Archived decisions

Contact: Denise Holden ex 7338

e-mail: [email protected]

1. Summary and Purpose

1.1. The purpose of this report is to alert Members to proposals from the NHS to vary or develop health services provided to people living in the area of the Committee.

1.2. Proposals that are considered to be substantial in nature will be subject to formal public consultation. The nature and scope of this consultation should be discussed with the Committee at the earliest opportunity.

1.3. The response of the Committee will take account of the Framework for Assessing Substantial Change and Variation in Health Services agreed by the Hampshire, Isle of Wight, Portsmouth and Southampton Joint Committee in March 2005. This places particular emphasis on the duties imposed on the NHS by Section 11 of the Health and Social Care Act 2001.

1.4. This Report is presented to the Committee in 2 parts:

_ Items for information: these alert the Committee to forthcoming proposals from the NHS to vary or change services. This provides the Committee with an opportunity to determine if the proposal would be considered substantial and assess the need to establish formal joint arrangements

_ Items for action: these set out the actions required by the Committee to respond to proposals from the NHS to substantially change or vary NHS services.

1.5. This report and recommendations provide members with an opportunity to influence and improve the delivery of health services in Hampshire and therefore support the delivery of Aim 5 (Improving Services) of the Corporate Strategy.

Items for Information

2. South West PCT Alliance/SUHT: Closure of Maternity Beds and Review of Maternity Services in South West Hampshire

2.1. SUHT has confirmed that the birth centre at Romsey will reopen on 20 March.

2.2. In response to comments from the Committee the South West PCT Alliance has confirmed that:

_ All local NHS organisations will be involved in informing the review

_ That women from across the area should have choice in where they give birth

_ There should be closer partnership working with services for children and families

_ The time frame for taking this work forward has been extended

Recommendation

2.3. Members note the Romsey Birth Centre will reopen on 20 March

2.4. Members are advised of the next steps of the review of maternity services in south west Hampshire when these are available.

3. Mid & South West Hants PCTs: Surgical Service Reconfiguration

3.1. Work is progressing with regard to activity and case mix.

3.2. A business case is currently being developed for spinal care

3.3. No final proposal is yet available

Recommendation

3.4. The Committee is up-dated on progress with the surgical service reconfiguration proposal at its next meeting.

4. The future of Services in Fareham & Gosport/ South East Hampshire Capacity Plan

4.1. The Chairman apprised the SHA of the concerns of the Committee about the development of community services in south east Hampshire at a meeting on the 11 December.

4.2. The PFI contract for Queen Alexandra was signed in December.

4.3. The revised capacity plan for South East Hampshire has yet to be considered by the SHA.

Recommendation

4.4. The Committee is advised of any further developments that will impact on the provision of services in this area

5. SHA: Acute Paediatric Services Review

5.1. The SHA is seeking the views of the NHS family and its partners on the review and recommendations by 31 January 2006.

Recommendation

5.2. Members are advised of the response of the NHS and its partners to review and the way in which this will be taken forward.

6. Mid Hampshire PCT: Mental Health Accommodation

6.1. An outline of the next steps planned by the PCT is attached at Appendix One. The PCT has indicated that there has been an extensive engagement with the individuals, their families and staff as well as adult services.

6.2. Confirmation has been requested that other key stakeholders, including the P&PI Forums are satisfied with the section 11 involvement that has taken place.

6.3. Subject to the above the Chairman has indicated that this is not a substantial service change.

Recommendation

6.4. Members confirm that, subject to confirmation that adequate section 11 engagement has taken place, this is not a substantial service change

7. East Hampshire/Fareham & Gosport PCTs: Elderly Mental Health Services

7.1. Further to the queries raised by the Committee about these services at the last meeting, the PCT has confirmed its intention that the management of these services will transfer to the Hampshire Partnership Trust on 1 April.

7.2. There will be no services changes associated with this transfer.

7.3. No additional issues have been raised with the Committee by the Patient Forum

Recommendation

7.4. Members note the change in management arrangements.

8. Blackwater Valley & Hart PCT: Rainbow Assessment & Treatment Group

8.1. No additional information has been provided about this proposal. Surrey HOSC and the relevant P&PIF have been alerted to the changes put forward.

8.2. The PCT has been appraised of the expectations of the Committee with regard to Section 11 engagement.

Recommendation

8.3. The PCT confirms the feedback from all stakeholders, including the P&PIFs whose population are affected in line with section 11 requirements.

