Mental Health of Older Adults

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 Alzheimers 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
• Alzheimers 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

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Need for change

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

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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

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New investment required 2 million

• Lewisham CMHT 488k
• Southwark CMHT 435k
• Lambeth CMHT (incl daycare) 479k
• Kings liaison 185k
• St Thomass liaison 185k
• UHL liaison 185k
• Central services 54k
• 2.0m

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Intermediate care development bids

• Intermediate care services c 1.5 million
• Lambeth 20 beds
• Southwark 15 beds
• Lewisham 15 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

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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
• Southwark 41 beds
• Lewisham 71 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

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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

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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

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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

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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

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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