This briefing for local authority colleagues has been produced by the Transforming Care Cross-System Finance Group, which consists of representatives from the Association of Directors of Adult Social Services (ADASS), Local Government Association (LGA) and NHS England (NHSE).
It updates briefing notes produced in February 2020 and July 2018, and outlines the work which continues to take place to ensure that there is a clear and agreed financial model underpinning our mutual objectives of:
- ensuring a reduced reliance on inpatient care for people with a learning disability, autism or both,
- through investment in community alternatives to hospital care.
This note has been written with Local Authority (LA) colleagues in mind but will also be relevant to those working within Clinical Commissioning Groups (CCG), Transforming Care Partnerships (TCP), and those leading on learning disability and autism within an Integrated Care System (ICS) or Sustainability and Transformation Partnership (STP).
Key points
Here, we have restated the key points from the July 2018 guidance which remain relevant, and the Cross-System Finance Group will continue to offer bespoke national support to assist with learning disability and autism finance and funding issues.
All partners are strongly encouraged to be equally and actively involved in the ongoing development of relevant financial plans and their refresh, whilst noting that in a number of areas this is likely to be increasingly part of the wider system development of ICSs and STPs;
Dedicated or ringfenced sources of funding consist of:
In addition, both CCG and LA expenditures continue to meet general and specialised health and statutory social care needs. CCGs could potentially release funding for investment in community alternatives as reliance on inpatient services is reduced;
Applications or agreed areas of spend from these funding sources are essentially as follows, although Pathway Panels will have freedom to decide priorities for funding based on local engagement and the development of a local Pathway Strategy for reducing reliance on inpatient services and investing in alternatives to inpatient care:
- packages of support for dowry-eligible individuals (these remain a first priority call);
- other packages of support in the community for individuals not dowry eligible;
- CHC and Section 117 mental health aftercare contributions;
- community services with a specific purpose in preventing hospital admission for people with a learning disability, autism or both, e.g. intensive support services.
We continue to recommend that these funding sources are transparent to all partners in the system, and that TCPs/STPs/ICSs have an agreed approach to mutual responsibilities. This may include an aligned or pooled budget, and model Section 75 agreements.
We would also suggest that each TCP (or equivalent) has a relatively simple high-level Risk Sharing Agreement in place, governing the key funding principles shared and agreed between LAs, CCGs, NHS-led Provider Collaboratives and NHS England Specialised Commissioning teams operating in the TCP area. The Pathway Panels which will oversee each Pathway Fund have additional guidance which sets out key principles for risk-sharing, engagement with local people and transparency.
Finally, the offer of providing bespoke finance/funding support for TCPs – first made available jointly between the LGA, NHS England and ADASS in 2019 - also remains available on request. Please email either Simon Williams at [email protected] or Ben Fletcher at [email protected] if you wish to take up this offer.
System changes
The July 2018 and February 2020 briefing notes described sources of funding, financial principles and tips for LAs to deliver the ambition set out in Building the Right Support1 (BRS). Since their publication, we have seen significant policy development which must now be taken into account when considering our current financial model.
NHS England Long-Term Plan
The NHS Long-Term Plan (LTP) was published in January 2019. This plan continues, and goes beyond the commitments made in BRS to reduce the reliance on inpatient care, as well as increasing the investment made in intensive, crisis and community support. The specific commitment made in respect of reducing the number of people with a learning disability, autism or both in an inpatient setting is as follows:
- by March 2023/24, inpatient provision will have reduced to less than half of 2015 levels (on a like for like basis and taking into account population growth)
- for every one million adults, there will be no more than 30 people with a learning disability and/or autism cared for in an inpatient unit
- for children and young people (CYP), no more than 12 to 15 children with a learning disability, autism or both per million, will be cared for in an inpatient facility.
The LTP also makes a commitment to improving the quality of inpatient care, and reducing the health inequalities faced by those with a learning disability, autism or both. It therefore builds upon the commitments made in BRS, and positions learning disability and autism as a fundamental pillar of NHS strategy. Given we are now operating within the scope of the NHS
LTP, this briefing note will primarily refer to commitments made in this strategy, and more widely to people with a learning disability, autism or both, rather than Transforming Care.