8.4. This information, and the views of Surry HOSC, will inform the recommendation of the Committee about the nature of the change

9. South East PCT Cluster: Maternity Services in South East Hampshire

9.1. The Chairman has written to PHT asking for clarification following press reports that a decision about the future of the centres was immanent.

9.2. Assurances that a date for the reopening of the Units will be available in the new year were given when the Units were closed in the summer. Advice provided to the Committee suggests that the grounds for temporary closure should include a date for reopening the service in question

Recommendations

9.3. Members are advised of further action taken with regard to the review of maternity services at the meeting in March.

9.4. PHT provides the Committee with a date for reopening the birth centres. If this is not provided then the Committee will wish to consider if the decision to close the units should be referred to the Secretary of State.

10. East Hampshire PCT: Transfer of Learning Disability Services

10.1. East Hampshire PCT has indicated that learning disability services will transfer to Hampshire Partnership NHS Trust with effect from 1 April.

10.2. There will be no change in services provided to the populations of East Hampshire and Fareham and Gosport

Recommendation

10.3. Members note the change in management arrangements

11. East Hampshire PCT: Transfer of Older Persons Medicine Services

11.1. East Hampshire PCT has indicated its intention to transfer Older Peoples Medicine Services to PHT. The initial date indicated for this transfer was 1 April 2006.

11.2. The Committee has requested that this delay be deferred for the following reasons:

_ There is no clarity about the service specifications or the service model

_ There is no clinical consensus on the transfer

_ The proposals is not in line with the policy direction set out in `Commissioning a Patient Led NHS'.

_ It is not clear what section 11 engagement has taken place

11.3. Portsmouth City HOSC shares these concerns.

11.4. The Chairman has written to the PCT setting out the issues that need to be addressed

Recommendation

11.5. That the PCT be asked to defer the transfer until this above issues have been satisfactorily addressed and additional information made available to members.

11.6. The views of Adult Services be formally invited

12. North Hampshire Primary Care Trust: Reprovision of Older Persons Mental Health services provided at Homefield House

12.1. The Primary Care Trust has reviewed the usage of Homefield House, Basingstoke. This facility provides a mix of residential and respite care to older adults with `continuing care' organic mental health needs (dementia). The details of this proposal are attached at Appendix Two.

12.2. The indicative usage of the home is 4 beds allocated to respite; 10 consultant-led `continuing care' beds; and 10 GP-led beds.

12.3. A multi-disciplinary assessment conducted by the PCT concluded that of the 20 residents, only 7 met `continuing care' type criteria vis-à-vis Mental Health domains. Over time it is not unusual for patients admitted under one category to change status as physical frailty increases.

12.4. The PCT proposes that patients with challenging behaviour are transferred to Parklands Hospital where additional staff resources are available. Patients receiving GP-led care remain at Homefield, although these patients do not meet `continuing care' criteria. It is intended to implement the reprovision in December 2006.

12.5. The PCT has had a contract with the proprietors of Homefield House, Shaw Healthcare (homes) Ltd, which has obliged the PCT to fully fund all patients in the home, regardless of whether they continue to meet `continuing care' criteria.

12.6. Following a meeting with the PCT, it has confirmed that:

_ all patients who were admitted prior to April 2004 will be guaranteed a `home for life'.

_ Patients admitted since that date, will not be entitled to a `home for life' but will be subject to the normal arrangements following single assessment after December 2006

_ when cost saving measures begin to deliver, any monies saved will be reinvested in older peoples services

12.7. Initial feedback from Adult Services indicates:

_ A need for clarity about the extent to which patients and carers have been involved in developing these proposals

_ A lack of clarity about the continuity of day care and respite care

Recommendations

12.8. The Committee formally invites the views of Adult Services about these proposals

12.9. The Trust provides detailed information about the section 11 engagement that supports the proposals, including the views of the relevant P&PIFs.

12.10. This information will be provided to Members at the next meeting to inform their views about the nature of changes proposed.

12.11. Any additional queries from Members will be directed through Martin Combs up to and including 10 March 2006.

13.

Items Requiring Action

14. Hampshire Partnership NHS Trust: Improving mental health services for people of working age.

14.1. Hampshire Partnership will attend the meeting to give an up-date on the feedback from local people and the next steps to improve services as outlined in the consultation document.

