|
Meeting: |
Executive Meeting |
|
Meeting date: |
10th October 2024 |
|
Report of: |
Corporate Director of Adult services and Integration (DASS) |
|
Portfolio of: |
Cllr Lucy Steels-Walshaw, Executive Member for Health, Wellbeing and Adult Social Care |
Decision Report:
Community Dementia
Model
Subject of Report
1. The purpose of this report is to approve the commissioning of a new Community Dementia Model for a period of three years (with an option to extend for two years), with the Integrated Care Board (ICB) as lead commissioner and City of York Council (CYC) as partner.
2. The Community Dementia model will be contracted by the ICB with CYC as partner.
3. This report discusses the benefits of investing in the above and risk / impact of not doing so.
Benefits and Challenges
Benefits
4. The positive impacts of these services on our residents are manifold and there is a risk and impact of not having these services. Some of the benefits are detailed below.
5. This will be a new dementia model with a lead specialist provider. This will involve joint working and collaboration with a focus on prevention, early intervention and maximising independence and is designed to minimise overlap and improve coordination and cooperation. The model will promote partnership working, innovation and flexibility of the services provided and is in line with the asset-based community development model. It will enable delivery of the priorities of the York Dementia Strategy[1] and be accountable to the Health and Wellbeing Board and York Place Board. There will be a steering group of stakeholders including people with lived experience and their carers.
The service will deliver:
· Wrap around pre and post diagnostic support for people with cognitive impairment and dementia and their families / carers
· Dementia helpline
· Dementia wellbeing cafés providing meaningful activities for those living with dementia,
· Carer breaks whilst those living with dementia attend day clubs providing activities
· Activities that both the person with dementia and their carer can do together, for example, singing for the brain
· Dementia Support Advisers (work with people living with dementia and their families at any stage of their illness) currently funded through the Council
· Memory Support Advisers integrated within primary care frailty hub and connecting GPs and patients with the voluntary / community sector
· Brain Health Cafes (weekly drop in cafes for people concerned about confusion or memory loss, supported by trained staff and volunteers as well as a range of health and social care professionals who attend)
· Community liaison – trainers who run sessions in various settings ensuring people are dementia aware
Challenges
6. The challenges of not having this much-needed community model for those who are just about coping means:
· Potentially putting further pressure / costs on other areas. The needs of the individuals will remain and increase with no support pushing individuals into a more costly package of support.
· Unable to fulfil Council Plan commitments for example:
“targeting our support at those who need it most, supporting communities to build on their own strengths and those of the people around them” A reduction in services will impact on Council Plan delivery and will limit ASC’s commitment to delivering areas of the Council Plan.
7. Through the dementia strategy, health and social care have signed up to deliver a model that supports collaboration with the third sector and voluntary organisations. The risks to not having an integrated model means that services are not accessible, streamlined or embedded within the community ensuring a coherent pathway. Not having this community model risks duplication in funding and use of already stretched resources.
8. The integrated model will have clear pathways that connect people to support in their communities ensuring people can be directed to the right level of support at the right time for them.
Policy Basis for Decision
9. The Care Act 2014[2], places a series of duties and responsibilities on local authorities to improve people’s independence and wellbeing. It makes clear that local authorities must “provide or arrange services that help prevent people developing needs for care and support or delay people deteriorating such that they would need ongoing care and support”[3]
10. Statutory Guidance[4] defines “Delay: tertiary prevention / formal intervention” stating these “are interventions aimed at minimising the effect of disability or deterioration for people with established or complex health conditions, (including progressive conditions, such as dementia). supporting people to regain skills and manage or reduce need where possible”
This describes the purpose of the Dementia Community Model, also supporting carers through the service.
11. City of York’s Council Plan, 2023-2027[5], has four core commitments, 3 of which are embodied within this proposal.
12. Equalities – “We will create opportunities for all”, by creating opportunities for our more vulnerable residents to access their communities and feel more included in our city.
