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Dementia Services (South Derbyshire)

Volume 404: debated on Tuesday 6 May 2003

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12.30 pm

The purpose of this debate is to highlight how an important new service and change to an existing service can be handled effectively, and some of the pitfalls that can occur when that does not happen.

On the background, the illness of dementia is reasonably well known, so I shall not describe either the distressing way in which its onset can have a huge impact on the lifestyle of the individual and the carers who know that person well, or the need for special help to deal with the facets of an illness that can have a range of different effects on the individual's personality and in relation to the built facility in which that person is accommodated. Some people with the symptoms of dementia need extremely specialised care and support, and some built environments are not suitable for them.

Having given that brief introduction, I am proud to describe some of the past history of south Derbyshire, where an attempt has already been made to establish innovative ways of supporting people with dementia. Joint NHS and county council provision was tested at the Oaklands residential home some years back and was visited by the Minister of State, Department of Health, my right hon. Friend the Member for Barrow and Furness (Mr. Hutton), when he came to my constituency about three years ago. That provision set high standards in examining how one could respond to the residential requirements of people with dementia, and in offering outreach services, whereby people came in and spent some time in the centre being supported and working with their carers with an appropriate package of assistance to make their lives better.

Sadly, that experiment was terminated when it was decided that the built environment at Oaklands—it is a 1960s or 1970s building near the centre of Swadlincote with a large amount of glass and many corridors—was unsuitable for some people with dementia as it might contain hazards that could produce harm. I understand why the decision was taken to stop the scheme, but I have been looking forward to the provision of a new, coherent range of dementia services in south Derbyshire for the future.

If one considers the strategic context in which the matter has been approached, one can see that there has been a good deal of sensible thinking. However, some of the conclusions reached, as well as the means of communicating the conclusions, have left a lot to be desired. Let us consider the role of Derbyshire county council, which owns the Oaklands residential home, and its approach to its building stock for elderly people's residential care. The strategic document, which supported the local improvement finance trust LIFT—bid from the partnership group that has sponsored a range of health improvements in my area, says in its section on Derbyshire county council that, within the LIFT projects, particular interest would be attached to the
"refurbishment or replacement of a number of County Council residential homes for older people. The intention is to modernise the service so that the facilities meet the National Care Standards Commission requirements."
I applaud that. We recognise that the timetable for meeting those requirements is not immediate. Nevertheless, it is right that that should be our goal.

The document continues:
"The strategic direction of the service is to support more older people in their own homes."
Derbyshire county council has a proud record of doing just that. It has placed considerable emphasis on supporting older people in their homes, rather than on moving them into residential care. The document adds:
"This means that there will be a move away from the provision of predominantly long term care. The service will increasingly focus on shorter term intermediate care support or more specialist longer term care such as for older people with mental ill health."
I probably agree with the priority implied in that paragraph, but the difficulty is that Derbyshire county council owns a substantial stock of residential homes that are occupied by a large number of older people. The bald statement that there will be a move away from standard residential care for older people towards more specialist care implies dramatic changes in the living conditions of many older people, and that can cause them and their carers distress. The document sets the strategic context of the proposal. In essence, Derbyshire county council wants to reduce substantially, or to eliminate, its residential care for older people unless they have particular needs that require support from other agencies.

Derbyshire county council, Derbyshire Dales and South Derbyshire primary care trust and the Derbyshire Mental Health Services NHS trust have co-operated to produce a proposal for a dementia resource centre at Oaklands in Swadlincote. One of the reasons for the selection of that site is Oaklands' history of provision of specific services for dementia, to which I referred at the start of my speech. It does not currently provide such services, but its history indicates that the site may have been suitable for some people with dementia and could provide the support that they need.

Another reason for the selection of the site is, to put it bluntly, that the county council owns it. As I said when I quoted from its strategic statement in support of the LIFT proposal, it is seeking to find ways of moving away from standard residential care for older people. It believes that Oaklands does not have a particular problem in meeting National Care Standards Commission requirements, but that a minority of the rooms do not currently comply with them. It has not estimated how much it might cost to meet those requirements at some stage: as I said, that is not yet an urgent priority. Nevertheless, the crux of the matter is that the county council owns the site and the building. There is, therefore, some freedom to proceed with the proposal.