14.2. No additional issues were raised by members in response to the proposals.

Recommendation

14.3. Members determine:

_ If the consultation process was adequate

_ If they consider that the proposal is in the interest of the health service in the area

15. Winchester and Eastleigh Healthcare NHS Trust: Changes to the Configuration of Services at Andover War Memorial Hospital

15.1. Further to the presentation to the Committee at the last meeting the Trust Board considered the detailed report of the consultation process and the preferred option for reconfiguring services at Andover War Memorial Hospital. The relevant minutes from the Board meeting are attached at Appendix Three

15.2. The Trust has confirmed that copies of the report from Article 13, setting out the outcome of the consultation process, will be made available to members on request.

Recommendation

15.3. Members note the detailed consultation and engagement process, which included input from the relevant P&PIFs, district councils and other key stakeholders

15.4. Members confirm

_ the consultation process has been adequate

_ the preferred option identified is in the interests of the community affected

16. North Hampshire PCT: Changes to the Configuration of Services at Alton Community

16.1. No further information has been provided about this proposal.

Recommendation

16.2. Members are advised of progress with developing the consultation document at the next meeting.

17. Department of Health: Commissioning a Patient Led NHS

17.1. Arrangements for consulting key stakeholders about the configuration of PCTs, SHAs and Ambulance services were published on 14 December. The consultation will finish on 22 March.

17.2. Members were circulated with an electronic copy of these document when they were published. They can be found at here

17.3. Members have previously expressed there views about the proposals and these were shared with the SHA to inform the final options presented for consultation.

Recommendation

17.4. The Committee reaffirms the views of members, emphasising the following points:

_ The need for robust local arrangements to ensure that local commissioning arrangements are able to reflect the different health needs of the population of Hampshire. This is particularly important for Ambulance Services and Public Health.

_ PBC areas to be aligned with District boundaries

_ Improved partnership working across the County Council, District Councils and the NHS

17.5. Members wishing to have additional points included in the response to consultation direct these to Denise Holden by 17 March.

18. Healthcare Commission: Engaging with Patients and the Public

18.1. The HealthCare Commission published a consultation document on engaging with patients and the public on 15 December. The closing date is 9 March 2006.

18.2. Copies of the document are available here

18.3. The following comments would inform the consultation process:

_ Recognition of the problems of going out to consultation over a holiday period

_ The need to recognise local partners in assessing health services, this includes P&PIFs as well as HOSCs

_ The need for improved working relationships with stakeholders and a two way exchange of information

_ The need to use local intelligence to inform the assessment process, underpinned by clear and objective evaluation procedures

18.4. That the comments outlined above be reflected in the response to the Healthcare Commission.

18.5. That additional comments from members are directed to Denise Holden by 7 March.

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.

NB the list excludes:

1. Published works

2. Documents that disclose exempt or confidential information as defined in the Act.

File Location

None

Appendix One

Mid Hants PCT: Mental Health Residential Remodelling Group: Next Steps

I wrote to you in November 2005 outlining progress to date in the mental health remodelling project taking place in Mid Hampshire. I explained then that MHPCT and Hampshire County Council have agreed formally to pool existing investment supporting adults with severe mental health problems in 3 residential homes, protecting this level of funding for the current and for future clients.

The first part of the project entailed residents in Compton Road moving on to alternative accommodation. This property is now vacant. The residents have moved to a range of different types of accommodation according to their assessed needs. Some needed more intensive levels of support and have moved to nursing home placement, others have moved to more independent living. It is early days for people in their new homes and care staff are continuing to work with them to ensure that their needs are being met. The early indications are very positive: some people who have moved have already said how much they enjoy their living in their new homes. We will wait until we are sure that all the new placements are working well before finalising the cost of the supporting people in their new homes, but the early indication is that between 30% - 40% of funds supporting the original placements will be released to support new clients. This may equate to 70 - 80 extra hours per week of support for new and existing clients.

Achieving successful placements for these people has only been achieved and can only be maintained through a tremendous amount of hard work on the part of those caring for and supporting them - this includes staff in Hampshire Partnership Trust and Adult Services, advocates and support from relatives. Most importantly it means a great deal of courage and forbearance on the part of the individuals themselves. I am enormously grateful to everyone who is contributing to the ongoing success of the project, greatly reassured that people are settling well into their new homes, and delighted that we will now be able to support more people with similar needs.

