Archived decisions

Contact: Nick Georgiou 01962 847211 [email protected]

1. Summary

1.1 This business case explains the rationale for creating 3.5 new posts to improve services to clients from the Children's Department and OP, LD and PD services. In addition to service improvements, significant savings to the Council are expected to accrue as a result of creating these posts and they will all become self-funding in less than 3 years.

1.2 Of these posts 1.5 fte will be Senior Nurses who will work with elderly people in our in-house homes and in the Independent Sector. The remaining 2 posts will provide an enhanced transition service for young people aged 14-25 years moving from Children's to Adult Services.

1.3 The role of the Senior Nurse posts is to ensure that clients receive their full entitlement to NHS Continuing Health Care funding and status whilst at the same time ensuring that Adult Services only provides services that are within its legal framework. The full time nurse will work within the Independent Nursing Home sector and the half time Nurse will support the ENHANCE homes. Gross savings to the Department of up to £200k per annum are anticipated. This proposal is explained in more detail in section 2.

1.4 The remaining two posts will work to develop person-centred and cost-effective care solutions for the young people with disabilities, typically numbering 50-100, who each year move over from Children's to Adult Services. The majority of these young people have a learning disability, although some do move to be supported in the physical disability and mental health sectors. Many are in receipt of a high cost placement at the time of transfer to the extent that the combined part and full year effect of transition of any single year's cohort on Adult Services budget typically ranges from £2.0 to £2.5 million pounds. A projected gross saving in Adult Services, made up of income and reduced expenditure of up to £300k per annum by year 4 is anticipated, following recruitment to these 2 posts.

1.5 This proposal has been jointly developed across Adult and Children's Services and has the support of both Departments' DMTs. Other savings are also anticipated for Children's Services but as yet these cannot be costed. This proposal is explained in more detail in section 3.

1.6 These investments will support the Corporate Priorities of Maximising Well Being and Hampshire Safer and Secure for All by providing the capacity to develop person-centred and cost effective solutions for young people coming through transition and by ensuring that clients receive their full entitlement to Continuing Health Care.

2. Recommendations

The following decisions are sought:

a) Approval is given for £0.063m of the Corporate `Invest to Save' Fund to be allocated to fund 1.5 posts to support the Continuing Health Care application process ensuring clients receive their full entitlement to Health funding, which will reduce Adult Services spending.

b) Approval is given for £0.076m of the Corporate `Invest to Save' Fund to be allocated to fund 2 posts to provide an enhanced service for young people in transition which will deliver efficiencies through better value for money placements.

3. The Invest to Save Proposals

3.1 Proposal for an additional 1.5 fte Senior Nurse posts

3.1.1 The Department of Health has recently released guidance regarding the New National Framework for Continuing Health Care (CHC) that came into force on 1st October 2007. This guidance states that all clients need to be considered for their eligibility for a full CHC assessment.

3.1.2 It is expected that many more people will be eligible for fully funded health care using the new guidance. HCC have large numbers of clients currently within the Independent Nursing Home Sector that should be reassessed for eligibility for CHC. The assessment process is long and complex and as a result local managers do not always have the capacity to pursue these cases to a successful conclusion.

3.1.3 The Department of Health has also recently made changes to the levels of RNCC that the PCT makes for all clients requiring Nursing accommodation.

3.1.4 As a result of this it will be necessary to assess many of our clients who are currently on a high band RNCC against the new criteria, to ensure that their needs are reassessed for full CHC funding.

3.1.5 There are currently approximately 100 clients receiving high band RNCC within the Independent Sector. One of the new posts will focus on the In-House sector and this will enable the reassessment of these clients to ensure that the Council is not purchasing care that should be the responsibility of the PCT.

3.1.6 The evidence from a recent pilot where some Nursing resources were diverted into the ENHANCE homes indicated that a substantial return in terms of successful CHC applications could be gained from investment in dedicated resources. However, the pilot cannot continue due to resource constraints. This pilot demonstrated that specialist knowledge and dedicated resources were required to achieve the desired outcome for the client and for HCC.

3.1.7 The proposal is to appoint 1.5 full time equivalent senior nurses who will work across Adult Service care groups (learning disability, mental health, older people and physical disability) - in-house and independent sector - to co-ordinate an approach to CHC and ensure applications are made. These posts would be based within the commissioning team but work alongside care management, in-house nursing staff and the Independent sector to achieve the best results.

