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                      APPENDIX C

Hampshire Primary Care Trust and Hampshire County Council

Joint Hampshire Commissioning Strategy for Older People's Mental Health

2008 - 2013

Executive Summary

Working in partnership with:

Executive Summary

The scale of the challenges facing Hampshire Primary Care Trust and Hampshire County Council Adult Services, in terms of population changes, growing demand for older people's mental health services and pressure on resources, means that we have to do things differently now. This strategy sets a direction of travel for 2008 - 2013 for all organisations and individuals involved in older people's mental health services that reflects national good practice guidance and that we believe will improve outcomes for older people with mental health problems and their carers.

In this Executive Summary we have proposed some early key areas to focus upon. The full draft strategy contains an overview of everything to be considered.

Why this is important

Depression severe enough to warrant intervention affects one in four older people living in the community. But only one in three of these will discuss the condition with their GP and only one half of those are diagnosed and treated.

Only a third to a half of older people with dementia receive a diagnosis.

Older People with a mental health need account for a significant proportion of those who use health and social care services. A conservative estimate is that:

    · 40% of people attending their GP

    · 50% of all general hospital inpatients and

    · 60% of home care residents have a mental health problem.

One third of people who care for an older person with dementia have depression.

Older people occupy two thirds of hospital beds and 60% of these will have or will develop a mental disorder during their admission. The presence of mental health needs is an independent predictor of poor outcomes for the individual affected.

The direct costs of dementia (Alzheimer's Disease) alone exceed the total costs of stroke, cancer and heart disease in cost of illness studies.

There is a growing demand

Nationally, the number of older people with mental health needs will increase by 30% over the next 15 years.

In Hampshire, significant demographic changes and growth in the population of older people are anticipated over the period of this strategy - 2008 - 2013:

    · 16% increase in older people with depression - around 5,500 additional people

    · 15% increase in older people with dementia - around 3,000 additional people.

If there is no change to the way we currently deliver services, we will not be able to cope with this growing demand. The increase in funding allocated by the government for 2008 - 2011 to both Hampshire Primary Care Trust and Hampshire County Council will be consumed in meeting this increase in demand, unless we plan jointly to manage our current investment and resources more efficiently and maximise opportunities for older people's mental health.

The benefits of changing how services are delivered

By developing this strategy, we believe there will be improvements to the quality of life for both the older person with mental health needs and their carer.

Effective interventions will promote independence and inclusion in society.

Early diagnosis and treatment and no artificial barriers to access services in a mainstream or specialist mental health setting will enable:

    · a coordinated response to complex needs

    · planning to avoid crises and unnecessary admissions to hospital that can lead to increased dependency

    · access to effective specialist mental health services.

Resources

We have assessed the current level of resources spent on older people's mental health services by Hampshire Primary Care Trust and Hampshire County Council Adult Services - see table below. This is an under-estimate and does not reflect all the associated costs linked to the care needs of older people with mental health problems, particularly in hospital where an individual may be treated for another illness.

Table: Expenditure on Older People's Mental Health Services

 

£000

Assumptions

Hampshire Primary Care Trust

29,000

Includes only specialist mental health providers, continuing NHS healthcare and joint finance budgets for 2007/08. Excludes acute and community/primary care spend.

Hampshire County Council Adult Services

51,500

Based on 2006/07 budgets, net of income and excluding management and support overheads and assumption that 50% of the older people's budget is spent on clients with mental health needs.

Current services - strengths and gaps

We have identified the strengths in our local health and social care provision for older people with mental health needs, for example specialist mental health services are generally well thought of, there are some excellent and innovative services in operation across Hampshire and there is a willingness to work collaboratively across agencies and sectors.

From the work we have done in mapping health and social care provision and in listening to staff from many agencies and to people with mental health problems and their carers, we know that there is variation across the county and that:

    · Information and support is patchy and uncoordinated

    · Accessing meaningful and stimulating things to do is difficult

    · Statutory services are tightly targeted

    · Access to respite care and the quality of care provided is variable

    · Knowledge and skills about the needs of older people with mental health problems amongst mainstream non-specialist mental health staff is poor

    · There is a lack of support in understanding and coping with behaviours that challenge

    · Accessing specialist assessment and treatment in some general and community hospital settings is difficult

    · There are issues about decisions about long-term care placement being made too early in the discharge process from hospital

    · Access to some services is based on age not need

    · Mainstream community services cannot always meet the needs of a person with mental health problems

    · There are issues around support provided in a crisis

    · There are difficulties with flexibility and continuity of provision

    · Organisational boundaries can limit the ability to work together.

