transforming adult mental health services and support in
TRANSCRIPT
Transforming Adult Mental Health
services and support
in Lambeth – an overviewin Lambeth – an overview
Health & Well Being Board
22 October 2014
The Collaborative
The Lambeth Living Well Collaborative: A collaborative platform for people to come together to
improve outcomes
Primary Care
People who
use services Commissioners
Voluntary Sector Providers
Carers
CliniciansPrimary Care
Public Health
Mental Health Trust
Social Care
Co-design and
collaboratively
deliver services
to support a
shift in how we
support peopleRunning an ongoing
process involving over
1,600 people actively
contributing to the
design and delivery of
improved services
support people
Co-production Principles (NEF/NESTA)
1. Recognising people as assets
2. Building on people’s existing capabilities
3. Peers support networks
4. Blurring distinctions
5. Facilitating rather than delivering
6. Mutuality and reciprocity
Six Design Principles
1. Improved Access: “Easy in, easy
out” arrangements for all services
focused on supporting “recovery” and
“independence”
2. Easier access: to secondary care
assessment and treatment; support for
primary care including link workers;
easier access back “in” should users
require this ; improved discharge
arrangements
3. More and Better Information: a
new resource information service –
both virtual and physical
Big 3 outcomes
1. Recover and stay well
experiencing improved
- Quality of life
- Physical and mental health
2. Make their own choices &
achieve personal goals,
experiencing increased
- Self-determination and
autonomy
3. Participate on an equal
footing in daily life
specifically
- To ‘connect’ with e.g. family,
The Collaborative’s Vision
“We will [work to] provide the context within which
every citizen whatever their abilities or disabilities,
can flourish, contribute to society and lead the life
they want to lead.”
both virtual and physical
4. Better Guidance: personal
guide/community recovery workers
within the Voluntary sector
5. Capacity where it counts:
improved capacity for primary care and
GPs to support and manage mental
health patients including easier access
to social and community support
options and peer support services led
by service users
6. Getting Connected: ensuring social
inclusion through various means
including time banking.
friends & neighbours
- To ‘give’ in the community
e.g. community activities,
volunteering, peer support
- To ‘be included’ especially
in relation to education,
employment, adequate
income and stable housing
- To ‘participate’ on an equal
footing with others with
reduced stigma &
discrimination e.g. in access
to mainstream services,
housing, education and
employment
Service User Priorities
1. Continuity of care when care is needed
2. Effective communication between all
3. Easy access and better Information
4. Steps to tackle stigma
5. Access to work and training
6. Reduced social isolation and actions to
promote inclusion
7. Bespoke services that are cultural and
gender specific
8. Services that respond outside of the
traditional working week hours
Principles of co-production
The Collaborative – A system wide change journey
Hurdles in the journey
• Public benefit approach not provider interest!
• Citizens and communities with assets
• Supporting positive risk taking
Today
• Users with needs and problems – in deficit
• Services not joined up, bureaucratic & inefficient
• Over professionalised with medical model dominant
• Competitive system
Tomorrow
• Users as citizens with lots to offer - assets
• Services flexible & responsive to need
• Person centred
• Collaborative integrated approach between statutory
6
• Easy in and easy out relationship with services
• Medium-longer term investment planning focused on outcomes
• Flexible procurement and contracting
• Competitive system
• Variability of service and quality across system
• Geared towards monitoring & crisis management
• Promotes dependency
• Professionals communicate via referral
• Performance measured by activity
• Financially unsustainable
approach between statutory services, VCS, & especially primary care
• Geared towards recovery
• Promotes independence and resilience
• Professionals communicate by working together
• Performance measured by outcomes
• Financially viable
1. Working with People Differently 2. Mobilising people and changing
our culture
3. Integrated services to
make a better offer1.1 Timebanking support growth
1.2 Peer Support – expand in all settings. Grow
information web base platform –EBE.
