Outline Joint Commissioning Strategy for Mental Health Services for Older People In

Outline Joint Commissioning Strategy for Mental Health Services for Older People In

Item 9 Appendix A


OUTLINE JOINT COMMISSIONING STRATEGY FOR MENTAL HEALTH SERVICES FOR OLDER PEOPLE IN HERTFORDSHIRE

November 2007

CONTENTS

Section / Page
Introduction / 3
Client Group / 4
The Vision for Hertfordshire / 5
Demography / 8
Needs Assessment / 9
Mental Health Promotion / 12
Functional Conditions / 14
Psychological Therapies / 15
Assessment and Treatment / 16
Practice Based Commissioning ~ Functional Illness / 17
Acute Inpatient Beds / 18
Dementia Services / 20
Practice Based Commissioning ~ Dementia Services / 20
Younger Onset of Dementia / 21
Day Hospital / Day Services / 22
Inpatient Respite Care / 23
Continuing Care / 23
Mental and Physical Illness / 24
Older People with Learning Disabilities / 25
Black and Ethnic Minorities / 25
Social Care Funding / 26
Housing and Accommodation / 29
Contribution of Users and Carers / 29
Voluntary and Private Sectors / 30
New Technology / 30
Mental Health Care at End of Life / 30
Conclusion / 31

Introduction

This draft Strategy for the development of Mental Health Services for Older People is a joint statement of intention between the 2 Primary Care Trusts in Hertfordshire, East and North Hertfordshire PCT and West Hertfordshire PCT, the Joint Commissioning Team and Hertfordshire County Council’s Adult Care Services. It builds on the previous and current work undertaken and will form part of the overall strategy for Older People being developed by Hertfordshire County Council’s Adult Care Services (ACS) and the Hertfordshire Intermediate Care Strategy which is being jointly led by Hertfordshire PCT’s and ACS. It will also be developed by a multi-agency group including representatives of the voluntary and independent sectors known as the Strategic Commissioning Group for Mental Health Services for Older People.

This strategy will be released for consultation in December 2007. The JCT would particularly like the views of interested parties but of course would also welcome comments on the whole document.

The consultation period will run from December 2007 to 1st February, 2008 and comments should be sent to:

MHSOP Strategy Consultation

C/o Sue Mahon

Joint Commissioning Team

Mount Pleasant

Hatfield

Hertfordshire

AL9 5PU

Or electronically to:

or

It is recognised that Mental Health Services for Older People has not been seen as a high profile service, however, with the introduction of the recent reports by Dementia UK and the Alzheimer’s Society, the Audit Commission and Age Concern’s “Improving services and support for older people with mental health problems” this has now changed. In particular we await the publication in the future of a focussed National Dementia Strategy.

It is now fully recognised that faced with an ageing population with increasing mental health needs, this is an area requiring urgent attention. It is hoped that through this Mental Health Strategy for Older People we will set out our priorities and try to pre-empt where possible the future national direction for dementia and seek to redress the balance.

There is not an endless supply of resources but this strategy identifies opportunities for remodelling existing services, improving the quality of services provided, expanding capacity, investing in new services and pump priming other changes, some of which will be achieved through service redesign. This commitment from Health and Adult Care Services represents a major opportunity for improving the quality and range of services available. As part of this Strategy, there is a recognised need that the workforce required in the future will be different to that which is currently in place. The Joint Commissioning Team is committed to ensuring that current and future providers of services encourage and support all staff in the development and reconfiguration of services.

The Joint Commissioning Team is committed to increasing choice in health and social care by working with Providers and Service Users to explore the potential of providing choices of treatment options both within a community setting as well as a traditional hospital setting. In a hospital setting it may be that this choice is limited to choice of clinician and location rather than a range of treatment options.

It is appreciated that these are not simple changes and that they will require careful development but they are in line with national and local aspirations to increase options and choices for patients.

It is expected that there will be an increase the range, number and sources of providers over time including commissioning more services from the voluntary and private sectors.

The development, by the Adult Care Services, of Extra Care Sheltered Housing and the implementation of expanded day care options in conjunction with Hertfordshire Partnership Foundation Trust (HPFT) will all provide alternatives to in-patient care.

Adult Care Services and the Joint Commissioning Team are committed to expanding the number of people receiving Individual Budgets and Direct Payments as a result. Service Users will have greater flexibility and choice as to what services they need and how best to provide them. The JCT will work with ACS and HPFT in taking forward this principle to promote the uptake of these choices. It is anticipated that this will also require a close working relationship with the Voluntary Sector, not only to promote advocacy services to support patients in taking up these options but also in being the potential provider of many of the services that the Service Users may wish to take up in place of the traditional services previously available.