We have an ongoing need to review how best to get the most out of available resources. A number of new issues have come to light that have encouraged the PCT to review the non recurrent resources currently invested in the 3 properties in order to release resources so as to:

· fund 4 additional units of supported living accommodation

· Improve the quality of the 8 residential placements in Winchester

· Contribute to the PCT's overall financial deficit by preventing the need for service reductions / helping to pay for the planned £500k investment in crisis resolution, assertive outreach and early intervention in psychosis.

The next stage of the project has therefore taken shape rather more quickly and in a different direction than originally anticipated. I am conscious that there may be some surprise at the current plans and wanted to set out for you the implications of our current proposals and what we hope will be achieved:

In summary the PCT is now proposing to revise the original plan to sell Compton Road, and instead to:

· Completely renovate Compton Road to provide high quality residential accommodation for 8 adults with severe mental health problems

· To buy, in addition, 4 new units of supported living accommodation for adults with severe mental health problems (of a type and at a location to be determined by the re-modelling group, taking advice from partners and stakeholders, particularly those in the housing field

· To use the residual funds to contribute to the PCT's deficit

In order to fund these plans we intend:

· Selling the remaining 8 bed Winchester based residential home in the current financial year, but with vacant possession not offered until March 2007. To achieve this we would probably need to plan on people moving by the end of October 2006.

· Encouraging residents and staff at the home to be involved in the new design for Compton in order to ensure it meets current and future needs

· Moving existing staff and residents (according to need) into Compton Road. (some of the residents are already assessed as needing move on to more independent living).

There are benefits to the individuals such as the greater proximity to town, being on a quieter road, having purpose built accommodation, and being able to move with their existing staff and house mates. I recognise however that there are also challenges to achieving this and we ensure that there is support for the individuals, their relatives and staff to ensure that the moves are as smooth as possible.

I also believe however that this is a very exciting development for the project as a whole: it is likely to release further funds to support new clients, it improved the residential accommodation and expands the availability of supported living accommodation. This will allow scope for creativity in determining what kind of units will best meet current and future need.

Appendix Two

NORTH HAMPSHIRE PRIMARY CARE TRUST

Report to: North Hampshire Primary Care Trust (NHPCT) Board meeting on Tuesday, 26^th November 2004

Subject: Reprovision of Older Persons' Residential Continuing Mental Health Care Service (Currently Homefield House)

Author: Jeremy Down, Service Improvement Manager (Mental Health)

Christina Sell, Partnership Manager

Purpose of report: To make members aware of the EMI Working Group's findings that the current service is no longer appropriate to meet the identified Continuing Mental Health Care needs of the local population;

To brief members on the recommendations for action arising from the EMI Group's Review and agreed in principle by the Head of Older People's Services HCC.

Recommendations: Members are asked to agree in principle the proposal for redesign and reprovision of this service and to the support a move to formal consultation on the proposals.

Resourcing Implications: It is proposed that the reprovision be delivered within existing investment levels.

The proposed course of action, "Option 4":

· Releases recurrent revenue funding (rising to £289k pa after Year 5) to support the development of specialist community and Day Hospital services;

· Delivers an estimated non-recurrent £313k cost saving in Year 1;

· Brings bed-based provision in line with Public Health projections of need.

I. 1. Summary

1.1 Homefield House is a 24-bedded registered nursing home on the Park Prewitt Estate originally established in 1997 as part of the Park Prewitt closure programme. It provides a mix of residential and respite care to older adults with "Continuing Care-type" organic mental health needs.

The reprovision of the Continuing Care-type resource currently provided at Homefield House was originally proposed in 2003 by the multi-agency EMI Working Group in response to concerns regarding excess capacity, low levels of clinical support and poor integration within the "whole system". It was also recognised, following a review by Older Persons' Mental Health Service that a significant minority (40%) of residents should, more appropriately be supported in a social-care nursing environment.

1.2 The paper considers appropriateness of the current service in terms of clinical and cost effectiveness and its ability to adapt to changes in the care needs of the individual service user and the nature of Continuing Care per se.

The paper outlines the findings of the EMI Working Group that the current reliance on a mid-sized residential provision, originally established to support the Park Prewitt closure programme:

· does not facilitate a recovery-focused care model;

· does not provide an appropriate environment for the management of such a wide scope of care needs (encompassing very challenging behaviours);

· is not flexible to meet changes in levels of demand;

· requires a disproportionate investment in non-clinical fixed costs and overheads

· prohibits investment in the development of specialist community and Day Hospital services.

