Agenda item

Context:

 

To outline the process undertaken and an update on progress to date by the Monmouthshire Integrated Services Partnership Board regarding the expenditure of the £200,000 investment from Aneurin Bevan University Health Board (ABUHB) to further develop an integrated model of support for older people with a mental health need.

 

In October 2017, Aneurin Bevan University Health Board considered a report on Older Adult Mental Health Services and approved a proposal to publicly consult on the redesign of Older Adult Mental Health Services across the Aneurin Bevan University Health Board region. The twelve week consultation period finished at the end of January 2018 and a report presenting feedback from the public consultation and recommendations on taking forward the redesign of services was received and approved by the Health Board on 21^st March 2018.

 

Key Issues:

 

Policy and Partnership Context

 

The Dementia Action Plan for Wales (2018) envisages a ‘dementia friendly nation that recognises the rights of people with dementia to feel valued and to live as independently as possible in their communities’. The Action Plan sets out the Welsh Government’s commitment to promoting the rights, dignity and autonomy of people living with dementia and the people who care for them.

 

The Gwent Dementia Board, reporting to the Greater Gwent Health, Social Care and Well-being Partnership has developed a Strategic Action Plan for the period 2018-2022 which supports the delivery at local level of the necessary measures to improve support to address the key issues:

 

• A widespread lack of knowledge and understanding of dementia amongst professionals and the wider public.

 

• A lack of flexibility to effectively meet the needs of people living with dementia and their carers.

 

• A lack of co-operation between services creates unnecessary barriers for people living with dementia and their carers.

 

The Action plans have been developed as a result of extensive work carried out nationally , including ‘Dementia: More Than Just Memory Loss’ -  The experiences of people living with dementia and those who care for them (2016) and ‘Rethinking Respite for People Affected by Dementia’(2018) – Older Peoples Commissioner for Wales.

 

The Integrated Services Partnership Board (ISPB) is the Monmouthshire local partnership of the Greater Gwent Health, Social Care and Well-being Partnership, and is jointly chaired by the Chief Officer for Social Services and the Director of the Primary and Community Care Division of the Health Board. The Head of Adult Services, and Service Manager, All Age Disability and Mental Health, and the Director of Mental Health and Learning Disabilities for the Health Board are also members.

 

The ISPB established an officer group to consider the priorities for the expenditure of the £200,000, specifically allocated to further develop an integrated model of support for older people with a mental health need which was consistent with the respite and support recommendations within the strategic and advisory documents. The remit was extended to include local residents with a functional mental illness as well as those with a dementia diagnosis, as many services provided in the community are able to meet the needs of both groups. The officer group decided to utilise the pre-existing framework for the Integrated Care Fund to support the bidding, decision making and evaluation requirements, albeit that the decision on expenditure would be made by the ISPB. The ICF process was chosen because it is a robust, tried and tested framework.

 

Key Local Challenges

 

There is a higher than average proportion of older people in the County and this is forecast to rise further. As evidenced in the Needs Assessment for the Monmouthshire Public Service Board Wellbeing Plan, Daffodil Cymric projects an 87% increase in Monmouthshire’s population aged 65 and over with dementia by 2035. This is above the increase projected across Wales of 72% and the second highest increase in Wales after Flintshire. The Needs Assessment also highlighted specific local issues related to the transport infrastructure and lack of accessibility of services at local level.

 

The closure of St Pierre ward will result in 50-60 relatives and carers of patients per year from throughout Monmouthshire, who will in future receive their care in another hospital, having to travel to visit them. A proportion of those relatives and carers will live nearer to Chepstow Community hospital than to the other hospital, and may not have transport or find travelling difficult.

 

The rurality of Monmouthshire impedes the access of people outside the main towns to the community based support which is already available, and will present barriers to accessing newly developed services.

 

There are gaps in the current community support for people with dementia or functional mental health issues, particularly for those with more advanced conditions and those who have received a diagnosis but are not receiving active secondary care clinical intervention (‘watch and wait’) because their condition is not advanced enough to warrant that, although they may have difficulties in daily life, resulting in distress for them, and increasing stress on their carers. 

