The south-east hub approach: a new and sustainable model of forensic care for people with a learning disability

Case study summary

Three Transforming Care Partnerships (TCPs), Kent and Medway, Surrey and Sussex pooled their resources to develop a new way of providing forensic services for people with a learning disability, autism or both across the south east.

 

Because relatively few people need forensic services – intensive, secure services for people who have committed an offence or are at risk of doing so – the three TCPs realised they could best meet local needs and avoid duplication if they commissioned services together across the whole region.

They have developed four separate but interconnected plans, which are also linked to the area’s Sustainable Transformation Plans (which look at the needs of the whole population in an area, not just the individual organisations).

The new model of care

Kent and Medway, Surrey and Sussex worked together to develop a new model of forensic care that supports people in their local community. This allows them to move away from secure inpatient care in placements away from the person’s home area to mostly community-based services, and has the secondary benefit of closing unnecessary inpatient beds.

The aim is to provide person-centred support which promotes wellbeing and independence. As well as moving people from hospital into the community, the three TCPs use a collaborative ‘at risk of admissions register’ to review people who might be at risk of being admitted, and put support in place to prevent this.

Care is commissioned and delivered across the region as part of a ‘hub-care’ approach. The hub is not one care model but collaborative local provision. This is a more effective way of funding and providing care and gives the three TCPs greater flexibility in how to use their remaining inpatient beds.

The model follows the vision of the national Transforming Care programme which is set out in Building the Right Support, and follows the national service specifications which describe what services should look like.

Principles

The three TCPs had to develop some core principles which underpin their collaboration:

  • Care is commissioned across the whole system to use resources collectively
  • It is important to engage and develop clinical leaders
  • There is the right workforce to deliver the new model in the right accommodation
  • The model must be sustainable
  • There is parity of esteem for physical and mental health

How they did it

  • They set up a steering group which was chaired by colleagues from NHS England Specialised Commissioning and the NHS England South region. This recognised the project’s partnership approach and having two chairs gave more flexibility in choice of dates for meetings. The steering group made sure there was good governance and helped to get everyone to commit to the new model of care for forensic services.
  • They set up a project workstream group to focus on the detail of the work, and had members from the local Clinical Commissioning Groups (CCGs), local authorities and providers. Because there was limited resource and capacity to take on the work, they had to make sure it had a realistic scope. Recognising this, the national Transforming Care programme gave them a project manager for a few months, and provided expert advice on finance.
  • They brought together collective data from all three TCPs which identified: where all the individuals currently lived (location and provider), their gender and security level. This was used to work out discharge trajectories. To do this they developed a secure web-based portal for sharing data and information.
  • They agreed priorities, scope and exclusions. The exclusions were child and adolescent mental health services (CAMHS) and high-secure services.
  • They developed a business case that builds on the local services already in place in the three TCPs. It takes account of the commonality of the four areas, but also some important different needs. It describes a sustainable model of care which pools resources to create a patient-centred pathway across the south east.

Benefits

  • A person-centred and needs-based approach to forensic care for people with a learning disability, autism or both across the south east. This will be primarily community-based and should reduce hospital admissions.
  • Sustainable and cost-effective, with shared governance and pooled resources
  • Improved access to care in the person’s local area. 49 people who are currently out of area will be moved closer to home
  • A co-ordinated approach to discharge planning with the Midlands and East region (where many of the people that are out of area are currently living)
  • New complementary model for secure services will be developed
  • The three TCPs have developed collaboration and momentum for Transforming Care more widely
  • A move towards a single approach for strategic commissioning

Key learning

  • Map who should be involved and make sure they are. Work collaboratively and pool resources.
  • Don’t underestimate lead-in time to start the work. Although holding webinars can help you catch up.
  • Use phone conferences and webinars to make it easy to work together across the area.
  • Use corporate knowledge, in particular on finance and commissioning, to avoid the mistakes of the past.
  • It helps to align the work to your local Sustainability and Transformation Plan STP from the beginning.
  • Use existing governance arrangements and other local processes where possible.
  • The national Transforming Care resource from NHS England helped to fill the gaps in capacity and made it easier to share the model with other areas.

Funding principles for the pooled resource

  • Funding will be released based on a business case to provide alternative, recurrent and sustainable care for patients previously in secure beds
  • The cost of support in the community should not exceed the cost of the current bed, unless additional funding is injected into the pool from outside the TCP or as part of a longer-term balanced plan. Additional contributions to the pool will be agreed by partners through the pooled-budget governance structure.
  • In the first instance, the funding released will be the marginal savings. The full cost will be released once beds are closed within agreed timescales.
  • Where the costs released exceed the costs of alternatives, any saving goes into the pool reserve.
  • Where the costs released are less than the costs of alternatives, the TCP will look in the first instance to the pool reserve before seeking funding from outside of the pooled budget.
  • Any overall shortfall on new community care is funded by CCGs and Local Authorities.
  • Any new or re-commissioned secure bed is funded at cost from the pool reserve in the first instance.
  • The NHS England contribution to the pool in future years will be uplifted or amended based on NHS England planning principles.

What were the existing financial arrangements?

  • In April 2016, Kent established a pooled budget between the Kent CCGs and Kent County Council for all community learning disability services under a section 75 agreement. NHS savings or dowries on hospital placements are transferred into the pooled budget and can be invested into community services. This allows the money to follow the person.
  • In April 2017 the Kent CCGs and Kent County Council started integrated commissioning for learning disability services under the section 75 agreement. The NHS England specialised commissioning budget for out of area placements has been transferred into the local pooled budget and savings will be moved into the pool as out of area placements decrease.
  • Medway is not part of the integrated commissioning arrangements in Kent, but the two areas are working to introduce a separate section 75.
  • Surrey is exploring a pooled budget arrangement.
  • Sussex does not have a cross-county section 75 pooled-budget. The three local authorities operate independently with different financial infrastructures. West Sussex has a pooled budget, East Sussex are considering shadow arrangements in 2017-18 and Brighton & Hove are looking to explore options and potential.