NHS-led Provider Collaboratives
The LTP sets out a vision for greater local system integration and autonomy. In specialised mental health services, this aspiration is being implemented by enabling NHS-led Provider Collaboratives (piloted as New Care Models). These groups of providers will take responsibility for specialised mental health, learning disability and autism services for their respective populations.
People who use specialised mental health, learning disability and autism services often receive care and treatment away from home, can spend longer in hospital than they need to, and their experience can be fragmented. NHS-led Provider Collaboratives will become the vehicle for shifting resources to community support to prevent avoidable admissions and support recovery in the least restrictive setting, as close to home as possible.
New Care Models
Since 2017, 14 New Care Models pilots have delivered tangible improvements for people who use services and their families. Through the pilots, over 300 people have been brought back into local services from out of area placements. Admission rates have fallen and there are now more than 70 fewer CYP and 350 fewer adults in out of area services. In a number of pilot sites, median distances from home and length of stay have significantly reduced.
All Wave 1 sites and most Wave 2 sites have made savings against their budgets and have been able to reinvest in new services including; Adolescent Outreach Teams, DBT (Dialectical Behaviour Therapy) Teams, enhanced talking therapy services, a Forensic Recovery Support Team, an Assertive Transitions Team, Women’s Forensic Step-down, Crisis Care and Home Treatment Teams. Within the sites there is a strong sense of ownership and empowerment, and a notable shift towards a more collaborative culture across all stakeholders.
Provider Collaboratives
From April 2021, 15 NHS-Led Provider Collaboratives will be financially and clinically responsible for delivering adult medium and low secure mental health and learning disability and autism services to their respective populations. (Provider Collaboratives in London actually went live earlier.) Each Provider Collaborative will span a number of CCGs, and be able to pool financial risk across the partnership, allowing funding to follow the person. Each Collaborative will have the flexibility to make savings and reinvest in community and step- down services to improve the whole pathway and reduce reliance on the most specialised and restrictive services.
NHS England will hold contracts with the Lead Provider of the Provider Collaborative. Lead Providers will hold subcontracts with other members of the Provider Collaborative, supplemented by a partnership agreement. NHS England will retain accountability for the commissioning of services which it will exercise through a contract with the Lead NHS Provider, which will carry out a number of the commissioning tasks across the collaborative.
Provider Collaboratives will work closely with ICSs and alongside service users, carers and families to support improved commissioning of services for people within their population footprint. This approach aims to improve clinical oversight of people’s care, with a view to delivering care closer to home and to enable money released from specialised inpatient care to be invested in community services to reduce inappropriate admissions and length of stay for people who do require hospital care.
Reinvestment in alternatives to inpatient care
The current mechanism for releasing funds from specialised inpatient services for reinvestment in community services is the FTA. This national ‘one size fits all’ formula is incompatible with the ambition for local service integration and autonomy, and a review of the FTA in 2020 developed a working proposal for Pathway Funds, each overseen by a Pathway Panel. Panels must be inclusive of local system partners including CCGs, LAs, the voluntary sector and those with lived experience. Further details are set out below, in a separate briefing note sent to Directors of Adult Social Services in late 2020 and in guidance sent to stakeholders in early 2021.
It is vitally important that plans developed by TCPs and equivalent bodies around the transformation of community services for people with a learning disability and autism are aligned with plans developed by Provider Collaboratives for the future of specialised inpatient services. Therefore, LAs and CCGs are strongly encouraged to engage with NHS-led Provider Collaboratives through Pathway Panels.
Integrated Care Systems and Transforming Care Partnerships
ICSs bring together local organisations to design and deliver place-based health and social care. The NHS LTP makes a commitment that, by April 2021, every area of the country will be covered by an ICS. Furthermore, the LTP confirms that we will continue to support local areas to align health and social care budgets where this makes sense to do so.
Transforming Care Partnerships (TCPs)
TCPs have been the vehicles through which local areas have developed and implemented their vision for people with a learning disability and autism, and deliver the ambition set out in BRS. In some areas, in line with the development and maturity of the ICS, the governance of the TCP may be merging with that of the ICS, so that there is a single place for strategic discussion and oversight of delivery of LTP commitments relating to learning disability and autism. Moving forward, when we refer to a TCP, we are also referring to any new structure that may be emerging/have been developed which delivers the functions of a TCP.