3.2 Proposal for 2 fte posts to provide an enhanced transition service

3.2.1 In 2003, a procedure (29/03) provided guidance for the then Social Services Department to enable a smooth assumption of responsibility by adult teams for the ongoing care of young people moving into adulthood. The 7 PCTs in Hampshire agreed to the values and principles and it was supported by the Learning Disabilities Partnership Board. The Department invested resources in Transition Social Workers (TSWs), based in each of the Adult Learning Disability Teams.

3.2.2 The role of the TSW was designed to cover four main areas of work:

· To ensure the financial information regarding young people transferring to Adult Services is accurate and gathered well in advance

· To ensure that the needs of young people are adequately met through service development

· To ensure that communication is developed between Children's Services, Adult Services, young people and their carers so that everybody is involved and informed of the transition plan.

· To concentrate on the most complex cases of young people in transition.

3.2.3 However, to date with the TSWs posts reporting to 7 different line managers' differential practice has developed and this post will tighten up their management and focus, which will contribute to improved quality and financial performance.

3.2.4 Whilst the full benefits are shown below the overarching benefit of this proposal would be to enable the coordination and clearer management and direction of the TSWs to work as a specialist county team, reporting to a Transition Team Manager. This would be a newly created post within the Learning Disability service.

3.2.5 The TSWs will remain based within the 7 Adult Services Learning Disability teams as at present, and will form part of the future integrated teams with health enabling them to retain strong local links and within the local learning disability service. Their direct managerial report will be to the proposed Transition Team Manager. They would meet regularly as a team to discuss operational and strategic issues that span the transition process. One of the Learning Disability Area Service Managers would take a lead for transition and manage the Team Manager post. Strong links to Commissioning will be developed

3.2.6 The Transition Team Manager and team will have strong links with Children's Services, in particular with the Children with Disabilities teams with whom they will work closely, giving support when considering placement and service options for children approaching the age of transition. The TSW team will not hold cases but will be involved in discussions and decisions, to include families and children, from the age of 14 in order to anticipate and plan for non-residential care options to the greatest degree possible to promote independence and effective service delivery.

3.2.7 The second proposed post would be a Commissioning Officer post managed by the Commissioning Manager with a lead for Continuing Healthcare in Adult Services that will focus on children and young people in transition. The post would be dedicated to working with children and young people in transition supporting both Children and Adult services, but this post can also be expected to work with younger children with complex needs.

3.2.8 Having a post dedicated to Continuing Healthcare for children will mean that the County Council does not exceed its statutory responsibilities and should achieve additional income that will offset expenditure that would otherwise have been incurred in Children's Services, and also offset expenditure in Adult Services when the young person transfers to these services.

3.2.9 This post would complement the care management for young people in transition by ensuring consistent and early applications to PCTs for Continuing Healthcare funding for children and young people.

4 Benefits of the Investment

4.1 Investment in 1.5 Senior Nurse Posts

· Financial savings for Adult Services by early intervention on CHC issues

· Clients receive their due CHC status and funding

· The benefit of expertise in progressing CHC cases.

· Links to Department of Health regards policy guidance and legislation.

· Applications for CHC funding made in a timely fashion, thereby producing better outcomes individuals and their families

· Post holders will join existing Adult Services commissioning team but maintain current line management for professional development.

4.2 Investment in Transition Team Manager and Commissioning Office will deliver the following operational benefits:

· Better quality outcomes for young people and their families before, during and after the transition process

· Increase skills and knowledge in a dedicated team for the benefit of service users and their families

· Streamline processes and care pathways

· Staff used more flexibly across the service to meet variable demands

· Collection of accurate data around the numbers of young people in transition across Hampshire (currently underway but needs to be collected annually)

· The ability to predict trends and identify needs much earlier, so as to inform commissioning plans

· Effective liaison with other organisations involved with the young people in transition (e.g. Health providers, Education, Employers, Provider services, PCTs)

· Involve and engage young people and their families/carers in Person Centred Planning

· Capture financial information for Adult Services

· By working as a countywide team , to identify commissioning needs and work with commissioning colleagues to develop bespoke services to meet gaps in the market as cost-effective alternatives to traditional solutions

· With commissioning colleagues to develop innovative and inclusive solutions to meeting needs of young people e.g. through use of Direct Payments, self directed support and non institutional solutions to accommodation needs and reduce the use of residential care

· Jointly commission with Children's Services to better manage the market and agree costs.