1.3 A number of proposals for the restructuring and reprovision of Continuing Mental Health Care services for this care group are considered and a preferred option (Option 4) is recommended. This proposes:

· Development of a 12-bedded, recovery focused, consultant-led Continuing Care provision with Hampshire Partnership Trust's Older Persons' Mental Health Service;

· Reprovision of bed-based respite care within the Hampshire Nursing Home Strategy;

· Development of a specialist OPMH Day Hospital service;

· Expansion of specialist Community Psychiatric Nurse provision;

· On-going health-funding to ensure continued provision to those current Homefield residents who may not meet Continuing Care eligibility criteria.

1.4 The paper is written within the context of the Hampshire County Council and Hampshire Partnership NHS document, "Towards an Integrated Hampshire Health and Social Care Strategy for Older People with Mental Health Needs" which states:

" there is a recognition of the emphasis on closer working across all services for older people and strengthening partnership and inter-agency working to improve pathways of care.... and must therefore be the main thrust of local strategies."

2. History of Service

2.1 Homefield House is a 24 bedded EMI registered nursing home within the Park Prewett site provided by Shaw Homes Ltd It was commissioned by North & Mid Hampshire Health Authority Managed and opened in1997 to provide

"...a permanent residence for people in need of 24 hour nursing / residential care."

who were judged to be:

"incapable of managing or being managed in an alternative residential setting, despite efforts at treatment and rehabilitation".

The initial cohort of residents being former long-stay residents of Park Prewitt Hospital's Liss Ward

2.2 Homefield House was a new build development supported by a Sect 64 capital transfer to Shaw homes at a cost of £1.4 million. The capital agreement states that upon termination of the contract the property should be disposed of on the open market with the "Health Authority" having the first legal charge on the process or returned to the "Health Authority".

2.3 Revenue funding is provided principally via a Section 28a revenue transfer from North Hampshire PCT (worth £894,218 in 2004/5).

The Revenue agreement also allows for the recovery of a contribution from residents "...having reasonable regard to the relevant allowances available from time to time to residents from public sources." This provision, however, is subject to subsequent changes to Sec 117 Aftercare funding guidance and has been further reduced by the loss of Residential Allowance.

2. Nature of the Provision

2.1 The Revenue Agreement supporting the original Sec 28a transfer refers variously to the service as "continuing care" and "home with care". No formal definition of either is given and no statutory definitions are referenced, however. It is not apparent, therefore, whether the former phrase references formal "Continuing Care" as described within the Continuing Care protocol.

However, the view formed by the EMI Working Group was, that based upon custom & practice and consistent with the commissioning responsibilities of the PCT, Homefield as currently constituted should be considered primarily a health Continuing Care resource.

Access is via consultant referral from OPMH and, since January 2004, all referrals have required approval by the Continuing Care Panel as meeting the eligibility criteria for Category 1 care.

A. 2.2 Beds are housed in 4 groups of 6. 16 of the beds are in single rooms and the remaining 8 are provided in double rooms.

Whilst there is no designation of bed-type within the Revenue Agreement, the service has evolved to provide:

Short stay respite provision - 4 beds

Consultant-led "continuing care-type" provision - 10 beds

GP-led "discharge" provision - 10 beds

2.3 It should be noted that the Care Policy makes no reference to consultant involvement and that para. 5.05 of states:

"Medical support will be provided by a local General Practitioner..."

Although no explicit reference can be found, it is reasonable to assume that the need for consultant-led care arose appropriately in response to levels of demonstrated health care needs amongst some residents.

3. Current Residents

3.1 In 2003, a multi-disciplinary assessment of the 20 residents at Homefield employing the Continuing Care Toolkit found that, when graded in respect to the Mental Health domains, only 7 met the criteria for health Continuing Care.

Residents	Continuing Care Score (when assessed against Mental Health domains only)	Proposed Continuing Care Category
7	10/10	1 (Health Funded)
4	6/10	2 (Health / Social care)
9	< 2/10	3 (Social Care)

POA Services advised that upon admission all residents would have met Category 1 Criteria, but that the typical profile of dementia set against the progression of physical frailty in old age indicated that a gradual move through Cat 2 to Cat 3 was entirely typical and to be expected in the majority of cases.

