Working Together

1. Working Together Beginning To Find A Way Forward For Trafford LD services Flixton House, Trafford – September 2007

2. Agenda • Introductions - Time to talk, think, reflect and strengthen relationships before the work really begins • Ground-rules • Need to reflect on the context & history • Need to understand different perspectives • Opportunity to answer Any ?s • Exercises • Identifying key strengths/problems • Joint problem-solving to develop practical change management strategies • Agreeing the way forward

3. Managing Interruptions- Challenging Unhelpful Assumptions • ‘My idea is better than theirs’ • ‘If I don’t interrupt them, I will never get to say my idea’ • ‘I know what are about to say’ • ‘They don’t need to finish their thought since mine is an improvement’ • ‘Nothing about their idea will improve with further development’ • ‘I am more important than they are’ • ‘It is more important for me to be seen to have a good idea than it is for me to be sure they complete their thought’ • ‘Interrupting them will save time’

4. Recognising Achievements • What is going well in your work or life? • What do you think we have accomplished? • What successes have you had? • What are you most proud of? For people with ld, families, staff and the service. • What have you discovered about yourself?

5. Valuing People Support Team

6. Better services for disabled children Better planning for young people moving into adulthood People to have more choice and control over their lives Better support for family carers Easier access to health services More options on where to live People to lead more fulfilling lives More people to get paid jobs Better quality of services Better training for staff Organisations to work together What did we want to happen?

7. Disability Rights Commission Formal Investigation (2006) Found: “people with learning disabilities and people with mental health problems are more likely to experience major illness, to develop them younger and die of them sooner than other citizens. They are less likely to get some of the evidence based treatments and checks they need and they face real barriers to accessing services” (DRC 2006: p4)

8. Additional financial & social costs of bringing up a child with LD increases likelihood of descending into poverty & reduces the chances of rising out of it (Emerson 2004) 44% of families in GB supporting a child with LD living in poverty compared to 30% of general population (Emerson 2003) Only 29% of people with LD are in any form of employment (DRC 2004) & of this most is “therapeutic earnings” Defining the Context: Socio Economic Factors

9. Higher mortality rates for people with LD (NHS Scotland 2004; Oulette-Kuntz 2004) Preventable mortality 4 times higher than general population. (Dupont 1990) Risk of dying under age of 50yrs was 58 times higher than general pop (Hollins study 1998) Main causes of death: 1st respiratory disease (linked to pneumonia, dysphagia & gastro-oesophageal reflux) 2nd Coronary heart disease (approx ½ people with Downs syndrome have congenital heart problems) 3rd Cancer (similar mortality rates but different presentation: oesophagus,stomach & gall bladder) Defining the Context: Health Issues

10. Epilepsy 22% v’s 0.4 -1% general population Diabetes 9% v’s 4% general population Gastrointestinal cancers 58.5% v’s 25% general population Dementia 21.6% v’s 5.7% 80% people with Downs syndrome unhealthy teeth Uptake of cervical screening 19% v’s 77%; 20% v’s 81% Call for mammography screening 33% v’s 90%; 52% v’s 75% Higher risk of leukaemia in kids with downs syndrome than general population Higher risk of congenital heart problems in Downs syndrome Defining the Context: Health Issues

11. Visual impairment 200 times more likely (rates around 63%) Hearing impairment 47% Lower than average take up rates for imms and vaccs (especially flu, tetanus & poliomyelitis) Higher than average problems with UTI’s; Osteoporosis; Hypothyroidism, and polypharmacy Increased use of psychotropic drugs which are in themselves linked to higher mortality rates in some instances Defining the Context: Health Issues

12. Anxiety disorders in children 8.7% v’s 3.6% Conduct disorders in children 25% v’s 4.2% 80% of adults physical activity lower than the minimum required by DOH equates to 64% lower than the general population Less than 10% eat balanced diet Reduced uptake of surgical specialities in secondary care Increased uptake of psychiatric admissions Lower bone density & prone to fractures Defining the Context: Health Issues

13. Wider determinants of health(Lifestyle issues; Unemployment; Poverty etc) Communication difficulties(including Consent & best interest) Genetic issues & problems related to physical disabilities Poor nutrition & exercise Diagnostic overshadowing Disability blindness Attitudes & assumptions about disability Reliance on care staff to identify possible problems Defining the Context: Reasons for inequality

14. The Key Questions Think about Trafford Think about what is happening for: People with learning disabilities, families and carers

15. Chances in life for children Young people moving into adult life Advocacy Person centred planning Direct payments/ILF Support for family carers Better health Choices about housing Things to do in the day Paid jobs Quality services Training and qualifications Organisations working together How much progress have we made about ...