· Achieve cost benefits to both Adult and Children Services through robustly managing costs in the transition period

· Identify where NHS Continuing Healthcare for children and young people in transition should be applied for and ensuring this happens

5. Financial Benefits

5.1 The following table summarises the financial benefit of the 1.5 Senior Nurses

Cost Benefit Analysis - 1.5 Senior Nurses
Year	1	2	3	4
	08/09	09/10	10/11	11/12
	£'000	£'000	£'000	£'000
Staff Costs	63	84	84	84
Savings	-25	-100	-150	-200
Net	38	-16	-66	-116
Cumulative	38	22	-44	-160

Notes to Cost Benefit Analysis:

1. Assumes staff are all in place by 1^st August 2008

2. On the basis of the above payback of the £63k investment will be achieved by the end of year 3

3. For Year 1 there will be a three month start-up period. Savings will then accrue throughout the second half of the financial year.


5.2 The following table summarises the financial benefit of the 2 posts within the Transition service

Cost Benefit Analysis Summary - Commissioning Staff
Year	1	2	3	4
	08/09	09/10	10/11	11/12
	£'000	£'000	£'000	£'000
Staff Costs
Transition Team Manager	38	50	50	50
Continuing Care Commissioning Officer	38	50	50	50
Savings
Adult Services:
Continuing Care Income	-25	-125	-175	-250
Procurement Savings	-3	-20	-40	-50
Net Total	48	-45	-115	-200
Cumulative	48	3	-112	-312

Notes to Cost Benefit Analysis:

1. Assumes staff are all in place by 1^st August 2008

2. On the basis of the above payback of the £76k investment will be achieved at the start of Year 3

3. Does not include any potential savings from Children's Services

4. For Year 1 there will be a three month start-up period. Savings will then accrue throughout the second half of the financial year.

6. Management and Accommodation

6.1 The additional post for the Transition Team Manager will require office space and administrative support at a suitable location. This will be taken into account in the project for integration of Learning Disability community teams when planning co-location of staff or new bases.

6.2 Management support for this post will be provided by one of the operational Learning Disability Area Service Managers who will take the lead for transition.

6.3 The post of Commissioning Officer for Continuing Healthcare (Children) will be accommodated with Adult Services colleagues at Trafalgar House Winchester and line managed by the Commissioning Manager (Adults) with the lead for Continuing Healthcare

6.4 Line management for the 1.5 Senior Nurse positions will be provided by the Commissioning Manager (CHC) with professional support provided by the Nurse Advisor based in the nursing and residential sector. Accommodation will need to be within Trafalgar House and the ENHANCE Sector. Administrative support will need to be identified.

7 Risks: possible issues that may affect success and how they will be managed

7.1 Recruitment to any of the posts is not successful and possible in-house alternatives e.g. secondments may need to be considered.

7.2 In respect of the enhanced transition service, retention of current TSWs through change may be an issue . This will be managed by involving them in planning future team role, changes to working patterns etc and through supervision and IPP.

7.3 It is expected that the PCT will fully comply with the guidance but there is a risk that the application process for Continuing Healthcare will be slower than forecast. Ongoing dialogue is being maintained with the PCT regarding the implementation of this guidance.

8. Conclusion

8.1 The investment in an enhanced Transition service will enable the County to better implement the policies laid out in `Valuing People' and other guidance, offering rights, independence, choice and inclusion.

8.2 There will be greater satisfaction for service users by enabling individualised solutions.

8.3 The Transition Team will be an expert service that is visible and easily identifiable for the service user's families and stakeholders to access

8.4 Advance planning will enable proactive solutions for individuals that are needs led rather than resource led, avoiding short term crisis solutions, and the County Council will be able to make the best use of resources and take a proactive approach to commissioning for young people as they enter adulthood.

8.5 The success of the approach taken in Adult Services towards applications for NHS Continuing Healthcare funding will be built on and extended into Children's Services.

8.6 In respect of the proposal to create 1.5 Senior Nurse posts, the new guidance allows us the opportunity to assess for CHC all client groups especially those who have been compromised by nature of their disability within previous DH guidance i.e. Learning Disabilities.

8.7 HCC will not provide services for people who should be the responsibility of Health and as such will not provide services that are deemed unlawful. Service users and their carers will not be charged for services that should be fully funded by Health.

8.9 In general terms, all the proposed posts will increase skills and knowledge for the benefit of service users and their families; they will allow processes and care pathways to be streamlined; they will enable staff to be used flexibly across the service to meet variable demands; they will enable accurate data to be collected; they will enhance our ability to predict trends and identify needs much earlier, so as to inform commissioning plans and they will capture financial information for Adult Services to evidence successful implementation.

Section 100 D - Local Government Act 1972 - background documents

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

NB: the list excludes:

1. Published works

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

NONE