What we are trying to achieve

We are aiming to secure services that deliver:

    · holistic, person-centred health and social care, which address mental, as well as physical health, needs and which provide dignity and respect

    · flexibility and are able to change in line with people's unique circumstances, enabling independence and choice

    · a comprehensive specialist older people's mental health service as part of a fully integrated pathway of care

    · promotion of equity of access to services and support based on individual and population needs

    · treatment and care based on the best available evidence of effectiveness.  

Our early commissioning priorities

We have produced our early commissioning priorities based on:

    · the needs led care pathways for dementia and functional mental illness (i.e. depression, anxiety and psychotic disorders) that have been developed as part of this strategy, which take a holistic approach to an individual's needs

    · the identified gaps in services

    · what people who use services, their carers and professionals have told us.

Hampshire Primary Care Trust and Hampshire County Council Adult Services have identified five key strategic priorities, which target the areas that most need our attention:

      1. Supporting carers

      2. Promoting independence and access to universal well-being services

      3. Balancing specialist and generic services

      4. Pathways in and out of hospital

      5. Mechanisms to enable organisations and individuals to work together towards shared goals.

Strategic Priority 1. Supporting carers - so that that they themselves are enabled to provide care and support and are actively involved in planning care for the older person with mental health needs.

What we have been told about why this is important:

"Groups like this [a carers support group] are great because we can support one another and share our thoughts and worries. Couldn't we have more things like this?"

"I get so tired and really do need my respite, but she gets so distressed and seems to go down hill before I can get her home again. It takes me another two weeks to get her back to her old self and by then I'm exhausted again".

"At 3 o'clock in the morning when I can't get him settled, who do I call? Why is there no support at the weekend?"

Proposed Actions

Responsible organisation

Work to commence

With the support of the Carers' Stakeholder Group and the Care Services Improvement Partnership, we will work closely with carers, users and the voluntary sector to develop specific information resources about available community based support.

HCCAS and HPCT

2008/09

The contact centre for all social care referrals will be established, which will provide a one-stop shop for advice and information.

HCCAS

2008/09

We will develop a flexible specification for new emergency respite services linked to the Hampshire Carers' Strategy work, which also includes the review of current respite availability and service models and will identify options for the future.

HCCAS

2008/09

We will aim to support older people with mental health problems and their carers to understand and take their medication.

HPCT

2008/09

Key: HCCAS - Hampshire County Council Adult Services HPCT - Hampshire Primary Care Trust

Strategic Priority 2. Prevention and access to universal well-being services - so that individuals can maintain their independence and live as "normal" a life as possible for as long as possible.

What we have been told about why this is important:

"I get confused and can't remember the way to places - I sometimes think it'd be good to have a befriender like. Someone to help me do the things I enjoy. I've never been any good in groups and could do with the company".

"I really couldn't cope without day care. It's my life line"

Proposed Actions

Responsible organisation

Work to commence

The Hampshire Older People's Well-being Strategy is being produced and local well-being plans developed in a number of areas around the county. Specific programmes such as the older person's area link worker project and the gardening strategy are underway. The well-being programmes will continue to expand to support older people's mental health.

Hampshire County Council

2007/08

People will be encouraged and enabled to continue accessing and pursuing universal services for their usual activities and hobbies, for example, the local choir, gardening clubs, the Women's Institute.

HCCAS

2008/09

The Community Innovations Teams will be expanded to include Community Development Workers, who will be employed by local Councils for Voluntary Services using the Invest-to-Save grant.

HCCAS

2008/09

In partnership with colleagues in district councils and the Housing Corporation, Hampshire County Council will commission a new generation of housing care and support services for older people that will be appropriate for older people with mental health needs. The first four schemes are already being planned.

