1. Mental Health of Older Adults LAMBETH, SOUTHWARK & LEWISHAM DEVELOPMENT PLAN

2. Background Review over the last year District Audit reports NSF Older People NHS Plan Lack of investment Structural financial deficit Clear that MHOA services are at breaking point

3. Clinical changes Workload Working practice Severity & dependency Treatment Expectation Morale

4. Changes in workload All elements of the service have experienced an increase in: – referrals – throughput – caseload Increases steady up to two years ago, since then marked increase in referrals of: – people with dementia (due to ADDs) – cases from social services (banding as SS financial pressures have increased)

5. Changes in working practice Changes in nature and quality of documentation and recording of activity: – Care Programme Approach – risk assessment – Mental Health Act – clinical governance requirements Changes allow improvement in quality and information but – cost in terms of time taken to complete – frustrations when information systems to support changes are absent – can seem tokenistic in the absence of feedback

6. Changes in severity and dependency Acute bed numbers have decreased by a third in 15 years: – general level of severity on wards has increased – only those at the most severe and immanent risk are admitted – knock on effect of increased severity to be managed in the community In tandem an increase in physical dependency: – local authorities divesting themselves of residential care – increase in the oldest old – more pressure on acute hospitals – service success in accessing hitherto unmet need

7. Changes in treatment and practice Introduction of anti- dementia drugs (ADDs) – sanctioned by NICE - requires initiation and review in secondary care – specified in NSF – advocated by Alzheimer’s Society – MHOA services the main provider – unstoppable clinical and political momentum Drug costs and non-drug costs – services already under pressure – increase referrals of the non-demented – assessment, investigation and monitoring costs – make clear deficiencies in wider dementia services – need to deploy psychological, educational and social interventions

8. Changes in expectation Cohort effects in expectations of users and carers – younger patients and carers have higher expectations of what should be provided – will increase as those in late middle age advocate for their parents then their partners and themselves Growth of a powerful and effective user voice – Alzheimer’s Society – Age Concern – Help the Aged – encourage referral – set reasonable expectations – we have strong links with these groups locally and nationally

9. Changes in morale In the last ten years clinical services have moved from being national leaders to a critical state Lack of any investment or development in the last 10-15 years Many plans, much enthusiasm - in the final reckoning none funded Stark disparity of investment compared with general adult services – massive investments – imaginative and successful developments – doubling of consultants and community staff in general adult services when no change in MHOA

10. Financial position Recurring cost pressures Year end position estimated c £750k – Lambeth £203k – Southwark£288k – Lewisham£226k Overspend 6% of budget Made up of staffing costs taken on by directorate, excess costs in continuing care, and unfunded developments

11. Need for change Change what we are doing, align with PCT internal organisation Lewisham – develop 3 rd community team Southwark – 2 nd team for north Southwark Lambeth – develop 4 th community team Liaison - develop specialist liaison services for acute hospitals (STH, King’s & UHL) Inpatient units - improve staff mix and levels Intermediate care services - to support service Central capacity - eg to administer CPA

12. Liaison services At least two thirds of all admissions to acute hospitals are aged 65 or more High prevalence of depression and dementia, up to 40% in some series Often not actively managed Increase stay length cause of failed discharge Successful pilot at KCH, 60 reefs in 2m; high satisfaction and fast response

13. MHOA intermediate care services National criteria – aim to reduce avoidable admissions to acute hospitals – timely discharge & promotes effective rehabilitation – minimises premature or avoidable dependence on long term care No agreed model for MHOA, nothing funded – multidisciplinary, nurse consultant led, 6-12 week max – includes intensive rehabilitation maximising function to ensure appropriate placement Part of an effective system including community teams, liaison services and acute wards – Reduce acute hospital bed days by 1,500

14. New investment required £2 million Lewisham CMHT £488k Southwark CMHT £435k Lambeth CMHT (incl daycare) £479k Kings liaison £185k St Thomas’s liaison £185k UHL liaison £185k Central services £54k £2.0m

15. Intermediate care development bids Intermediate care services c £1.5 million – Lambeth20 beds – Southwark15 beds – Lewisham15 beds Intermediate care only if new money is available, utilise capacity released from continuing care beds in Lambeth & Lewisham Develop new beds via Becket house & Dulwich schemes in Southwark

16. Service changes WE CAN FUND ALL BUT INTERMEDIATE CARE BY REDUCTIONS IN CONTINUING CARE LEVELS Lambeth – Rationalise places at Greenvale, Knights Hill & Woodlands Lewisham – Allocate top floor of Becket house to Southwark – Rationalise number of domus beds Southwark – Allocate Knights Hill to Lambeth

17. Worst case scenario - reductions in continuing care beds Currently 196 continuing care beds costing £7.4m – Lambeth 84 beds – Southwark41 beds – Lewisham71 beds Plan to reduce to 132 beds – 44 beds in each borough Any development monies secured – decrease loss of continuing care beds – fund intermediate care service

18. Implementation Major decrease in services in continuing care in Lambeth and Lewisham Short term resettlement team – based on a maximum of one move per patient – may require transfer of responsibility of care Five year plan to release beds Staged implementation Political complications closing beds, impacts on Lambeth and Lewisham

19. Funding summary Total required c £3.5m Reductions in continuing care places yields £2m Shortfall of £1.5m – to be linked to LMR schemes The greater the development monies available the fewer the reductions Requires us to make our case to LSL and the new PCTs

20. Final choice: scenario A Close continuing care beds Deal with structural overspend Fund new community teams Fund new liaison services Cost - bridging finance only Positive – cheapest option Negative – very high political risk – no intermediate care funded

21. Final choice: scenario B Close continuing care beds Deal with structural overspend Fund new community teams Fund new liaison services Fund intermediate care beds Cost - bridging finance and £1.5m development funds Positive – middle cost option – intermediate care funded Negative – high political risk – need to secure development funds

22. Final choice: scenario C No closure of continuing care beds Deal with structural overspend Fund new community teams Fund new liaison services Fund intermediate care beds Cost - bridging finance and £3.5m development funds Positive – intermediate care funded – no political risk Negative – highest cost option – need to secure development funds – need for sites for IC

23. Final choice: scenario D Continuing care beds converted to intermediate care Deal with structural overspend Fund new community teams Fund new liaison services Fund intermediate care beds Cost - bridging finance and £2.9m development funds Positive – intermediate care funded – low political risk Negative – need to secure development funds – moderately high cost option