13. Affordability – this new model will be “targeting our support at those who need it most, supporting communities to build on their own strengths and those of the people around them” by investing in residents and communities earlier if additional, more formal support, is required this will be at lower level or much later in a resident’s dementia journey.
14. Health – “We will improve health and wellbeing”, those accessing the dementia community model and their carers are often more isolated and vulnerable and in need of bespoke communities they can access to improve their wellbeing.
15. A key priority in Adult Social Care is the continued development of our Home First Model where one of the 5 key priorities outlines in City of York Council’s (CYC) All Age Market Position Statement[6] is to “Move to a community asset approach of prevention and living well in older age.”
16. The Joint Health and Wellbeing strategy[7]’s, 2022-32, sets out ‘Ten Big Goals’ within it and this proposal supports the strategy as outlined in the table below.
|
No. |
Description |
Action Plan |
How |
|
8 |
Improve diagnosis gaps in dementia…to above the nation average |
support the implementation of the dementia strategy |
Dementia Community Model |
|
10 |
Reduce the proportion of adults who report feeling lonely |
identify gaps in provision for those at greatest risk of loneliness |
Dementia Community Model |
17. The York Dementia Strategy[8] (2022-27) states, “We recognise that it is important to support people living with dementia to live the life they choose and to feel included in the community”. Having the right community services to access is key to ensuring York is a dementia friendly city.
Financial Strategy Implications
18. The proposal for the dementia model requires Council funding of £140,000 p.a. (potentially £700,000 over the five year contract) which can be met from the existing budget envelope.
19. There is a duty under the Care Act for Councils to ensure there are services which prevent and delay Carers and individuals needing care which this proposal falls under (see Legal section for these duties). This proposal is congruent with that duty: It is difficult to assess whether this delivers that duty at the minimum level but as CYC are contributing £140,000 out of £379,000 annually, it suggests the scheme is supported with an appropriate level of resource according to our duties.
Recommendation and Reasons
20. Executive are asked to:
Agree the funding to continue CYCs contribution to funding the new Community Dementia Model for a period of three years (with an option to extend for a further two years) noting
· the contract will be procured by the ICB with CYC as a partner,
· through a lead provider model and engagement with the market and to delegate to the Corporate Director of Adult Social Care and Integration (in consultation with the Head of Procurement and the Director of Governance) the authority to enter into an agreement with the ICB for the provision of the funding and to agree to the award of the resulting contract for the Community Dementia Model service by the ICB.
21. Reasons to support this proposal are outlined below.
· Prevention, as defined in the Care and Support Act Statutory Guidance[9], is about the care and support systems actively promoting independence and wellbeing, it states, “These are services, facilities or resources provided or arranged that may help an individual avoid developing needs for care and support, or help a carer avoid developing support needs by maintaining independence and good health and promoting wellbeing.”
· There will be an increase in those living with dementia, those needing care and those providing unpaid care. York’s Joint Strategic Needs Assessment[10] projects care needs of some adults over the age of 65:
|
Population |
2020 |
2040 |
|
Living with dementia |
2,927 |
4,291 (+47%) |
|
Needing care |
11,380 |
15,207 (+34%) |
|
Providing unpaid care |
5,271 |
6,592 (+25%) |
· York’s JSNA estimates there will be 3,860 people living with dementia in York by 2030.
· All health and care services will be put under increasing pressure with an increased and ageing population. Population growth forecasts indicate:
· The resident population of York is forecast to grow by approximately 35,000 between 2023 and 2033 with the largest percentage increases in the over 65’s, an estimated additional 13,800 residents aged 65+ by 2033.
· The GP registered population is forecast to increase from 251,000 (currently) to 255,600 by 2033.
· Population health forecasts indicate continued challenges on an already stretched system:
o In 2022, life expectancy for males declined from a peak of 80.2 years (2019) to 79.2 (2022), and for females declined from a peak of 84.1 years (2019) to 83.3 (2022). Male life expectancy in York has now crept below the national average for the first time (York is 75th out of 148 LAs).
o The number of individuals living with multiple Long Term Conditions is increasing in York, indicating increased and more complex health and care requirements for these individuals in future years.