HCCAS

2008/09

We will seek to promote awareness amongst the general public and professionals in all settings about dementia and depression in old age and messages about maintaining good health. We will build on the higher profile gained through consultation on this strategy to assess current activities, information campaigns, training and education available and develop a local plan.

HCCAS and

HPCT

2008/09

Hampshire county Council has been chosen, along with nine other local authorities in the country, to take part in a project to determine how people who need support can take more control of their own lives and how their care and support needs can be responded to in more varied and flexible ways. This is called Self-Directed Support.

We are currently working together with others, such as service users and service providers, to develop a project plan that will detail how Self-Directed Support will be implemented across Hampshire.

HCCAS

2007 onwards

Key: HCCAS - Hampshire County Council Adult Services HPCT - Hampshire Primary Care Trust

Strategic Priority 3. Balancing specialist and generic services - through skilling up mainstream staff, removing barriers to services and gaining clarity on the respective roles and functions of specialist mental health and mainstream services, so that the majority of mild and moderate severity mental health needs can be managed in mainstream settings.

What we have been told about why this is important:

"I've been using adult mental health services for 14 years, my Community Psychiatric Nurse wants to refer me to the older people's mental health team, but if that happens I'll have to start using a completely different set of services. I'm not ready to sit around making cards!"

"`These young girls come in, a different one every day. They don't understand Dementia at all. I feel sorry for them really - they don't get paid a lot and only have 15 minutes to put Dad to bed. It's no good telling someone to take their trousers off when they can't remember what the word means."

Proposed Actions

Responsible organisation

Work to commence

A joint Hampshire Primary Care Trust and Hampshire County Council primary care mental health strategy is being developed, which aims to enable the primary and community care team to provide improved support for those with mild to moderate mental illness.

HPCT and HCCAS

2007/08

The current guidelines and pathways for referral and initial assessment will be reviewed jointly between mainstream and specialist mental health clinicians, so that trigger symptoms can be consistently recognised and community-based support resources can be more easily accessed.

HPCT

2008/09

We will work towards developing a specification for memory services to provide: early diagnosis, specialist assessment, information and support, memory matters that will be available in all areas. Day hospital provision within Hampshire Partnership NHS Trust will be remodelled to maximise linkages with memory assessment and treatment services and improve the therapeutic basis with clear outcome based programmes.

HPCT

2007/08 -

Day Hospitals

As part of the Hampshire strategy for day opportunities, we will develop a specification for day opportunities specifically targeted at specialist dementia care.

HCCAS

2008/09

We will work towards developing a broad training strategy for health, social care, voluntary and independent sectors to support all phases of dementia and functional mental illness pathways, linking with the Sector Skills Councils

HCCAS and HPCT

2008/09

We will develop a service specification to define the social care team deliverables for older people with mental health needs through:

    · a generic social care rapid response function via a single point of access

    · community social care support teams working with generic primary care teams and specialists who support long term conditions, including specialist older people's mental health teams.

The pilot sites for integrated social care and specialist mental health working will continue to be introduced, initially through a staged approach in two sites: New Forest and Andover.

HCC

2008/09

We will seek to promote equity of access based on individual and population needs and based on the best available evidence of effectiveness to:

    - the whole range of mental health services across working age and older people's services for people with a functional mental illness (i.e. depression, anxiety and psychotic disorders)

    - all current generic older people's community support services.

HPCT and HCCAS

2008/09

We will make sure that older people with mental health needs are included in the work of the Care at the End of Life Hampshire Health Overview and Scrutiny Committee Review Project. Care plans for older people with mental health needs at the end of life will be available to out of hours services to avoid unnecessary hospital admissions.

HPCT and HCCAS

2007/08

Key: HCCAS - Hampshire County Council Adult Services HPCT - Hampshire Primary Care Trust

Strategic Priority 4. Pathways in and out of hospital - so unnecessary admissions are avoided and the older person with mental health needs receives timely and appropriate care in response to their individual needs while in hospital and the focus is on maintaining independence on discharge.