The proposal is for a mixed provision of mental health services beds for those with acute dementia requirements and a smaller number of beds for social services specialist cases. In both instances, the provision is aimed at those with some form of dementia, whether acute or with lesser expressions of the illness. In many ways, I applaud such a proposal, as my area needs such provision. Some people in my area have said that it is not a priority, but I believe that it is, so I am delighted that a proposal is coming before the decision-making bodies involved in the LIFT project.

However, one difficulty is that the selection of Oaklands had an immediate impact on the well-being of the residents, many of whom have been there for a considerable time. It caused significant distress, which was not helped by the clumsy way in which the proposal was communicated locally. Perhaps understandably, it was felt that a briefing to staff would be sensible, and that was done just before Christmas. However, that was naive, because the local newspaper was then told of the proposal by a member of staff who thought that their job might be threatened or that the story was of local interest. The proposal was then communicated informally through the newspaper to residents and carers just before Christmas, causing considerable distress and concern.

There was a great deal of confusion about the exact proposal: what was its time scale, how quickly would one expect the building to be demolished, would there be any possibility of retaining residential accommodation on site or would it be a wholesale demolition and so on? Poor communication added considerably to the distress of all concerned. That distress has gone beyond the community of those immediately involved with Oaklands. The local vicar, the Rev. Horsfall, whose church is next door, expressed his concern about the project, and I know that some local county councillors who have been contacted about how the council has addressed it have also expressed concern.

The first question is: is it the right site to choose? I would argue that two issues should be confronted. First, is it the easiest way to proceed for such a project? It is clear that gaining occupancy of the site and removing those who are currently resident—we must be blunt about it—will be both distressing and difficult. It will take some months, and possibly years, to achieve that outcome sensitively, which is how I expect Derbyshire county council to work. Secondly, are there alternatives? It has been drawn to my attention that one residential home in the private sector in south Derbyshire—Cedar Court at Bretby—already provides dementia beds. It is happy to co-operate with the county council and the NHS in developing a more specialist role in that field, but it has found it incredibly difficult to get the decision makers to discuss that in an organised fashion. I am not saying that that proposal is right, but I would expect it at least to be given proper reflection by the county council, the primary care trust and those on the mental health services trust who would be involved in delivering the service.

What appears to have happened instead is a fairly lengthy and inconclusive correspondence, which may have been guided by some issues that are not atypical in the nursing home and residential sector, including concerns about existing arrangements at that home and whether nursing cover has been adequate. All Members know that residential homes sometimes find it difficult to recruit nurses on a continuing basis, and Cedar Court at Bretby has had that difficulty. Nevertheless, I would expect it to be possible to discuss how a facility could be provided there as an alternative strategy to that identified in the LIFT project.

LIFT is a sensible way of funding a range of primary care services in my constituency, and in those of other hon. Members, but I am far from clear about it. That may be an innate difficulty with how the mechanism delivers such projects. The financial implications of the project's delivery are unclear, because they depend substantially on the private sector partner and its input. It is, therefore, difficult to evaluate the project in the way one would do normally.

An estimated capital cost of £2.7 million has been set aside in the LIFT proposal. However, of equal importance, if not more so, are the revenue consequences of the bid and how it will be distributed between the county council—the ongoing manager of services—and the mental health services trust. The project requires rather sharper evaluation than it has received; it must be benchmarked against other means of delivering a laudable goal. I do not want to give the impression that I do not wish such a project to proceed in my constituency. However, the detailed means by which the county council and the NHS intend that the project should proceed require further consideration before authorisation is given.

12.46 pm

I congratulate my hon. Friend the hon. Member for South Derbyshire (Mr. Todd) on securing this important debate and thank him for the considered, thoughtful way in which he made his representations. Also, I acknowledge his support for changes and improvements to services for older people with dementia in his constituency. He raised some important issues.