 

Respite services are limited, and insufficiently flexible to meet the individual circumstances of patients and their carers. Respite can take many forms, including a stay in a residential or nursing facility to enable a carer break, facilitating a break for the service user and their carer together, and support in the community for someone to access a service or activity, and support in the home.

 

Member Scrutiny:

 

·         It was considered that the Chief Executive and the Chair of Aneurin Bevan University Health Board should have been in attendance at today’s meeting due to the seriousness of this matter.

 

·         A short extract of a letter written by the Chief Executive of ABUHB and sent to the local Member for Larkfield last year was read out regarding delivery of new services within Chepstow hospital.

 

·         In response to a question regarding the engagement and consultation process, it was noted that within the specialist Older Adult Mental Health Services, ABUHB was facing significant challenges.  One of the issues related to having an appropriate work force in order to safely deliver the services.  ABUHB is mindful of the growing numbers of people with a mental health need and the need to develop modern sustainable services, going forward.

 

·         Another key element was that people wanted to be supported within their own communities, where possible and only being admitted to hospital as a last resort.

 

·         A range of engagement exercises were therefore undertaken across the Gwent region.  Following this process a number of options were identified for a possible way forward and these options were consulted upon via a formal consultation process. In October 2017 the Board gave its approval for public consultation to commence which started in November 2017 and was completed in January 2018.

 

·         Two key areas arising from the consultation were (i) a proposal for ABUHB to further enhance its specialist community services for older people with a mental health need and (ii) ABUHB to consolidate the number of specialist in-patient units to three specialist dementia facilities and one facility for older people with a mental health need.

 

·         ABUHB spent considerable time to identify the best ways it could engage and consult with individuals.  Based on the previous engagement that had been undertaken, when the formal public consultation meeting had been planned, only day time hours had been suggested. However, it had become clear that people were keen for ABUHB to provide some evening meetings.

 

·         Throughout the whole process the Community Health Council was aware of the consultation process being provided and helped ABUHB to develop the consultation process. It had been noted that some individuals considered that the consultation process could have been undertaken in a better way.  Going forward, ABUHB would welcome the opportunity to have further discussions with the local Authority regarding ways of making future consultation better.

 

·         In response to a question raised regarding Monmouthshire County Council’s involvement in shaping the options appraisals, it was noted that engagement events were held across the five authorities within the Gwent region. During this process it was agreed that a small number of individuals who had participated in these events form a small group to take the information produced from the engagement and consider some of the options. At that point, there was no involvement from Monmouthshire County Council.

 

·         ABUHB stated that via the consultation, there were a number of areas where there was broad consensus and support for Option 3 and there were some areas where there were significant differences of opinions.  The areas where there was significant support, 99% of individuals, who responded to the consultation, were clear that they were aware of the challenges being faced in Older Adult Mental Health Services. 88% of people who responded believed that they had sufficient information to comment on the consultation. 78% of people agreed that ABUHB needed to change its Older Adult Mental Health Services, going forward. 75% of people agreed that ABUHB needed to strengthen its local community services for older people with a mental health need.

 

·         There were a number of areas where a difference of opinion merged. This was clear from the analysis and depended on where the responses were from, i.e., from within Monmouthshire or from outside of the County. The areas where those differences of opinions merged was in relation to whether there should be a consolidation of in-patient services and the proposal to close the dementia ward within Chepstow Community Hospital.

 

·         Members considered that the overwhelming response to the consultation process was negative.  The majority of people in Monmouthshire who responded to the consultation were against Option 3. Under the circumstances, Option 1 would have been the better option, i.e., hold the status quo.

 

·         ABUHB stated that at the end of the consultation process all data was analysed.  Based on this analysis, a paper was presented to ABUHB Board on the 21^st March 2018. There had been detailed consideration of the feedback from the consultation.  The Board approved the recommendation to further enhance community services and to consolidate the number of in-patient services whilst acknowledging that further work was required to address some of the concerns that had been raised, particularly in relation to transport and car parking.

 

·         In response to a Member’s question, it was noted that the decision to close the ward was not made until the Board’s decision had been made. At this time there were six in-patients within the ward.

·         In response to information relating to a bed consultation exercise having been undertaken and that information had not been fed back to the Integrated Services Partnership Board, the representatives from ABUHB stated that they were not aware of this matter but would investigate and refer back in due course.  However, it was noted that ABUHB would have liked the results of the consultation to enable it to obtain the views of the public regarding the expenditure of the £200,000.  This was not obtained via the Integrated Services Partnership Board.