What we have been told about why this is important:

"He went into hospital with a chest infection and now he can't walk. They didn't feed him and left him to wet the bed on more than one occasion. I'm frightened he'll have to go into a home when he comes out."

Proposed Actions

Responsible organisation

Work to commence

Working with our NHS partners, we will review the discharge pathway for older people with mental health needs, including options for longer periods of assessment, recovery and rehabilitation that allow the individual and their family and carers to make timely and informed decisions about future long-term care. The aim will be to reduce the length of stay in hospital and strengthen links between primary care and acute and community hospitals.

HCCAS and HPCT

2007/08

We will aim to develop a service specification for delivering psychiatric liaison in acute and community hospitals, based on good practice, which will reflect the needs led care pathways and address the identified key areas for attention.

HPCT

2008/09

    We will undertake a "Balance of Care" project* approach across Hampshire to identify the costs of unnecessary bed usage in acute and community hospitals, specialist mental health inpatient services, residential and nursing homes and to identify appropriate alternatives to hospital for people with dementia.

HCCAS and HPCT

2008/09

Telecare can help older people with mental health difficulties to remain living independently in their own home and can be used in a variety of ways to help improve confidence and minimise risk. It can also provide peace of mind to carers and family members. We will jointly look at ways that Telecare can help keep people in the community.

HCCAS and HPCT

2007/08

We will seek to develop a specification and plan for crisis response with providers that works towards enabling:

    - access to current working age adult specialist mental health and social care crisis services for older people with functional mental illness, i.e. depression, anxiety, and psychotic disorders

    - access to primary care and social care crisis response services for older people with dementia.

We will work with our partners (out of hours services, NHS Direct and ambulance services) on the development of an emergency care pathway for older people with mental health problems

HCCAS and HPCT

2008/09

We will be reviewing falls services across Hampshire and will include older people's mental health within the scope of this work.

HPCT and HCCAS

2008/09

Key: HCCAS - Hampshire County Council Adult Services HPCT - Hampshire Primary Care Trust

nb* A "Balance of Care" project involves surveying bed utilisation in acute and community hospitals, specialist mental health inpatient services, residential and nursing homes. It creates a snapshot of the ages, conditions and status of patients in these beds on a single date and looks at whether their care needs might have been met in an alternative setting, either through avoiding admission or earlier discharge.

Strategic Priority 5. Mechanisms to enable organisations and individuals to work together towards shared goals - so that shared governance arrangements support delivery of the joint strategy

Proposed Actions

Responsible organisation

Work to commence

    We will establish a joint implementation group to oversee and take forward our commissioning intentions.

HCCAS and HPCT

2007/08

    We will map the total joint resources for older people's mental health to identify the envelope of funds and enable maximisation of available resources through identification of gaps and areas of duplication or inefficiency.

HCCAS and HPCT

2007/08

    We will jointly monitor outcomes and standards for services using agreed measures of performance, which reflect the phases and levels of the care pathways and which will be kept under review.

HCCAS and HPCT

2008/09

Key: HCCAS - Hampshire County Council Adult Services HPCT - Hampshire Primary Care Trust

How we have developed our strategy

There has been wide engagement from statutory and voluntary agencies and carers, plus support from the Care Services Improvement Partnership. A Steering Group with membership from Hampshire County Council Adult Services, Hampshire Primary Care Trust, Hampshire Partnership NHS Trust, Surrey and Borders Partnership NHS Trust and the Alzheimer's Society has been overseeing development of the strategy.

The Alzheimer's Society has undertaken a communication exercise to find out what matters to people who use older people's mental health services across Hampshire, including meeting service users and their families/carers from gay, black, minority and ethnic groups. We have included some of the things that they have said to us in the tables above.

In 2006 we assessed the level of service provision in Hampshire with the involvement of Older People's Local Implementation Teams (where they were operating).

Needs led care pathways for dementia and functional mental illness, i.e. depression, anxiety and psychotic disorders, which are based on national best practice, have been developed with the involvement of professionals and carers.

We have worked to achieve cohesion with other Hampshire strategies, e.g. Older People's Well-being, Carers, Sheltered Care Extra Housing, Day Opportunities, Mental Health for Working Age Adults and Primary Care Mental Health Strategies.