I share my hon. Friend's concern for his constituents who live and work at the Oaklands residential home, and I understand the impact of the proposed changes on individuals, especially when they are elderly or in poor health. Such changes can cause immense distress. The closure of that residential home for older people is a matter for Derbyshire county council. My hon. Friend says that he has had close discussions with the council about that, and I am sure that they will continue as the process moves towards formal consultation. This is only the pre-consultation stage and a range of ideas is being considered. Nevertheless, if there were a proposal to close the home, there should also be a period of formal consultation. I am sure that my hon. Friend will retain close contact with the process.

There are those in the area who wish that the home could remain. I understand, however, that that cannot happen without significant investment to bring it up to the national requirements set by the National Care Standards Commission. I appreciate that the time scale is lengthy, but the home would need to achieve significant changes, if not some demolition and rebuilding, to meet those standards. We must consider things in that context.

Will my hon. Friend set matters out in more detail? There is, as she said, a long timetable for compliance. It would be helpful if she told us how long that could take, or if there is any uncertainty about it.

Clearly, the original time scale pertaining to the physical requirements of existing properties has been put back, and it now runs beyond 2007. I could supply my hon. Friend with a more detailed timetable, if that would assist him. In any event, it is correct that authorities should plan ahead, consider the context of existing buildings, be aware of requirements that will come their way in due course and make contingency plans and decisions accordingly.

I would expect any relocation of individuals to be dealt with sensitively and the wishes of individuals and their families to be respected. I know that my hon. Friend has concerns about how the matter has been handled. Local social services representatives have already had discussions with the individuals, their carers and relatives. It is important in such circumstances to outline the available options, and I would expect the families to be offered a variety. Derbyshire county council generally has a good record in such matters, and its service that provides care for older people scored well in the recent comprehensive performance assessment of local authorities. I urge the council to handle the matter sensitively.

I understand that long-stay admissions to the residential home have been stopped to try to ensure that a range of options is developed. With the proposed closure likely to be at least 12 months away, if it goes ahead, there should be plenty of time for suitable arrangements to be made that meet the needs of individual patients and their families. I also expect that appropriate arrangements will be put in place for the staff at the centre. Again, that is a matter for the county council to resolve.

About 30 people reside at Oaklands, so we are discussing a significant task. I share the Minister's view that the county council has a good track record on delivering service for elderly people and on consulting, but the concern with this project is that the elderly will be railroaded out.

Elderly people should not in any circumstances be subject to any pre-emptive decision making that would, in my hon. Friend's terms, railroad them out. Clearly, the issue is difficult. It is a matter for negotiation not only with the patients, but with their carers and families, to ensure that any alternative options meet needs that are, in some cases, complex. Decisions should not be taken unless proper options have been developed. I urge the local authority to make every effort it can in that respect.

As part of the NHS review of services in Derbyshire for older people with mental health care needs, it is proposed that services, particularly for those with dementia, should be developed from locally accessible resource centres. I acknowledge my hon. Friend's support for that general policy thrust. Such centres do not exist. Indeed, the joint mental health strategy for older people's services identified a need for significant investment in community mental health service provision. Many people have to go to Derby or other centres for services. The move is to bring those services out of the centre and put them closer to people's homes. The strategy has been jointly prepared by the primary care trust, social services and Derbyshire mental health services trust, so there is good joined-up strategy development.

A hub-and-spoke model is proposed, with one-stop primary care centres in Ashbourne and Swadlincote. Such centres would provide a full spectrum of health and social services. The NHS in Derbyshire proposes developing dementia care from four community-based resource centres, including one to serve the Swadlincote area. Social services and the NHS are working together to develop a joint service delivery plan, which will build on their good working relationships. The centres will offer specialist care in a multipurpose resource with sheltered housing and day services close by. They will provide joint social care and NHS community facilities, including provision for in-patient services, a community team and day assessment services. I believe that my hon. Friend would acknowledge that that will be a significant improvement on the services that are available.