 

·         Prior to the consultation, ABUHB had 72 beds across the Gwent region to support older people with a mental health need. Following the consultation the figure reduced to 67 beds. In terms of current occupancy, generally, this fluctuates with the wards becoming busier in winter.  Guidance suggests that ideally, 85% of beds should be filled at any given point.

 

·         ABUHBs aim is by further enhancing and developing its community services, it will mean that fewer people will need to be admitted as an in-patient.

 

·         ABUHB aims to recruit and retain staff.  It has been a national challenge in terms of recruiting to some nursing posts. Significant in roads are being made on an integrated basis working between Health and Social Care to look at all opportunities to increase recruitment and retention of staff across the Gwent region.  In Monmouthshire, ABUHB operates Integrated Community teams whereby Health and Social Care staff work together with a view to developing better services. It is hoped that Chepstow could be a flagship for this development and will aid in recruitment and retention of staff.

 

·         By re-investing in community services, this will enable people to access support closer to home.  Therefore, the areas that can be taken forward in terms of developing community services are strengthening memory services within the community and providing additional support into care homes within Monmouthshire.  ABUHB has been able to invest via the re-design additional posts in access to psychological therapies for older people within Monmouthshire. Ideas are being developed around how ABUHB can ensure crisis community based teams are able to support older people with a mental health need within their own setting.

 

·         The factors to determine which ward would be closed included the geographical location of the wards across Gwent, the ward environments for individuals, where there were recruitment and retentions issues regarding staff, and to explore where there was access for non-emergency support for physical health issues.

 

·         ABUHB highlighted the exceptional work that both Social Care, Health and the voluntary sector play in terms of supporting older people with a mental health need across Gwent.

 

·         There was an equality impact assessment undertaken throughout the process. This was included in the papers that went to the Board to support its discussion around its decision making.

 

·         One of the key issues that arose from the equality impact assessment was the significant concerns around travel for individuals within Monmouthshire. There is an opportunity for ABUHB to share some of the work that it has been doing between the Authority and the Health Board to address some of the travel issues for Monmouthshire residents.

 

·         The Health Board, at its meeting in March 2018, provided a further £200,000 investment for the Older Adult Mental Health Service to work in partnership with Monmouthshire County Council and other stakeholders in Monmouthshire to further develop an integrated model of support for older people with a mental health need. In order to ensure this was a transparent process and undertaken in partnership, ABUHB formed a sub group of its Integrated Services Partnership Board.  The sub group comprised of members of the Health Board, local authority staff, a Public Health representative, the Wellbeing Lead officer for Monmouthshire County Council, the Older Adult Directorate Manager, and the Community Mental Health Team Manager. The evidence that had come out of the consultation process was used to identify the areas of concern of the changes to the service.  The £200,000 was used for additional services.

 

·         A developing transport service is being provided by Bridges which is a volunteer based community transport service which enables people, in its original form, to attend a range of facilities in the community. ABUHB worked with Bridges to develop a specific element of its service which will be to support older adults with mental health needs and their carers. Bridges made a bid which came to the sub group which was approved by the Integrated Services Partnership Board. This enabled Bridges to train their volunteers to be able to deal with the specific needs of the people and to transport them to their required destination. Further work has been undertaken to ensure that this is a robust service and that people can get to their destination and get home again afterwards.  This scheme covers the whole of Monmouthshire and is in place to mitigate the closure of the ward in Chepstow hospital.

 

·         With regard to the lack of support for people with significant needs for respite and for carer respite, a bid was prepared on behalf of the wider respite needs of people.  The key recommendation that arose was the need to have access to a respite bed. 

 

·         The provision of day opportunities are not available in the north of the County.  The service that is operated by Crossroads in Chepstow hospital meets a need for the local people with dementia.

 

·         A scheme is being looked at for increasing the use of leisure centres and building group resilience. A pilot is being run for 12 months.

·         ABUHB has received a request from the Museum Service to do a pilot which would be to support recognition therapy and for people to work with familiar objects. The evidence gained from the pilot will strengthen the Museum Service’s bid for Big Lottery Funding to take forward recognition therapy.