1.3My Health Locker (patient held record)
1.4 Community Connecting i.e. Connect and Do
1.5 Living Well Live and Buddy Pack – Dec 2014
1.6 Work with communities e.g. Black Well Being
commission
2.1Workforce and Culture Change
2.2 Develop diffusion strategy
2.3 Communications strategy – grow website
plan/social media
2.4 Develop technology strategy to support co-
production approach
2.5 Personalisation/Support planning training
2.6 Introduction to LWN training
2.7 Recovery and Support Plan – Implementation
3.1 Revise Collaborative
Principles/Values/Vision
3.2 Deliver the Living Well Network
across the whole borough from Sept
2014
3.3 Develop Community based
Forensic/MDO services with NHSE
3.4 Increase access to Vocational and
Employment services and opportunities4. Changing the way services are
Collaborative Road Map – Key Workstreams (July 2014)
2.7 Recovery and Support Plan – Implementation3.5 Implement SLaM AMH redesign
3.6 Integrated Talking Therapies -
expand access
3.7 Improving information and choice
options – Living Well Partnership
3.8 Support for people to maintain
tenancies and increase access to range
of housing provision
3.9 Roll out Primary Care Mental
Health Community Incentive Scheme –
July 2014
3.10 Agree plans for location and
deployment of social workers – Dec
2014
4. Changing the way services are
commissioned4.1 Revise Commissioning Framework
4.2Whole system dashboard to monitor
capacity/flow of LWN and AMH redesign
4.3 Support design led approach to service
improvement
4.4 GSTT Charity Bid – to support LWN- Dec
2014
4.5 Develop Alliance Contracting Framework -
Rehabilitation services – Oct 2014.
4.6 Development of outcomes based specification
– Big 3/Health of the system metrics including
evaluation with IOP/NIHR
4.7 Scale up access to Personal Budgets
4.8 Review PbR requirements
5. Collaborative Leadership
5.1 Advocate the case for change/evidence base
to support economic case for change
5.2 Continue to engage and support development
of the co-operative council and SLIC
5.3 Engage with regional and national
organisation and networks to promote and share
co-production
5.4 Continue the development of the Collaborative
platform - hold 3 large scale borough wide
workshops
Commissioning is about enabling an effective
dynamic with communities and individuals to
understands their needs, their assets and their
Commissioning supporting co-production
understands their needs, their assets and their
aspirations, in order to fund effective, meaningful
and efficient support.
System Resource Map: Adult Mental Health 2014/15
9
June 2010:
Lambeth Living Well Collaborative established
September 2011:
Innovations already in place :• Cooperative Council demonstrator site – Nesta People
Powered Health Programme
• Community options service and Primary care support
team – 500+ people supported
• SWOT team and VCS supporting people to move to
independent living – better outcomes, reduced cost
• Range of peer support initiatives – 700+ people
Innovations already in place :• Cooperative Council demonstrator site – Nesta People
Powered Health Programme
• Community options service and Primary care support
team – 500+ people supported
• SWOT team and VCS supporting people to move to
independent living – better outcomes, reduced cost
• Range of peer support initiatives – 700+ people
March 2011:
Range of new initiatives commence
Our Collaborative Journey
April 2014:
System change
September 2011:
Provider Alliance Group established
November 2013:
LWN commenced
Next steps at scale and pace
• Grow innovations to scale – peer support,
connect and do, personal health budgets etc
• Implement an expanded LWN across the
borough
• Implement Secondary care remodel
• Implement Integrated Personal Support
Alliance contract framework to support
transformation – Oct 2014
• Support workforce development and culture
change
Next steps at scale and pace
• Grow innovations to scale – peer support,
connect and do, personal health budgets etc
• Implement an expanded LWN across the
borough
• Implement Secondary care remodel
• Implement Integrated Personal Support
Alliance contract framework to support
transformation – Oct 2014
• Support workforce development and culture
change
• Range of peer support initiatives – 700+ people
contacts
• “Connect and Do” initiative supporting people to get
connected.
• Living well partnership resource centre
• Personal health budgets – 110 in place
• Living well network hub – 900 people “introduced”
since November 2013
• Multi agency “co-production” workforce development
via the LWN
• Development of Buddy pack and Living Well Live
• Range of peer support initiatives – 700+ people
contacts
• “Connect and Do” initiative supporting people to get
connected.