The Pathway Panels and Funds envisaged as the future mechanism for releasing resources from specialised inpatient services for reinvestment in community services are expected to extend TCPs or equivalents by ensuring NHS-led Provider Collaboratives are included too. Hence, Pathway Panels are generally expected to build on or align with these existing forums, rather than replace or compete with them.
Review of existing guidance and funding arrangements
National Programme funding
The National Learning Disability and Autism Programme (NHSE) has secured resources to enable delivery of LTP commitments both at a national and local level. Over the next 3 years, significant additional funding will be made available, increasing from £55.7m in 2020/21 to £168.0m in 2023/24. The majority will be delegated to NHS Regions for onward investment by local systems. Most of the regional funding will be allocated on a ‘fair shares’ (population) basis, with the rest offered for targeted investment.
Priorities for National Programme funding include:
- community services in line with the BRS service model
- key workers for children and young people with the most complex needs
- Care (Education) and Treatment Review (C(E)TR) delivery and full implementation of dynamic support systems
- health screening services in residential schools
- continued support to, and development of, the Learning from Deaths (LeDeR) programme.
Funding Transfer Agreement
The FTA has incentivised local systems to reduce the number of people in specialised inpatient services with payments of £180,000 per net inpatient reduction per year. It is expected to be worth over £90m for inpatient reductions achieved to the end of 2020/21.
However, the FTA in its current form is incompatible with the implementation of NHS-led Provider Collaboratives. Each collaborative serves a different population footprint and has different challenges in reducing the number of inpatients.
A review of the FTA was carried out in 2020, overseen by an Executive Group co-chaired by chaired by Ray James (the former National Director for Learning Disability, NHSE) and Simon Williams (Director of Social Care Improvement, LGA). A working group brought together representatives of the LGA, ADASS, NHS Regions and Specialised Commissioning, and the voluntary sector, plus Experts by Experience, to develop a working proposal for locally-determined Pathway Funds.
Pathway Funds will replace the FTA from 1 April 2021. Therefore, the FTA will end on 31 March 2021. Final FTA amounts will be confirmed at the end of the financial year and these will become recurrent payments in future years.
Pathway Funds
Pathway Funds are intended to be locally-determined replacements for the FTA. NHS-led Provider Collaboratives will sponsor the creation of Pathway Panels which provide the governance for and oversight of each Fund. It is expected that there would be a Panel aligned with each TCP, with TCPs themselves providing the logical starting point for ensuring appropriate stakeholder representation.
Each Panel is expected to develop a Pathway Strategy which sets out, as a minimum, how the specialised inpatient target for adult services is to be achieved, the scope for releasing resources for reinvestment in alternatives to inpatient care and the priorities for investment. Panels can decide locally if they wish to extend the scope of the Fund, for example, including Children and Young People services, and which funding streams could be aligned with the Fund, besides costs released from adult secure services.
A series of webinars in autumn 2020 introduced the Pathway Fund proposal. Further sessions are being held in early 2021. Full guidance has been sent to Provider Collaboratives and will be shared with LAs, CCGs and TCPs in early 2021. Questions about Pathway Funds and the guidance can be sent to [email protected].
Dowry commitment
BRS included a commitment to make resources available to support the ongoing care of those patients with the longest length of stay as they move into the community. Inpatients with a stay of five years or longer on 1 April 2016, and who remain in inpatient care, remain eligible for a dowry payment. It was expected the dowry would be funded out of the FTA for patients discharged from specialised services and CCGs should fund the dowry for patients discharged from services they had commissioned. The size of the dowry would be locally determined.
We appreciate the intense financial and operational pressures faced by the health and social care system, but it is important to celebrate success too. Since the publication of Building the Right Support, through collaborative working the number of people with a learning disability, autism or both in hospital has reduced by well over a fifth, and progress has continued even through the pandemic. Fewer than ever people with a learning disability and autistic people are in hospital – which means more than ever are living fulfilling lives in their own homes.
Thank you for all of your hard work and support to improve the lives of people with a learning disability, and autistic people.