3.2 The view of Parkland's clinicians is that at least 8 people of the present occupants of Homefield House, who are under the care of a GP rather than at Parkland's medical consultant, have never been formally advised that they may have to move out of Homefield at some time in the future. To ask them to do so would cause considerable distress to patients and carers, create ill feeling and probably result in legal challenges. Shaw Homes, who have an active carers group and close links with the Alzheimer's society, have supported the view of residents that they have a home for life which is free at the point of delivery.

3.3 Therefore 8 beds are used for patients who are cared for by a GP. According to a recent multi-disciplinary assessment they do not meet the criteria for continuing healthcare. Neither the patients themselves nor social services are paying for their care, they are funded by the original £850 grant. The patients are however claiming DHSS benefits and some are giving this to Shaw Homes to help to fund their care

3.3 12 beds are used for patients who remain under in-patient services and could be considered to meet continuing health care criteria. They require regular 6 month assessments to determine whether they still meet the continuing care criteria. We anticipate that 3-4 of these 12 patients no longer meet the continuing health care criteria.

3.4 The remaining 4 beds are informally identified as EMI health respite. However, it is generally understood that only 2 are required for people with continuing care needs and hence would require reprovision.

4 Service Issues

4.1 As a registered nursing home the home manger has a duty of care for all residents and as such feels that to accept some patients with challenging behaviour would pose some risk to residents. The view of Shaw is that these residents with challenging behaviour need staffing levels higher than that which than is currently funded

4.2. The home is made up of 4 separate 6 bedded bays connected by a wide and airy corridor. Although very attractive and spacious, the seclusion of each bay means that the home needs comparatively high staffing levels

4.3 The home does not provide care for people with functional mental illness such as schizophrenia. These patients are funded by the separate continuing care fund, overseen by a panel which covers the three PCTs in the north east of Hampshire, and are placed in a number of EMI nursing homes within and outside of Hampshire. There are problems with reviewing the patients who are placed out of county which result in difficulties in monitoring both quality and cost of care.

5. Funding Issues

Continuing Care Funding

5.1 Normally, in order to decide who should legally fund care, based on a multi-disciplinary assessment, a panel will determine whether patients:

a) wholly meet continuing care criteria and should therefore wholly be funded by health - Category 1 Continuing care

b) partly meet continuing care criteria and should therefore partly be funded by health or - Category 2 Continuing care

c) do not meet continuing care criteria and therefore required either to fund their own accommodation and social care or to be funded by the local authority.

5.1.1 The situation in Homefield is complex as until recently access to Homefield has not been via the continuing health care panel referred to above. However , the patients' needs prior to admission to Homefield are discussed with a multi-disciplinary team, who agree whether or not their needs are at a level which meets continuing care criteria. The difference is that this assessment does not give the legal protection required to ensure that patients do not fund their own care. As a result of this, up until very recently all clients were supported via section 28 monies.

5.1.2 Following an assessment in Parklands by a multi-disciplinary team, if the patient seemed to no longer need the input of the medical consultant it was deemed that they did not meet continuing health care criteria and were discharged to the care of a G.P. but remained resident in Homefield House.

5.1.3 Although a social worker may have been present at the team meeting, no formal care management procedures were routinely involved in following up the redesignation of the patients' continuing care status. The impact of this was that no agreement had been reached with social services that funding for their care would no longer be provided by health.

1. 5.2 Revenue Funding & Residents Contribution

5.2.1 The service was established as a "deficit funding scheme" supporting the provision of community care placements within the non-statutory sector. Section 28a powers were employed in accordance with HSG(92)43 to transfer such funding direct to "voluntary sector" care providers.

This protected service users' status as "discharged" and allowed them to access social care benefits and residential allowance. It also allowed for the care provider to seek a contribution from residents towards the cost of care.

5.2.2 In 1997, Residents' fees accounted for 5% of revenue funding. By 2004/5 this had fallen to 2.3%.

5.2.3 This reduction in available funding was due to three factors:

a) The change in clinical management arrangements for some beds.