• Living well partnership resource centre
• Personal health budgets – 110 in place
• Living well network hub – 900 people “introduced”
since November 2013
• Multi agency “co-production” workforce development
via the LWN
• Development of Buddy pack and Living Well Live
Living Well NetworkNetwork of support and
services in communities to
help support people with
mental health problems
Integrated Personalised
Support Alliance • Support people with severe and
enduring mental health problems
and complex life issues
• Agrees and manages funds for
those assessed as needing funded
personalised packages of care and
support and Personal Budgets
Work with wider system
to create appropriate
services and support
Approve small
personal budgets
AMH System Transformation
Adult MH Services • Improve ‘easy in’
• Reduce reliance on bed
based services
• Reduce relapse rates
• Transfer patients to
primary care
support and Personal Budgets
Identify appropriate
personalised care
packages (see below)
In reach to plan
discharges and co-
design personalised
support
Approve and manage
care packages
Early intervention
and person centred
support prevents
crisis
Short intense
interventions
if needed
New Rules - Care package and
personal budget funding only
approved if:
- User owned integrated assessment
- User owned recovery and support
plan
- Commissioned service identified
or rationale given for not using
commissioned service
- No residential care placements
A new model of support led by Primary Care and Social Care
The big 3 outcomes developed by Lambeth Living Well
Collaborative:
1. Recover and stay well
2. Make their own choices & achieve personal goals
3. Participate on an equal footing in daily life
Primary Care
Outcomes – must represent value to all
People who
use services
Commissioners
Voluntary Sector Providers
THE
COLLABORATIVE
THE
COLLABORATIVE
Carers
CliniciansPrimary Care
SLaM
Public HealthPlus other outcomes that matter
4. Social value
5. Cost
6. Safety
“Detecting and
facilitating the
wobbly factor”
The community boundary
Current crisis
management and
investment focus
Change investment pattern to support outcomes
Current investment
Turning the system on its head
2014-15 - total investment
c£66m
2016-17- total investment
c£58m
Investment shape – now and future
Secondary
Care
(£43m)
LWN
(£23m)Secondary
Care
(£28m)
LWN
(£30m)
Living Well Network
• In the first nine months to July 2014 the Living Well
Network North Hub received 1280 introductions
• In recent months 50%-60% of those were offered
alternative support in a primary care/community
Living Well Network - Impact and outcomes
alternative support in a primary care/community
setting via the Hub
Secondary
Hub
Living Well Network - Impact and outcomes
Referrals to secondary care have dropped to below 40
Secondary
care
GP
A&E
Talking Therapy
CMHT
Sources of introduction
Living Well Network - Impact and outcomes
CMHT
Police
Home Treatment Teams
Voluntary Sector
Other
Not known
We believe that:
1. A more connected community helps people to flourish
2. People can develop their ability to grow and sustain connections
around their interests
3. People just need a little bit of a hand, but at the right time
Supporting people to get connected back to life – Connect and Do
:3. People just need a little bit of a hand, but at the right time
4. There are great people, great groups and great places in our
communities who can make this happen
We aim to connect people to friends, groups and places that exist outside of specialist care services
Connect and Do
First quarter over 800 visitors with 60% returning
• Good background of collaboration
• Strong ethos of co-production
• Strong shadow Provider Alliance Group
(PAG)
• But – have we reached limit of change
through informal partnership?
Lambeth Living Well Collaborative Review of rehabilitation services
• 2013: Lambeth CCG and SLaM review of inpatient
rehabilitation services concluded that services should
be redesigned in order to deliver personalised,
recovery-based community based services.
• People receiving in-patient services had similar profiles
to those accommodated within residential care spot
placements.
• Jan 2014: Integrated Commissioning team set up
project to create new commissioning and contracting
Alliance Contracting – supporting system change and integrated care
project to create new commissioning and contracting
arrangements.
• 55 in-patients currently in SLaM Rehabilitation
Services; c£5.5m
• c150 people supported in Local Authority social
care placements; c£5m
Transforming Rehabilitation –
Integrated Personalised Support Alliance
• Existing / new service users who are:
– resident of the London Borough of Lambeth
– registered with a Lambeth general practitioner
– have complex mental health needs
– assessed as able to benefit from engagement with the
service
Improved personalised, integrated service and support for:
Rehabilitation Services in Mental Health: A fresh approach
8
10
12
c25% savings
based on SWOT
experience
200 people in
in-patient and
residential
placements
across Lambeth
CCG and
Lambeth LA
• c50 people currently in inpatient rehabilitation facilities (funded by the CCG)
• c150 people residing in mental health spot placements (social care).
