planning on the basis of need and unmet need.

(v) The current Mental Health Service Manager posts have enabled closer scrutiny of purchasing and encouraged the brokering or joint funding arrangements but it has highlighted the need for more accessible information about need and purchasing patterns. With the development of joint locality management posts with both Health and Social Services responsibilities new monitoring systems may need to be developed.

(vi) Given the lack of provision in terms of volume and range across the County, the use of joint funding needs to be seriously considered to maximise existing resources and develop new services which are effective and efficient.

Costs

Mental Health Accommodation Services can be divided into two distinct areas for financial purposes: Registered and Non-Registered accommodation, both with different funding streams.

Registered Accommodation Consists of:

o Nursing Homes

o Residential Care Homes

o 24 hour, Residential Supported Housing

Non-Registered Accommodation Consists of:

o Supported Housing (support as integral part of service)

o With Domiciliary Care and support, OR with support only

o General Needs Housing (support subject to a separate contract)

Funding Streams

o Social Services

o Health

o Service User contribution

o DSS / Benefits Agency

o Supported Housing Management Grant (SHMG - not for Nursing and Residential Care Homes)

o Housing Support Grants (rent)

o Social Services (domiciliary care and support)

Cost - March 2001

Gross - £2,561,000

Net - £1,582,000

The current recording system does not allows this calculation to be undertaken.

5.2.2

Market Analysis: The Changing Shape of the Market

1. Deregistration Issues

Since April 2002, Nursing and Residential Home providers are required to register with Local Care Standards Commissions and comply with new national service standards. There are a number of implications which include: deregistration of Homes to maximise Transitional Housing Benefit (THB); additional costs require to meet the new registration standards; a reduction in the number of care beds

Outcomes

(a) Increased use of THB, reducing Social Services costs which could be reinvested:

o To ensure those services which are still funded are paid a fair and defensible rate for what they provide thus ensuring the long term viability of the service.

o Provide funding for non-housing residential facilities needed such as respite and crisis housing.

o Provide support for preventative services such as "floating support".

(b) Increase in more independent supported accommodation could increase the number of service users living in the community, accessing local facilities, thus leading to greater inclusion. However, this would be dependent on:

o The appropriate level of support being available, funded and delivered in a flexible manner.

o An increase in community services and resources including improved professional practice in relation to housing assessment and need.

Cost Implications

Work is still underway to calculate the number of Provider deregistering in each area and the cost implications.

2. Current Provision of Registered Accommodation

o Type

Number of Providers

Type of Accommodation

Location (County)

In

Out

12

Nursing Home

9

3

67

Residential Care

42

25

6

Other

5

1

Totals - 85

56

29

o An area by area breakdown is detailed in an Analysis of number of Providers of Registered Care by type of accommodation and by area (based on April - August 2001 figures). See Appendix 10a and 10b.

o Most areas have a mixture of the three types of Registered Care in varying amounts

o the total number of Registered Providers is 85 with the following breakdown by type of accommodation:

Nursing Homes:

Residential Homes:

Other:

15%

78%

7%

o Location

Accommodation locations i.e. within Hampshire or Out of County.

Type of Accommodation

In County

Out of County

Nursing Homes

75%

25%

Residential Homes

63%

37%

Other

84%

16%

Thus the majority, 66% of Registered care is available within Hampshire. However, 34% of provision out of County does not fulfil the NSF standard of care "as close to home as possible" and consideration needs to be given to stimulating the market within Hampshire or providing services directly.

3. Current Provision of Non-Registered Accommodation with Support

Details of the main Providers in each area can be found in Appendix 10B.

Key Findings

1. There are relatively few main providers including: Stonham, MACA, Southern Focus Trust and Carr Gomm, 2 Saints, with significant gaps across the County.

2. A number of local Housing Associations (HAs) provide accommodation with a variety of levels of support. In addition, other providers are local to specific areas only.

3. Comparison of community resources by area indicates the complex and interrelated issues which need to be taken into account when assessing need, cost, provision, and in planning developments of Housing with support.

Cost Variations

o Registered Care - ranges in cost between £247 per week, the Hampshire rate, and £1,125 per week (Alton / Aldershot placement - In County).

o Non-Registered Care - is difficult to cost as there are several elements involved: rent; service charges; support charges; Domiciliary (support) charges.

Social Services, under the new arrangements should only be directly funding domiciliary care, (social and emotional support for people with mental illness), and the cost of any support seen as falling outside Supporting People (as currently interpreted through the THB scheme).

A transparent mechanism for calculating and assessing the costs of providing support and care linked to accommodation needs to be developed. The ROCC Report offers examples of how this might be achieved.

5.2.3

Gaps in Service Provision

The ROCC Report and Internal Activity mapping details gaps in provision across the areas. This is summarised in Appendix 4.