Initially all patients were under GP-led care and deemed to be discharged. At some point this changed and new residents remained under consultant-led care. Where residents have not been discharged from an episode of consultant-led care they can not be required to contribute to their care.

b) Guidance Concerning Sec 117 After Care Orders

Whilst NHS Guidelines on the use of Sec28a powers (HSG(92)43) , legitimise the contribution by service users to the costs of provision of "health-related services", this can not be applied to users subject to a Sec 117 Aftercare Order (LGO Special Report- "Advice & Guidance on the Funding of Aftercare under Sec117 of the MHA").

c) The Loss of Residential Allowance

In 2003/4 the Benefits Agency withdrew provision of Residential allowance. In calculating the impact of this the Benefits Agency did not make specific provision for residents of services supported primarily through health monies. Subsequent grant funding made available to Local Authorities does not appear, therefore, to have taken account of this deficit.

5.3 Capital Funding

5.3.1 Shaw Homes have been required by the National Care Standards Commission to make adaptations and renovations estimated at approximately £98k over the next three years.

5.3.2 Shaw Homes have not previously operated a sinking fund or allowed for depreciation of capital items. Consequently, the capital programme is unfunded.

6. Current Concerns re. Homefield Arrangements

6.1 In accordance with NCSC regulations, all admissions must be agreed by the Home Manager. Increasingly, however, the Homefield manager has been reluctant or unable to admit patients with more challenging needs. Shaw state that more funding is required to increase the staffing and skill levels to meet requirements for caring for people who need continuing health care.

6.2. The criteria for continuing health care remain vague and interpretations are likely to change in the future. The possibility remains that in the future there may be an increase in the number of joint funded packages.

6.3. Homefield House does not meet the needs of the more challenging patients with organic mental illness that require continuing health care. Such patients currently either occupy acute beds or care is spot purchased in individual EMI nursing homes.

This group of people with challenging behaviour who meet the criteria for continuing health care is relatively small and the individual people will differ over a period of time. They will require more intensive medical and nursing support and will always be hard to place in the independent sector.

6.4. The 8 people who currently occupy GP-led beds ("discharged residents") are felt to be appropriately provided for within the Homefield service as currently configured. They do not meet the criteria for heath funded provision, do not exhibit challenging behaviour and require a level of care that would ordinarily be commissioned by the Local Authority or self funded.

However, these individuals were not included in the recent review of nursing home capacity and therefore present demand which has neither planned nor budgeted for by Social Services.

6.5. As stated in the terms of admission to Homefield, the "discharges residents" are only required to make a contribution equal to their welfare benefits towards their care. There is a view that legal action could be taken by both the local authority and the families of the residents themselves if any changes in funding liability was to be taken at this stage.

6.6. Although they do not meet continuing care criteria, the "discharged residents" have been resident at Homefield for a considerable period of time and the PCT would not wish to distress patients by requesting that they move out of Homefield. Historical experience has highlighted that unnecessary moves for this client group are detrimental to their health and well being. None of the stakeholders would support a move unless supported by clinical need.

6.7. The cost of a bed at Homefield House is considerably above social services fee ceiling. (approx £760 per compared with £398 plus free nursing care.)

7. Current Demand

7.1. Capacity is always difficult to accurately predict, but based on public health data, current uptake of service and with reference to current waiting lists, the following capacity requirements for people with organic mental health illness has been agreed:

· 6 beds for people with challenging behaviour who meet continuing care criteria

· 6 ordinary continuing care beds

· additional CPN x 1 plus 2-4 respite beds and day care provision

7.2 It should be noted that this refers specifically to organic mental illness. Continuing Care patients with functional mental illness are supported through specialist placements commissioned on a spot-purchase basis.

8. Organisational Perspectives

In August 2004, a meeting between Gill Duncan, the then-CEO of NHPCT and Andrew Brooker, Head of Older Persons Services agreed that in the case of Homefield House being reproved the following principles should apply:

a) health should seek to reprovide at least the equivalent level of service for this client group;

b) but that changes in the understanding of care for this client group mean that a reliance on bed based care is longer appropriate. Resources should be available for reinvestment into alternative care such as community based services, level of provision should be flexible and dictated by assessment of local heath need not historical precedent.

c) It is an established principle that patients may be discharged from continuing care. If a multi -disciplinary team agrees that the patient no longer meets the Continuing Care criteria then that individual may be discharged with future care supported by the appropriate funding authority.

d) However, current residents should not be disadvantaged as a result of changes to commissioning practice. Accordingly, for those Homefield House residents currently occupying GP-led beds supported via the Section 28a grant, Health would make specific provision to support their on-going care on a dowry basis. This does not prohibit the recovery of a contribution towards care from residents.

e) it is not reasonable to require current residents to move to another home once their disease has progressed to a stage where they no longer meet the continuing health criteria, unless they have been previously advised that this would be the case.