· Investment into a new community dementia model will bring together current community provision into one cohesive pathway and enable a more integrated offer for those living with dementia and their carers. Dementia is a growing need within the city and this model allows a more targeted approach to the use of limited funding.
· The impact of not having social connection is well documented on a human level and the links between loneliness and poor health are well established, the LGA comment in their report, Combating Loneliness[11], “It is associated with higher blood pressure and depression, and leads to higher rates of mortality-comparable to those associated with smoking and alcohol consumption. It is also linked to higher incidence of dementia, with one study reporting a doubled risk of Alzheimer’s disease in lonely people compared with those who were not lonely. As a result of these health impacts, lonely individuals tend to make more use of health and social care services, and are more likely to have early admission to residential or nursing care.”
· Good, accessible information and advice are essential to enable people living with dementia and their carers to play a full part in their community, make informed decisions and be able to access the right services for them. Care and Support Statutory Guidance[12] states; “It is critical to the vision in the Care Act that the care and support system works to actively promote wellbeing and independence , and does not just wait to respond when people reach a crisis point.” It states prevention services include services that, “…provide universal access to good quality information…”. As part of the
· To not have an integrated community dementia offer will increase costs onto an already overstretched budget position and increase expenditure of statutory services.
Background
22. York has moved to an asset-based community development model that empowers individuals and communities. Through an ethos of strength-based practice the aim is to support and assist individuals in remaining as healthy and self-sufficient as possible, enabling people to manage their own health and well-being in their own homes whenever possible. This proposal works within this model building community strengths by bringing residents and communities together.
23. Dementia services have been provided previously through an Older Persons Community Wellbeing contract which is ending on 30th September 2024. A bridging service has been put in place from 1st October 2024 for other elements of this contract.
Consultation Analysis
24. York’s Dementia Strategy, 2022-2027 was, “developed through collaboration between City of York Council, The York Health and Care Partnership, Healthwatch York, local community and voluntary providers, our local NHS Mental Health service provider (Tees Esk and Wear Valleys Trust), and the York and Scarborough Teaching Hospital NHS Foundation Trust. Through face-to-face conversations, online surveys and focus groups with people who have experience of living with dementia in York, and with those staff and organisations who have learned experience of the opportunities and challenges this creates, we have been able to better understand how York can become a better place to live, with better quality services for people with dementia and their carers”.
25. Healthwatch have consulted with people living with dementia, their carers and other stakeholders and their report, “Listening to people with dementia” was published in January 2023, attached alongside this report. Findings in this report showed that some people reported receiving no support at all, and others gave examples of inflexible and impersonalised support. This supports the need for an improved integrated community offer of support that is equitable for all.
26. There have been two annual events to mark the anniversaries of the strategy and examples of feedback at these events are:
· People need a timely diagnosis so they can access support and treatment sooner and so they and their family and carers know what to expect and make plans.
· The importance of the care plan process and carers wanting to engage in this
· Receiving the right information at the right time
· There are gaps in provision for people with young-onset dementia. Carers of people with young-onset dementia report a lack of age-appropriate activities and support, and the need for support to be flexible to accommodate employment.
· There is a challenge in finding crisis support around the clock
· When people are not supported correctly, crises – such as hospitalisation, carer breakdown and health deterioration become more common
· People told us they were unsure when they last had an annual review of their dementia care with many of those who did have an annual review saying it did not help them manage their condition
· Difficulties in navigating/accessing health and social care
· Respite for carers
· Meaningful activities, day care etc
Options Analysis and Evidential Basis
27. The population in York is aging, with an estimated increase of 50% for those aged 80 and over[13]. As people age the risk of living with dementia increase. Social connection is a vital part of a good life and access to good information and advice plays a key role in this.