6

6.1

6.2

6.3

CONCLUSION

Development of the Service - A Whole Systems Approach

An appropriate, effective and efficient accommodation with support service must be seen as part of the total comprehensive mental health service, using a whole systems approach. One of the key messages from the ROCC report is that the maximum opportunity should be taken to move towards the use of non-registered provision `as close to home as possible.' The Supporting People agenda provides a strong driver for more support to be delivered to people in their own home, and to reduce the need for specialist housing schemes, especially registered provision. The proposed introduction of Community Treatment Orders under a new Mental Health Act will also break the requirement that compulsory treatment must be given in a hospital or registered nursing home.

A key component of future options must therefore be for mental health LITs and the Supporting People networks to develop alternatives to residential care, and to work towards the de-registration of existing accommodation where it is safe and prudent to do so. The ROCC report and this Best Value Review give some indication of needs in each locality.

There will, however, also continue to be a need for some 24 hour nursed care and residential care for people with specialist or high care needs. This will include people with severe and enduring mental illness, challenging behaviour or offending, a history of compulsory admission to hospital, and often with additional needs arising from substance misuse or learning disability. Some will be the responsibility of the NHS, some for the Social Services Department, and some will require negotiation and joint funding in accordance with continuing care criteria. A comprehensive needs assessment of this group of people still needs to be completed, although it is in hand or planned in most parts of Hampshire.

The recommendations of the ROCC report (Appendix 1) have been developed into a draft action plan (Appendix 2). The key outcomes required are:

1. Development of a range of residential care and housing with support in each locality informed by the needs analysis in the ROCC report.

2. Development of integrated planning processes incorporating the NSF and Supporting People agendas

3. Development of robust joint financial and management information

4. Improved housing practice in mental health services through joint training

5. Services are responsive to specialist needs

6. There is effective user and carer involvement

7. Revenue and capital resources are maximised across agencies to meet need and promote independence

8. Services have clear, jointly owned and published care standards

To implement the action plan, funding is required from a number of sources: Supported Housing through District Councils; Primary Care Trust (PCTs); investment and Social Services.

NSF development requires revenue funding from the Modernisation Funds of Social Services and the National Health Services, with capital funding at present provided by the NHS.

6.4

Comment on Resources

(i) Over £1 million additional mental health grant has been invested by Hampshire County Council Social Services Department since 1999 to develop social care services as part of NSF implementation. However, from 2002/03 additional mental health modernisation funds, "earmarked funding" for mental health, is being channelled through PCTs to fund the NHS plan priorities contained in the joint investment plans of mental health LITs. In spite of stated government intentions to invest an additional £75 million (approximately £300,000 per PCT was expected in Hampshire) the indication both nationally and locally is that very little of this additional investment will reach mental health services. Investment of earmarked money in social care by PCTs is expected to be nil. (In the absence of additional mental health grant and earmarked funding for social care, the County Council has agreed to fund a £50,000 recruitment and retention package for Approved Social Workers to enable minimum statutory requirements are met). The implications of the recent budget settlement and new NHS implementation plan for mental health services (including proposals to charge Councils with Social Services Responsibilities for delayed discharges) are not known.

(ii) Capital: potential sources of capital include the Department's capital programme (£900,000) or Mental Health Supplementary Credit Approvals (SCA) awarded by the Department of Health each year. Both sources are severely restricted: the DoH has prioritised SCA for the development of integrated mental health information systems for 2002/04.

(iii) At this stage detailed costed proposals for service development are not available. However, comparative unit costings are contained in sections 4 and 5 above.

(iv) The benefits and risks concerning joint commissioning and provision of services will be evaluated as part of existing work plans in partnership with PCTs and Mental Health Trusts.

(v) An important part of the County Council's Overview and Scrutiny Function will be the investment by PCTs in mental health services, and of the use of modernisation funds to assist developments in social care.

7

OPTIONS EMERGING FROM WORK TO DATE

Two options have been identified to achieve these objectives:

1. Option 1: minimal change, within current resources, that will partly meet objectives

2. Option 2: significant change, requiring substantial changes to services and levels of investment to implement the NSF, including actions identified in the draft action plan.

Option 2 has a number of components:

i. Develop a mixed economy of provision, including the deployment of County Council capital resources to meet gaps in provision e.g. 24 hour specialist residential care provision. It would be jointly commissioned with NHS and housing partners, and consideration given to pooling capital and revenue

ii. Jointly commissioning the above, but without County Council capital investment

iii. Developing a range of community services through recycling of current resources and additional investment, which should reduce the demand for residential placements

Appendix 12 uses the Best Value tool to evaluate the options.

8

RECOMMENDATIONS - PREFERRED OPTIONS

Members' comments and preferences are invited on the preferred options outlined in this report. These will then be developed into a detailed Improvement Plan for inclusion in the final report.

Section 100 D - Local Government Act 1972 - background papers

The following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report and attached appraisal.

NB - the list includes:

1. Published works.

2. Documents which disclose exempt of confidential information as defined in the Act.

Title

Challenge and Change: Developing a Mental Health and Housing Strategy for Hampshire County Council Social Services. (2 copies have been placed in the Members' Library).

Appendix 3 of this report lists a number of documents referred to in this report that can be found on the Best Value Residential Care File.