16. Recognising Achievements 2 • What do you think is going well in our local services? • What is the key thing that you want to improve? • What is stopping you? How? • What support do you need in order to do it?

17. Do you think ... Things have got better for many people Things have got better for some people Not much has changed overall Things have got worse

18. The Trafford LD Service Design Project • Initiated 2006 as partnership between Trafford Council and Trafford PCTs • Core Project Group led by TMBC Head of Adult Services • Clear intended outcomes But limited results • Objectives still valid today But £ situation worse

19. How are Learning Disability Services Provided? • Pooled Fund - £15 million • Provides range of Health and Social Care Services • Targets at people with highest need • Driven by Valuing People

20. What is the State of the Service? • Seeking to modernise • Under severe financial pressure • Increased budget over the last few years • Demand is increasing • Resource are likely to remain static

21. Why is Demand Increasing? • Increased life expectancy • Increased levels of complexity • Changing expectations

22. What is the Problem? • As the service stands more resources would be required • Further limiting of who gets services is unlikely to be effective • Saving money on existing services is short term and unlikely to be sustainable • Doing nothing is not an option

23. What is the Answer? • Looking at more cost effective ways of doing what we do • Doing different things • Pragmatic strategies to achieve real person centred results

24. How Can We Do This? • New models of care/support • Individualising provision and groups of like-minded/interested people • Mainstreaming

25. New Models of Care • Understanding the link between need and cost • Working with existing and new Providers to look at different ways of providing services • Identifying new support models that are more cost effective

26. Individualising Provision and groups of like-minded/interested people • Being clear about funding for individuals • Being flexible over how people use the funding • Assumes this will be more cost effective

27. Mainstreaming • Looking at where people can access mainstream services rather than specialist separate LD services

28. What are the Risks? • Moving away from perceived best practice • De-establishing services • User/Carer resistance • Options may not be more cost effective • Not quick enough – We have pressures now

29. What Are We To Do? • Analysis of cost/needs to build up a detailed profile • Set up process to work with providers/users/ carers/staff on real options for change • Build up new ideas and then choose the best value options • Be honest over the problem we face • Look at short term measures to control costs

30. What are the Benefits? • New ideas, new options • Greater control for users and carers • Sustainable future • A new focus on Valuing People

31. Priority areas for action • Community LD Team • Adult placement • Help at home • Pathways (Day Services) • Residential care • Short breaks and respite care • Supported accomodation • Transport

32. Project Planning For large projects, Team Leaders use sophisticated project management software to keep track of who’s doing what. The software collects the lies and guesses of the project team and organises them into instantly out dated charts that are too boring to look at closely. This is called ‘planning’. Scott Adams, Creator of Dilbert

33. The Phases of a Project Enthusiasm Disillusionment Panic !! Search for the Guilty Punishment of the innocent

34. ‘Taking Stock, Taking a Breath, & Planning for the Future’ A Strategic Review of Mental Health & Learning Disabilities Commissioning Priorities and Investment/Development Programmes

35. ‘review commissioned by Trafford PCT’s Chief Executive and Acting Director of Commissioning & Performance. The objective was to develop an honest and robust understanding of the key priorities for action locally in Trafford within the context of national policy guidance and recognised best practice in commissioning mental health and learning disability services’ Supported by TMBC with joint report and recommendations currently being prepared for further discussion and consultation

36. ‘process participative involving structured dialogue with stakeholders and teams across health and social services, involvement in a variety of service planning/commissioning meetings and a detailed review of historical records/papers/ strategies’ Information gathering stage – May/June 07 Initial stakeholder consultation phase - July 07 Draft report presented to PCT Exec Team - Aug 07 TMBC consultation phase - August 07 Draft report recommendations to PCT PEC – Sept 07 Final stakeholder consultation phase – Sept 07 Shared stakeholder action plans agreed – Oct 07