28. The challenges of not having a community dementia model, on an already stretched social care and health system, are significant.
|
Risk / impact of closure |
Result /effect / consequence of closure |
|
People living with dementia and their carers will not have access to support and advice both pre and post diagnosis |
No cohesive community dementia model |
|
Carers |
Information and advice about support opportunities are crucial to help support to maintain a caring role. |
|
Carers |
The impact of no services and the anxiety caused to people using these services and family carers reliant on the respite provided should not be underestimated as well as increased costs elsewhere. |
|
Additional pressure on other services |
Potentially pushing the costs to other parts of the system. The need these services fill will still be there and will need to be fulfilled through other services – perhaps at a more costly level as people hit crisis. |
|
No offer will impact on other services |
Other statutory services will be impacted therefore offsetting any perceived saving. |
|
Adverse publicity |
The decision to close these services will have a negative reaction. |
|
Unable to fulfil Council Plan commitments for example: “targeting our support at those who need it most, supporting communities to build on their own strengths and those of the people around them” |
Reduction in dementia provision and other services will impact on Council Plan delivery and will limit ASC’s commitment to delivering areas of the Council Plan |
Organisational Impacts and Implications
29. Financial
The proposal for the dementia model requires £140,000 funding per annum from the Council towards the funding of the model as described below. This can be met from the existing budget envelope.
|
2025 to 2032 (5 years plus option to extend one plus one years) |
||
|
New Community Dementia Model (Lead Provider) |
Funding per annum (£) |
Funding Source |
|
140,000 |
CYC funding contribution (£34,000 from the Better Care Fund and £106,000 ASC budgets) |
|
|
60,000 |
ICB (currently invested in Dementia via CYC contract) |
|
|
40,000 |
ICB post-diagnostic support |
|
|
64,000 |
ICB recurrent funds for specialist dementia nurse and MSAs |
|
|
75,000 |
ICB SDF (service development fund) for MSA & dementia nurse |
|
|
379,000 |
TOTAL PER ANNUM |
|
|
£1,895,000 |
For the 5 year contract |
|
This means a commitment for the Council of £700,000 over the five year period.
The costs will be fixed for the lifetime of the contract and providers will need to demonstrate how they will manage the budget within this timeframe. The awarding of a five year contract mitigates the risk that no-one will bid for the contract if it doesn’t include inflationary uplifts.
The Better Care Fund grant is generally only allocated on an annual basis. Given it has been in place for approximately ten years there is limited risk in this ceasing and causing a £34,000 annual pressure to the Council.
30. Human Resources (HR)
The very specific details of the recommendations of this report in terms of the proposed service delivery options have been discussed with Human Resources and there are no HR implications based on the options presented.
31. Legal
There is a duty under s2 Care Act 2014 to prevent needs for care and support:
2(1) A local authority must provide or arrange for the provision of services, facilities or resources, or take other steps, which it considers will –
Contribute towards preventing or delaying the development by adults in its area of needs for care and support;
Contribute towards preventing or delaying the development by carers in its area of needs for support
Reduce the needs for care and support of adults in its area
Reduce the needs for support for carers in its area.
Any contracts being procured must be done so in accordance with the Council’s Contract Procedure Rules and the Public Contracts Regulations (2015) or the Provider Selection Regime (2023), as applicable.
Arrangements with the ICB in relation to the provision of the service may be done via a Section 75 arrangement which would be subject to the requirements of the NHS Act 2006, the NHS Bodies and Local Authorities Partnership Arrangements Regulations 2000 and related law.
Section 75 of the NHS Act 2006 can enable partners (certain NHS bodies and Councils) to collaborate in respect of defined “Prescribed Functions”. This can (subject to also meeting other criteria) enable partners to collaborate including as below:
a) by contributing to a common fund which can be used to commission health or social care related services;
b) for a local authority to commission health services and NHS commissioners to commission social care; and
c) for joint commissioning and commissioning of integrated services.
The power to enter into section 75 agreements is also conditional on meeting the following:
i. The arrangements are likely to lead to an improvement in the way in which those functions are exercised; and
ii. The partners have jointly consulted people likely to be affected by such arrangements.
Any elements of section 75 arrangements that would attract competition under the PSRs, PCRs and CPRs will also be subject to meeting competition rules.