Client Group

The strategy covers all adults over the age of 65 and those of a working age with early onset of Dementia. Although the NSF for Older People starts out at 50, the way that services are currently commissioned it is felt that this arrangement should be maintained for a number of reasons although these can be challenged:

  • There is a comprehensive strategy already set out for Adults of a Working Age.
  • It is proposed that functional services are commissioned in the future as a single entity regardless of age. This is not to say that service provision will be centralised but that in commissioning a service, the pathway will consider all age groups and where best and by whom the needs of the service users are best met.
  • Younger adults suspected of dementia will have access to older people’s services where their needs may be best met.

The Vision for Hertfordshire

The Joint Commissioning Team encompassing Health and Social Care services in Hertfordshire seek to commission a high quality outcome focussed, integrated and evidence based mental health service for older people which is appropriate to need. Where possible within the community as close to the population we serve ensuring they are delivered in a timely, responsive, dignified, culturally sensitive and non discriminatory manner.

The key principles which form foundations of this strategy are that:

  • We aim to move towards the creation of a single commissioning budget where appropriate and realistic for Health and Social Care across Hertfordshire.
  • The NHS, Adult Care Services, and Third Sector will together aim to deliver a seamless service to users across all organisational boundaries.
  • To provide services which are flexible to support and promote independence, either at home or in a care home when remaining at home is no longer an option.
  • To continually strive to improve Mental Health Services for Older People, to reduce health inequalities, improving access and the quality of life of older people and their carer’s. Older People should have access to the same range of services as Working Age Adults including access to counselling and therapeutic services.
  • To work towards the integration of all functional mental health services and support services ensuring they are fully inclusive and accessible to service users of all ages.
  • To mainstream Mental Health Services for Older People as far as possible integrating them into local services.
  • To work in conjunction with Practice Based Commissioning Groups across Hertfordshire to increase community based services.
  • We recognise the importance of securing quick and accurate diagnoses at the earliest possible time and that means strengthening the skills and capacity within primary care.

Everybody’s Business set out the following principles which we believe underpin older peoples mental health services to ensure that they are fit for purpose. Services will:

  • recognise the dignity of individual service users. Respect their values and diversity as well as acknowledging their major role in the process of planning and developing services
  • respect all people who engage with mental health services, not only those using them but also their supporters and carers
  • provide practical advice and information for service users and their carers as well as developing a consistently high quality, comprehensive package of care and support which minimises bureaucracy
  • make sure that the best and most effective treatments and widely and consistently available
  • respond on the basis of need not age and ensure that wherever older people with mental health are in the system they are not discriminated against and have their mental health needs met

Other factors incorporated into the commissioning decision making process for implementation in service models include the relevant standards drawn from the existing National Service Frameworks (NSF’s) for Older People and Mental Health. Some of these have already been mentioned above but are included here for completeness.

National Service Framework for Older People:

Standard One - Rooting out age discrimination. Services will be provided regardless of age on the basis of clinical need alone. Social services will not use age in their eligibility criteria or policies to restrict access to available services.

Standard Two - Person Centred Care. NHS and Social Services will treat older people as individuals and enable them to make choices about their own. Achieved through integrated commissioning arrangements and integrated provision of services.

Standard Three - Intermediate Care. Ensure access to a range of services at home or a designated setting to promote independence by enhancing NHS services and Council services to prevent hospital admissions or premature or unnecessary admission to long term residential care.

Standard Seven – Older People with Mental Health needs. To have access to integrated mental health services provided by the NHS and Councils to ensure effective diagnosis, treatment and support for them and their carers.

Standard Eight – Promote health and active life in old age. Health and well being of older people is promoted through a co-ordinated programme of action led by the NHS with support from Councils.

National Service Framework for Mental Health:

Standard One – Health Promotion. As per Standard Eight for Older People but also specifically mentions combat mental health discrimination and promote social inclusion.

Standard Two – Any Service User who contacts a primary care health team with a mental health problem should:

  • have their mental health needs identified and assessed
  • be offered effective treatment including onward specialist referral

Standard Three – Any individual with a common mental health problem should:

  • be able to make contact round the clock with local services to meet their needs and receive adequate care
  • be able to use NHS Direct and or be referred to a specialist helpline or local services

Standard Four – All mental health service users on a Care Programme Approach should:

  • receive care which optimises engagement, anticipates or prevents a crisis and reduces risk
  • have a copy of a care plan which includes action to be taken in a crisis, advises GP’s of how they should respond if service users need help, care plan is regularly reviewed by the care co-ordinator, able to access services 24/7

Standard Five – Each Service User requiring a period away from home should have:

  • timely access to a hospital bed or a placement in the most least restrictive environment required to protect them and the public
  • copy of written after care plan agreed on discharge

Standard Six – Caring about Carers. All carers who are responsible for a service user on CPA should have:

  • assessment of their caring, physical and mental health needs
  • have their own care plan to support their well being

Standard Seven – Suicide Prevention.