9. Options for Reprovision

9.1. Option 1 - "Do Nothing"

(detailed costs shown in appendix 1

Current commissioned provision remains the same either with Shaw Homes or retendered with alternative provider organisation.

Headline Revenue Implications

9.2. Option 2 - Mixed Economy at Homefield / Joint Commissioning

Detailed costs shown in appendix 2.

Mixed economy with Social Services and Health commissioned beds.

Social services would commission the 8 "GP-led" beds as residents were as discharged from consultant-led Continuing Care provision.

Health funding released by disinvestment in GP-led beds reinvested to provide enhanced nursing staff at Homefield to a level appropriate to support high level Continuing Care needs.

Headline Revenue Implications

9.3 Option 3 - Partial Reprovision

(Detailed costs shown in appendix 3)

Retain Homefield contract, but reduce number of Health commissioned beds to 12 (6 "low need" Continuing Care, 4 Respite);

Reprovide 6 "high need" Continuing Care beds within Hampshire Partnership Trust's OPMH service;

Social services to commission the 8 "GP-led" beds as residents are discharged from consultant-led Continuing Care provision;

Remaining 6 beds at Homefield to be privately funded

Cost of reprovision of 6 beds in Parklands = £300k revenue costs plus £140 capital costs

9.4 Option 4 - Full Reprovision

(Detailed costings are in appendix 4)

Terminate commissioning agreement with Shaw Homes and, pursue sale of Homefield as a registered nursing home. (Hampshire Partnership Trust to manage home in the period between end of contract with Shaw and sale of home).

Retain Health investment supporting existing 8 residents in GP-led beds in situ.

Reprovide 12 Continuing Care beds (flexible mix of high & low need) within HPT's OPMH service.

Reprovide 3 respite beds within the Oakridge contract,

Enhance specialist community provision through appointment of new CPN post and development of Day Hospital provision.

Benefits

The capital release from the sale is anticipated to be approximately £1.4 million.

Current "over-spend" on additional nursing fees (approx £313k) would be removed.

PCT would have a financial commitment of £216.5k within Year 1 in support of the 8 "discharged" residents (£192.1k with Residents Contribution netted off). It is anticipated that this would reduce over 4 years.

Recurrent funding of £608k would be required to support the reprovision of services and enhancement of CPN resource:

· 12 beds in Parklands @ annual revenue costs of £500k

· CPN post @ £38k

· 3 respite beds @ total cost of £70k

This would release funding of £58.8k in Year 1, rising to a recurrent value of £251.0k by Year 5 for reinvestment in additional services and development of Day Hospital provision.

Headline Revenue Implications

10. Conclusion & Recommendations

10.1 The current provision was commissioned in response to a specific and time limited strategic aim - that of supporting the Park Prewitt closure programme. It was designed to meet the specific needs of a known group of individuals and, consequently, is neither dynamic nor flexible enough to adapt to the changing care needs of the population over time.

The service is constrained by the physical layout of the building, skill mix amongst staff, organisational boundaries to integration, funding restrictions and statutory regulations from providing a comprehensive provision appropriate to the broad scope of care needs associated with this care group.

These issues can not be solved merely by the investment of additional resources.

10.2 The nature and size of the current provision gives rise to disproportionately high unit costs and consequently represents poor utilisation of public funds. This restricts the PCT's ability to maximise effective commissioning by "tying-in" health funding that could otherwise be employed flexibly.

10.3 Implementation of a dynamic recovery focused Continuing Care model is hindered by current service gaps such as the lack of specialist Day Hospital provision and inadequate levels of CPN provision.

10.4 Option 4 allows the opportunity to redesign local service provision in such a way that it can adequately and appropriately meet the diverse care profile currently experienced across a broad and growing care group, and remain sufficiently flexible to adapt to further changes in need and levels of demand.

This can be delivered within existing resource limits and will positively enhance the care received by existing service users, deliver an integrated and expanded local Continuing Care service, limit risk within the Health Economy by reducing the reliance on spot-purchased care and make available additional nursing home capacity with North Hampshire.

10.5 Members are asked to agree Option 4 as the preferred way forward and authorise a move to public consultation and preliminary exit negotiations with Shaw Homes.

Appendix Three