32. Procurement
The intention would be for the ICB to Direct Award a contract to the existing Providers under a Lead Provider model. However, subject to any initial responses to published notices informing the supplier market of intentions to award contract, the ICB may be required to conduct an open procurement but would still work towards Contract Award by 01 April 2025.
33. Health and Wellbeing
Good brain health at all stages of life is a public health priority, as is the early detection of dementias and other cognitive issues so the right support can be given to residents and carers. There is a developing evidence base around the preventable components of dementia, with the Lancet Commission on Dementia suggesting 14 modifiable risk factors (e.g. high blood pressure, hearing impairment, smoking, air pollution) are responsible for up to 50% of dementia; and given the rising incidence of the disease and York’s aging population, a preventative and early detection approach is a key part of the city’s Health and Wellbeing Strategy. This model aligns to the strategy, and provides a more integrated and flexible community offer which emphasises health, emotional and social support for residents and carers along the assessment, diagnosis and post-diagnosis pathway. The provider should incorporate prevention and social / community support – including mutual support from peers – into its work to ensure dementia services are sustainable against the background of rising disease incidence.
34. Affordability
As cited in the EIA individuals on lower incomes have a three-times-higher risk of developing early-onset dementia in comparison to their counterparts on higher incomes, and agencies are seeing more complex needs from disabled people being presented which are needing support. The recommendations in this report seek to mitigate these impacts from a multi-disciplinary perspective reducing the impacts and improving outcomes for the individual.
35. Equalities and Human Rights
The Council recognises, and needs to take into account its Public Sector Equality Duty under Section 149 of the Equality Act 2010 (to have due regard to the need to eliminate discrimination, harassment, victimisation and any other prohibited conduct; advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it and foster good relations between persons who share a relevant protected characteristic and persons who do not share it in the exercise of a public authority’s functions).
An Equalities Impact Assessment has been carried out and is annexed to this report at Annex A. In summary, the results of the assessment are that overall, it is considered that the proposal will have a positive impact in creating fairer and more equitable community provision for the population of York. The dementia community model is designed to align resources and enable partners and organisations to work in a more coherent way to ensure the best possible service for those with dementia and their families.
36. Data Protection and Privacy
37. Communications
This report sets out a positive benefit for residents across the city and will require external communications, both immediately and in the longer term. We recognise there will possibly be some challenge from stakeholders who feel the new model is unaffordable or unachievable and we will mitigate this with a robust communications plan and thorough stakeholder engagement.
38. Economy
As the report recognises, a significant proportion of York’s residents are carers, as well as being employees or business owners. While the impact on low income groups is highlighted above, there are also challenges provided by balancing caring and working for people across all income levels. The impact of providing unpaid care on these residents’ ability to work is noted in the York Economic Strategy. For those with early onset dementia, there are direct impacts on employment, or for those who are business owners, on business resilience and the livelihood of employees. The service proposed in this report would therefore represent a positive impact on the economy.
Risks and Mitigations
|
Risk |
Mitigation |
|
Providers unable to afford to provide the expectations within the dementia community model |
During provider engagement any issues can be identified and any risks / concerns regarding viability and operation of the model can be addressed in relation to design of the model. |
|
Fixed cost makes new model unaffordable |
During engagement with providers funding and expectations will be discussed and fed back into the model. |
|
Budget envelope may decrease service provision |
Basic Key Performance Indicators within the contract but also there will be flexibility for innovation and new ways of working. |
|
Complaints if provider changes or activity changes |
Managed through the implementation plan (strong communication plan will be required) |
Wards Impacted
39. All wards are impacted.
Contact Details
Author
|
Name: |
Katie Brown |
|
Job Title: |
Commissioning Manager |
|
Service Area: |
All Age Commissioning Team |
|
Telephone: |
554068 |
|
Report approved: |
Yes |
|
Date: |
26 September 2024 |
Background Papers and Annexes
Annex A: Equalities Impact Assessment (EIA)
Annex B: Listening to People with Dementia, Healthwatch York, January 2023