37. Commissioning • In the past, commissioning too often passive/reactive/ST money and activity based • Rather it now needs to be about enhancing the quality of life of individuals/their carers by: • Having vision and commitment to meaningful outcomes • Connecting with needs/aspirations of local people • Making the best use of all available resources • Understanding demand/supply • Linking financial planning and service planning • Making relationships and working in partnership

38. Detailed review of existing S31 Partnership Agreement Agree strategy to maximise income from Pooled £ Agree action plan to develop more effective local LD Team and better range of home/day/respite services and realise outcomes from previous stalled service redesign programmes Develop and implement new provider monitoring and development arrangements, including using assistants to review all high cost out-of-area placements Complete recruitment of Consultant Psychiatrist and secure access to LD crisis admission bed options Benchmarking Adult Learning Disabilities

39. Key Themes for Action • Strategic and senior professional/clinical leadership to inform real commissioning / informed decision-making • Clear specification of current investments, contracts / SLAs and outcomes • Greater integration / coordination of management resources • Significant service review / redesign programmes • Targeted investment programme • New ways of working and sustained relationships

40. Clear your mind of everything except what I will invite you to do. Don’t worry about any uncompleted tasks, your work, your family or friends. Just focus and open up. • In your mind’s eye, see yourself going to a funeral of a loved one. See the faces of family, friends and colleagues. As you walk to the front of the room and look inside the casket, you suddenly come face to face with yourself. This is your funeral 3 years from now, with all these people coming to honour, love and appreciate you. • As you take a seat and wait for the service to begin, you look at the programme in your hand. There will be 4 speakers - a close family member, a friend, a colleague from work and some community organisation you’ve been involved with.

41. Now think deeply. What would you like each of these speakers to say about you and your life? What kind of husband, wife, partner, mother or father would you like their words to reflect? What kind of friend? What kind of working associate? • Take time to record the impressions you had in the funeral visualisation, in terms of your character, contributions and achievements. • Write down your roles as you now see them. Are you satisfied with that mirror image of your life? • We may be very busy, we may be very efficient, but we will also be truly effective only when we begin with the end in mind - A clear personal definition of success.

42. The Real Challenge • How many people on their death-bed wish they’d spend more time at the office? Learn to identify your ‘center’ and key associated roles • Anything less than a conscious commitment to the important is an unconscious commitment to the unimportant • What is the one activity that you KNOW if you did superbly well and consistently would have significant positive results in your PERSONAL and PROFESSIONAL/WORK life? • If you KNOW these things would make a significant difference, why are you NOT doing them now?

43. ‘Things which matter most must never be at the mercy of things which matter least’ ‘Because where you’re headed is more important than how fast you’re going’

44. Outline of Approach: Effecting Change & Tackling Inequalities Begin with the end in mind Seek first to understand Be pro-active Principle Centred Leadership ( S Covey 1994) Think “win / win” Put first things first Synergize

45. Focusing Energies & Resource (Stephen Covey, 1994)

46. l Urgent/Important 20-25%vs 25-30% lll Urgent/Non-Important 15% vs 50-60% ll Non-Urgent/important 65%-80% vs 15% lV Non-Urgent/Non-Important Less than 1% vs 2-3% High Performance vs Typical Organisation Investments

47. What is helping things get better? • Think about what has helped to make change happen • What has made the biggest difference?

48. What’s getting in the way? • What are the most important problems getting in the way of change?

49. Child Health Services Finance Directors & Commissioners Borough Council staff People with Disabilities Public Health Directors & Analysts Family Members Local Councillors Direct care staff Joint Partnership Boards Private / Voluntary sector Agencies Education The STAKEHOLDERS - Who Do We Need To Influence and Support? Local Employers / Businesses Primary Care staff (GP’s; Nurses; Therapists, Commissioners) Secondary Care staff (e.g. Medics; Clinical Dept heads; Nurses; Dieticians; Radiographers) Corporate Teams (e.g. PCT / PECS / Hospital / LA Council Boards) PALS Specialist Community Teams

50. What needs to happen next? • What could make a big difference for people with learning disabilities and their families? • What do you want to see change in Trafford? • What specific changes in particular services and relationships? • What meetings/communication strategies will help?