There will be less emphasis on long-stay care, which is why the service must be redesigned. Our policy is to provide more care in people's homes and in the community. There will also be a dramatic increase in the number of staff—up to 120 from 24—providing dementia care in the community across southern Derbyshire. That represents a major shift of resources. For the Swadlincote area, the increase will be from three staff to 14. That significant extra help will be redeployed from existing central services.

It is proposed for the moment that the Swadlincote centre should use the site occupied by the Oaklands residential home. The proposal is to demolish the building, which does not meet the required standards, although linking the centre's development to the local improvement finance trust—LIFT—project would be one way to bring it on stream sooner than by simply awaiting capital from the NHS source.

The estimated capital cost of the building is £2.7 million, and the LIFT option is being appraised. If the company accepts, it would fall in the second tranche of the delivery programme. The first is due for invitation to tender and financial close by December. Approval of the second tranche, which the centre would come under, would follow early in the new year, fairly shortly after closure on the first. Any construction on the Oaklands site would therefore be unlikely to commence until mid-2004. That is the time scale we are looking at for the development.

My hon. Friend mentioned the other proposal from Bretby, which involves Cedar Court. I understand that the county council is talking to the organisation to consider the proposals. My hon. Friend is right: one proposal should not be favoured, and all proposals should be properly evaluated to see which is the best way forward. If it is decided that this proposal should not be in the LIFT scheme, other funding arrangements will be considered, including seeking partners for a separate private finance initiative. However, I am encouraged by the fact that the LIFT company is considering putting the proposal in its programme.

My hon. Friend will be interested to know that, as well as the four resource centres across Derbyshire, we are funding the creation of a dementia service development centre for the east midlands. The centre will improve dementia care throughout the region, including his constituency, through a combination of information, education and training. The resource centres will provide the physical base for the services, and the information and education base will be improved. That will concentrate on four key areas: staff training and practice development; data collection and sharing; service development; and research. We are putting £62,000 into that project this year, and similar amounts will be provided in the next two years.

My hon. Friend has a particular interest in services for the group of people that we are discussing, and I hope that he is encouraged that we want not only to redesign the service, but to make it one that people want to work in—an attractive place to work. People will have access to research, training and information, so that they can share the good practice that they develop throughout the region and provide better services.

I understand my hon. Friend's concern that if a proposal is not handled sensitively and properly, distress will be caused to patients, their families, carers and the whole community. Any change or major service redesign is difficult to accommodate, particularly when people have made a residential home their home. That is why I will say clearly to the local authority that it needs to ensure that there is proper, detailed and individual consultation with everyone involved, and that they should be given a variety of options and as much security for the future as possible.

The Government have made the care of older people a top clinical priority. That is why we have the national service framework for older people, why there is such emphasis in standard 7 of the NSF on services for people with dementia and why there is such focus on developing integrated services between the NHS and social services. We are trying to ensure that we create a seamless system of care.

I can reassure my hon. Friend that the planning and priorities framework for the coming year requires that, by 2004, protocols must be in place across all health and social services systems for the proper care and management of older people with mental health problems. Placing that requirement in the planning and priorities framework gives us a performance management lever to ensure that our objective is achieved in communities, and that people who, perhaps for many years, have been neglected become a real priority for both services. I am advised that all trusts in the Trent strategic health authority area, including those in Derbyshire, will have their protocols in place by the April 2004 deadline, and that they take this matter extremely seriously.

Extra investment is going into the service. There will be an extra £1 billion for social services for older people by 2006, including £100 million for additional carers services, which will increase to £185 million, and £70 million to support the training of social care staff. All that extra funding will help to improve services for older people with mental health problems.

The primary care trust and the social services department in my hon. Friend's area collaborated on proposals to redesign and improve services for that group of people. He is absolutely right to raise concerns about whether this is the right site, whether there are alternatives and whether we can proceed as quickly as possible, perhaps through the LIFT company. I urge him to continue his constructive discussions with the local authority and to ensure that the proposed service developments really make an improvement.