 

·         The Integrated Care Fund process, to be carried out in partnership, has been administered over the previous four years.  The schemes mentioned are not a part of the Welsh Government funding but it was felt that process was required that was robust and could be evaluated. 

 

·         The funding is permanent but the schemes will be evaluated after 12 months.

 

·         It was noted that Welsh Government has launched the Dementia Strategy and Dementia Action Plan to support areas in implementing the actions from the Dementia Action Plan. There is additional monies for partners to develop proposals.  The funding allocated to the Gwent region equates to £980,000.

 

·         ABUHB is aiming to ensure that GPs and those in primary care settings have the correct knowledge and expertise regarding dementia. This area is being further developed.

 

·         Memory Assessment Services will accept people of any age if it is considered that an individual was experiencing cognitive issues. There is no restriction on the age of an individual. Community Mental Health Teams also accept people with dementia who are younger.

 

·         By using Bridges for transport purposes people will not be financially disadvantaged with the service being moved from Chepstow hospital. People will not be charged more than the cost that they would have paid to get to Chepstow hospital.

 

·         Regarding the cost and accessibility of obtaining transport, this is one of the main reasons that the Bridges service started as the rurality of Monmouthshire makes it difficult for people to get to their appointments. Bridges has submitted bids for grants to enhance the service that it provides.  The funding being provided by ABUHB will enable people in the community to access services in the community.  There is a service provider from Monnow Vale for people with dementia. There is a day service that runs from Monnow Vale. An integrated transport system operates from Monnow Vale with Health and Social Care vehicle provision for the facility.

 

·         The changes were made to the ward three months ago.  About two thirds of the beds were occupied.  ABUHB is confident that there are sufficient beds to meet the needs of the population across Gwent. Since the closure three months ago, there have been nine individuals from Monmouthshire who have been admitted to an in-patient provision.  Two of those were individuals from the north of the County and seven individuals from the South of the County.

 

·         A Member expressed concern regarding alleged misinformation from ABUHB regarding the closure of the St. Pierre ward at Chepstow hospital. Concern was also expressed that the south east of Monmouthshire was no longer receiving a good system of care for its residents.  St. Pierre ward needed to remain open in order to provide residents with quality care.

 

·         Members expressed concern that the care system in place is not adequate.  The removal of the Severn Bridge tolls is leading to an increase in the number of people retiring to the south east of Monmouthshire.  Therefore, there should be investment in dementia care for this area and that it should not be removed.

 

·         There seems to be a breakdown in trust with ABUHB.  There is a need to move forward to try and rebuild the relationship with the Health Board.

 

·         At the Health Board meeting in March 2018, a decision was made to fund the £200,000 for some innovative community based solutions for Monmouthshire.

 

·         As part of the public consultation, ABUHB was not just consulting on the closure of St. Pierre ward. Bed stock included wards that were already temporarily closed in Newport, Pontypool and in Blaenau Gwent. The investment plan that went to the Board, which indicated the consolidated savings from bed closures, included all of the beds identified, and not just the beds within the St. Pierre ward. This saving equated to £846,000.  Details of the breakdown of how this was to be invested was identified in the report for this meeting. As part of this package, ABUHB prioritised Monmouthshire, and in particular south Monmouthshire as an area where the Health Board wanted to see the initial investment go into. Proportionately, more investment has gone into Monmouthshire than in any other county borough.

 

·         The total savings equated to £846,000.  Of this, an initial proposal to the Board was to invest £429,000. To invest another £217,000 to improving its in-patient care. A proposal was also put forward for the Board to endorse the £200,000 saving to invest in the historical cost improvement programme. The Board did not accept this recommendation.  Therefore, this is where the £200,000 new investment funding has come from to invest in Older Adult Mental Health Services within the Community.

 

·         The Chief Officer for Social Care, Safeguarding and Health informed the Committee that what is being offered by ABUHB as community support options are in line with what is considered to be best practice and what the Social Care Directorate is looking to integrate with.  With regard to the transport issue, ABUHB is fortunate that we have the Bridges Community Transport option to be able to utilise. The investment that can be made from the £200,000 is going to have a wide benefit to people in Monmouthshire.  The issue regarding beds needs to be looked at carefully.  The number of people that were accessing this support was a reasonably small number of people with intense need and this needs to be looked at as to how this will be managed over the medium and longer term.