  • Older People with depression are at a greater risk, this group should be targeted and monitored

It is proposed:

  • that an annual review is provided to the Strategic Commissioning Group and to the Joint Commissioning Partnership Board on progress towards implementing the national service framework standards and principles set out within “Everybody’s Business”.
  • Local implementation and monitoring on the standards are reported regularly to the Local Implementation Teams who will facilitate the development of action plans to achieve the NSF standards.

Demography

The strategy for future services for older people has to take full account of the projected demographic changes over the next decade and beyond.

The number of older people is rising in Britain. It is estimated that the number of people over the age of 65 will increase from 9 million to 14.5 million by 2020, and people of age 85 or over will increase from 1 million to 2.2 million over the same period.

  • 85 year olds are the fastest growing population segment.
  • By 2015 the number of people aged over 85 will increase by 27% and by 2025 over a fifth of the population will be aged over 65.
  • By 2040 there will be 5 million more people aged over 65 than there were at the turn of the millennium.
  • By 2025 just under a million people aged over 65 will have a dementia.
  • It is likely that the proportion of older people owning their own home will grow from two thirds to four fifths over the next twenty years.

For Hertfordshire the over 65 population is expected to increase by 22% by 2020, from a ratio of approximately 1 in 6 people being over 65 to 1 in 5. Most significantly, is the dramatic increase in the over 85’s. This section of the community is expected to grow by over 40% compared to today’s figures. From a present day figure of 1 in 46 people in Hertfordshire being over 85, by 2020 it will be 1 in 35. It is important to recognise that very old people, especially those with cognitive impairment make up a large proportion of those in need of long-term care. It is also recognised that this population group account for the largest amount of resources consumed within Health care. The same can be said for Adult Care Services where the budget for older people services in general represents over 60% of the total.

Mental health has always been the poor relation in terms of resources and service provision however with an ageing population, the proportion of older people as a total of the overall population will increase significantly over time. This means that the number of older people with conditions such as Dementia will rise dramatically. This can be shown in Table 1 which sets out the population projections for the next 18 years.

Table 1: Population Projections, Hertfordshire , by Age group and Year

Age groups / 2008 / 2010 / 2015 / 2020 / 2025
65-69 years / 42,900 / 45,700 / 56,000 / 51,000 / 56,200
70-74 years / 39,600 / 39,500 / 42,000 / 51,700 / 47,300
75-79 years / 34,100 / 34,400 / 35,200 / 37,900 / 46,800
80-84 years / 25,200 / 25,900 / 27,900 / 29,500 / 32,200
85+ years / 22,900 / 24,300 / 27,800 / 32,100 / 36,900
Total 65+ / 164,700 / 169,800 / 188,900 / 202,200 / 219,400
% Increase from 2008 / 3.1% / 14.7% / 22.8% / 33.2%
No of 65+ as % population / 15.52% / 15.87% / 17.27% / 18.06% / 19.17%
No of 85+ as % population / 2.16% / 2.27% / 2.54% / 2.87% / 3.22%

Source:Sub-national population projections (2005 base) National Statistics, September 2007: Herts All Districts.

Needs Assessment for Older People

In general, older people experience two main types of mental health problems:

  • organic conditions such as dementia;
  • functional conditions such as depression or psychoses.

In the future we will provide different types of care depending on what mental health needs older people have.

The Public Health Team of the PCT is publishing a needs analysis for mental health services across the county. Once it is published this strategy will be amended to reflect any material changes.

The needs assessment will cover the whole of Hertfordshire, it will include:

  • local epidemiological on the prevalence of older people’s health problems forecasted at least 10 years into the future and beyond,
  • an audit of current services
  • a gap analysis of services against the elements of services recommended in Everybody’s Business and NSF for Older People.
  • an analysis of service usage
  • engagement of the views of service users and carers

Traditionally a strategy document is based upon the findings of a needs assessment. In this case the timing of the publication of both documents has not been ideal. To progress the important work required to modernise mental health services for older people the publication of an over arching strategy is required. This is however seen as a re-iterative process and any omissions revealed by the publication of the needs assessment will be incorporated into future versions of this document. It is envisaged that the demographic and prevalence data reported in this document will not be significantly different from that which will be eventually published in the needs assessment in 2008.

Table 2: Prevalence of Dementia within Hertfordshire

Age groups / 2008 / 2010 / 2015 / 2020 / 2025
65-69 years / 620 / 666 / 813 / 740 / 820
70-74 years / 1,027 / 1,028 / 1,103 / 1,348 / 1,243
75-79 years / 2,191 / 2,187 / 2,252 / 2,417 / 2,827
80-84 years / 3,146 / 3,240 / 3,463 / 3,638 / 3,970
85+ years / 5,722 / 6,025 / 6,846 / 7,923 / 9,063
Total / 12,706 / 13,146 / 14,477 / 16,066 / 17,923

Source:National Prevalence data in Dementia UK report extrapolated for Hertfordshire residents. All Districts.

Table 3: Prevalence of Dementia by Age Category

Source:National Prevalence data in Dementia UK report extrapolated for Hertfordshire residents. All Districts.