• any and all future referrals
Financial Overview
0
2
4
6
Current budget Proposed new budget Direct costs / overheads Gain share /pain share
Mil
lio
ns
Commissioner
P
PP
Commissioner
Traditional contract Alliance contract
P
PP
P PP
What is an alliance contract?
Alliance
PP
P
Separate contracts with each party
Separate objectives for each party
Performance individually judged
Commissioner is the co-ordinator
Provision made for dispute
Contracts based on tight specification
Change not easily accommodated
One contract, one performance framework
Aligned objectives and shared risks
Success judged on performance overall
Shared co-ordination, collective accountability
Expectation of trust
Contract describes outcomes and relationships
Change and innovation in delivery are expected
P
• Delivery of savings targets: to what
extent will this new model of
commissioning / contracting enable us
to deliver against our savings plans
across the CCG, Borough, providers etc
• Achievement of desired outcomes:
commissioners will need confidence
that providers / the provider landscape
will ensure that high quality services are
Procurement models
Delivery of
savings
targets
Achievement
of desired
outcomes
Enabling
integration
and co-
production
Balancing
innovation
and
sustainability
Nochange No change L L L L
Go to market for
some services based
on existing
contracting model
M M L L
Assessing options
Procurement Options – Integrated Personalised Support Alliance
will ensure that high quality services are
delivered to all current and future
patients
• Enabling integration and co-
production: ensuring that services,
providers, professionals and teams work
together for a coordinated approach to
provision co-produced with service
users.
• Balancing innovation and
sustainability: provider configuration
needs to bring forth the innovation
critical to achieving change – while also
ensuring a sustainable provision for
residents of Lambeth.
Current
providers
Lead provider M M M L
Alliance H H H H
Open market
Single provider M M L M
Lead provider M M L M
Alliance M M M H
Key Result Area Key Performance Indicators
Recovery and staying
well
Mental health wellbeing
Physical health
Unplanned use of services
Self determination Place of residence
Draft KRAs
• KRAs underpinned by KPIs and
thresholds set by Commissioner
• Alliance Leadership Team proposes
metrics, review cycles and processes for
performance management
• Metrics have thresholds of Game-
IPSA – Key Result Areas (i.e. Outcomes)
Self determination Place of residence
Use of personal budgets
Participation In employment
Meaningful activities
Social Value Measure of community asset development,
community resilience or ‘citizen lifetime value’
Cost Actual costs compared with target costs
Safety Number of incidents of safeguarding, self harm
or offending
• Metrics have thresholds of Game-
breaking; Stretch; Minimum Conditions
of Satisfaction; and Failure
Invitation to apply 27 June 2014
Commissioner / Provider alignment July 2014
Development phase – modelling, development of new model of
care and support
August – October 2014
Commissioning agreements – Memorandum of understanding October 2014
Convergence Audit (due diligence) undertaken October 2014
Commercial Alignment workshop – Heads of terms and 19 November 2014
Alliance – outline timetable
Commercial Alignment workshop – Heads of terms and
implementation plan to be agreed
19 November 2014
Approvals - Outcome panel, procurement board, cabinet, CCG
board
December – January 2015
Alliance agreement signed – new service commences on phased
basis
January 2015
1. Implement LWN across the borough – Oct 2014
• Grow innovations to scale – peer support, connect and do, personal budgets, community incentive scheme etc
• Build network in south and develop housing and employment support plans
• Pilot asset based community development (ABCD) approach
2. Implement Secondary care remodel – Sept 2014
• Improve recovery rates by earlier intervention
• Increase community, home based support and reduce bed base
• Support LWN and alliance development
Next Steps
• Support LWN and alliance development
3. Implement alliance contract – Jan 2015
• Finalise new model of support / contractual terms - Nov
• Commence service mobilisation Nov
• Obtain approvals Dec/Jan 2015
Plus
Workforce development and culture change – including future deployment of social workers/function
Develop links with SLIC, LEAP and other asset building initiatives