 

·         It is only three months since the closure of St. Pierre ward. However, ABUHB is already beginning to see the benefits of what it wanted to achieve. One of the areas was to have further investment in support for people with dementia who were living in either nursing or residential homes.  Additional resources have been put into ‘In Reach’ support to those nursing homes. Prior to the changes, one of the aims was that people in care homes, if they have dementia and are on anti-psychotic medication, they should have their review every 12 months, as a minimum. Prior to the changes these targets were not being met for Monmouthshire residents. The latest data since improvements have been made in the last three months, ABUHB is almost at the point where these individuals will be able to have a review every six months.

 

·         In relation to the availability of cognitive stimulation therapy. Via the changes that have been made, there will be an additional 36 individuals within Monmouthshire who will be able to access this therapy per year.

 

·         The impact on patients who have been admitted to the ward – When the decision was made to close St. Pierre ward, there were six in-patients.  Five of these patients were transferred to another in-patient ward and the other patient was able to be discharged to a care home.

 

·         With regard to the impact on staff following the changes that have been implemented, when the decision was made, there has been in advance of the closure of the ward, individual discussions with staff to reassure them that help would be on hand to support them seeking alternative employment and, as part of the redeployment policy, all but one individual has an alternative job. Support has been received from Human Resources in helping staff through this process. ABUHB is confident that it is going to be able to accommodate staff as the redeployment process comes to an end.

 

·         Prior to the changes St. Pierre ward was the only specialist in-patient ward for people with dementia within Monmouthshire.  The vast majority of Monmouthshire residents, if they required an in-patient admission, would have been admitted to St. Pierre.  However, because of the challenges ABUHB was facing, some people were occasionally being admitted to a hospital in other areas.

 

·         When Chepstow hospital opened there was one ward for dementia patients on Llanfair ward.  When the Community ward closed the decision was made to move from Llanfair ward onto St. Pierre ward. Llanfair ward was then utilised as the base for the south Monmouthshire Community Mental Health Team.

 

·         With regard to a question raised in respect of recruitment and retention of staff, it was noted that ABUHB does not have difficulty in terms of appointing to community nursing posts.  Through the service redesign, it is hoped that consolidation of its in-patient units will make these units centres of excellence for patients as well as staff. Additional deputy ward manager posts have been put in place within the nursing skill mix to ensure that there is more support for nursing staff.

 

 

Committee’s Conclusion:   ·         There were flaws with the consultation process and there are lessons to be learned, going forward.   ·         Aneurin Bevan University Health Board (ABUHB) took on board the comments made regarding areas where there was significant support, namely, the need for community services and the need for services to change.   ·         The areas where there was significant discontent were around consolidation of services including the closure of St. Pierre ward. This was consultation that was ignored.   ·         Recruitment and retention of staff is essential to ensure that services are retained.   ·         The £200,000 settlement will be assessed over time to ensure it is enhancing and providing much needed services.   ·         This could be seen as an opportunity to move monies into the Social Care fund to help people receive care in their homes.   ·         ABUHB is aware of the issues regarding rural transport. However, there are still some unresolved issues that require attention.   ·         It is hoped that the partnership between ABUHB and Monmouthshire County Council can be further developed, going forward.   ·         Develop further training for Elected Members regarding dementia awareness.   ·         Options for pool budgeting needs to be explored.   ·         The future of Chepstow hospital needs to be looked at and be discussed at a future meeting of the Select Committee providing services fit for purpose for the local community.   ·         Representatives of ABUHB, with its Chief Executive, to be invited back to the next meeting of the Select Committee on 11th September 2018.   The recommendation of the report is as follows:   Members are asked to endorse the proposed schemes to support older adults with mental health needs and their carers agreed by the Integrated Services Partnership Board (ISPB).   Having taken a vote on whether to support the recommendation, the following votes were recorded:   In favour of the recommendation     -     1 Against the recommendation           -     2 Abstentions                                      -     1   We resolved not to support the recommendation, as this matter requires further scrutiny and monitoring of the future of Chepstow hospital and to review the change of direction in service provision, being undertaken by Aneurin Bevan University Health Board.