Devon Partnership NHS Trust Profile

This provides a profile of the Trust: the services it provides, how these are organised, the populations it serves, how it is performing and the sources of its income.

Overview

Devon Partnership NHS Trust provides a range of specialist mental health and learning disability services. The Trust turnover in 2010/11 is £131m and it has 2,000 staff operating from over 40 different sites.

The Trust provides the following services for people in Devon and Torbay: • Mental health services for adults • Specialist services for adults • Mental health services for older adults • Drug and alcohol services : • Learning disability services for adults

The Trust also provides secure, gender identity and eating disorder services for people in the south west region .

The Trust has a strong track record of successful change management and is proud of its achievements since it was formed. It has effective partnerships with Devon County Council and Torbay Care Trust to provide integrated health and social care. Its main commissioners are NHS Devon and Torbay Care Trust.

The Trust was established from five organisations in 2001 to provide a specialist mental health and social care service across Devon and Torbay. It brought together services previously provided by a community trust, two acute trusts and two local authority social services departments. The comprehensive range and integrated nature of the services provided through a single organisation is one of the Trust’s main strengths.

The Trust has led the implementation of the mental health strategy in Devon and successfully delivered a three year service redesign programme between 2006 and 2008. This has reduced operating costs, provided financial stability led to improvements in efficiency, a more cohesive service and a significant shift from inpatient to community services.

The Trust has reduced the number of hospital beds it provides by over a third between 2005 and 2010. This redesign of services has resulted in fewer people being admitted to hospital and an increase in number of people supported by community and primary care mental health services.

The Trust’s service strategies are based on redesigning services to make them simpler and easier to access. This has led to major reforms in the way community and hospital services are organised and how they interface with other parts of the health and social care system. The establishment of local networks of care has helped to reduce duplication and to significant improvements in quality and efficiency.

The key to this approach is close working with other organisations so that people receive an integrated service, regardless of which organisation provides the care and treatment. The Trust has deliberately set out to create partnerships with other organisations which offer added value to commissioners and opportunities for efficiencies and service improvement.

The Devon County Council health scrutiny committee has commended the Trust for its open and transparent approach to consultation on service changes and these positive relationships are crucial to ongoing success in redesigning and reshaping services.

The Trust has made significant progress since its establishment in 2001 but there remain a number of challenges to achieving uniformly excellent services across Devon and Torbay. These were highlighted by the Care Quality Commission review in 2009 of the Trust’s services for older people.

This review has proved to be a catalyst for an even stronger focus on patient safety and the strengthening of the Trust’s management and clinical governance assurance processes. The Trust has encouraged an open and transparent approach with its staff and partner organisations to meeting these challenges, working closely with partner organisations to learn from shortcomings in the quality of its services to ensure these do not impede its drive to be a national leader in maximising patient safety and putting recovery at the heart of everything it does.

A key step has been the establishment in 2010 of four clinical directorates covering all the Trust‘s services which each are led by consultant psychiatrist, head of professions and a senior manager. The directorates are accountable for the standard of professional practice and clinical care in their areas to the Trust Management Board and Board of Directors.

The Trust’s estate is relatively modern with the exception of its secure services at Langdon Hospital in Dawlish. It has invested in modernising its hospitals for adults and is now developing a similar investment programme to improve its inpatient services for older people.

The Trust has a highly respected Research and Development Unit. The Unit has a successful track record of research, acting as host for a wide range of research projects and providing them with a robust research governance framework. The Trust’s research strategy aims to ensure all people using its services are provided with care and treatment which complies with NICE guidance or, where there is no guidance, a research protocol. The Trust works as part of the Peninsula Mental Health Research Group to deliver the research strategy priorities, which include understanding and reducing suicide and suicidal behaviours and involving people who use services in research.

The Trust’s approach is to work closely with its main commissioners to identify opportunities to achieve cost reductions for the health economy whilst also enhancing the quality of services. An example is the Trust’s management of the budget for purchasing care and treatment for people for whom there are currently no local specialist mental health services (the individual patient placement budget).

The management of this budget has enabled funding previously spent outside Devon to be redirected by the Trust to provide more local specialist services. The Haldon Unit – an inpatient service for people with eating disorders - established in Exeter in 2006 is one example of a new local centre of excellence.

The financial position in Devon has meant that the Trust is well prepared to meet the challenges of maintaining quality of services whilst reducing costs. It achieved this successfully between 2006 and 2008 when there was a need to reduce overall expenditure on mental health by £12m. The measures the Trust took were based on ensuring its services were provided as economically as possible and at or below reference cost whilst seeking to improve productivity as measured by length of hospital stay, readmission rates and patient contacts in the community.

This experience places the Trust in a good position to manage the QIPP programme for mental health and learning disability on behalf of the Devon and Torbay health and social care community. The priorities within the QIPP programme have been shaped by the Trust strategy and the opportunity to improve outcomes for patients from development of mental health services in primary care and general hospitals. The key areas for expansion of these services are dementia care, medically unexplained symptoms and more local specialist and secure services to avoid out of area treatments.

Range of Services Provided

Geography and population

Devon is a predominantly rural county, bordering Cornwall, Somerset and Dorset. It has a large farming community and two significant urban populations in Exeter and Torquay. It has a mix of 28 small market and seaside towns as well as many villages and hamlets. Dartmoor is the national park in the centre of Devon. The size and geography of Devon means that providing integrated care in or close to peoples’ homes and in their local communities is very important - especially in the more remote areas which do not have good public transport links. For example the distance by road from Tavistock to Axminster is seventy miles and from Ilfracombe to Dartmouth it is ninety seven miles.

The population of Devon and Torbay is over 890,000. Devon is the third largest county in England. It has the twelfth highest county population and is the third most sparsely populated. The county is a popular holiday destination and attracts people who retire to live in the country and by the coast. It has a higher proportion of older people and this is expected to increase significantly in the next decade. This rising elderly population presents a major challenge for all health and social care providers.

The Trust’s networks of care, operating from over 40 sites, cover all parts of the county and have strong links with social care and primary health care services. The Trust has consolidated its adult acute inpatient services in the main centres of population to achieve economies of scale but there is still further work required to achieve this fully in services for older people. This is therefore one of the Trust’s priorities for cost and service improvement.

How the Trust’s services are organised

Networks of care

One of the Trust’s key innovations has been the redesign of its community services to create a simpler, more coherent network of care. These networks have put the Trust in a strong position to manage the care pathway for patients across a range of provision from primary care to specialist services. This integrated model of care is central to the Trust strategy and is one which can be adapted for implementation in other geographical and service areas.

The networks ensure a coherent system of recovery-focused care operates in every part of the county. They work closely with other agencies, to promote mental health and social inclusion, and to ensure that the shared aims of strategic and local partnerships are achieved.

Each network has three interlinked functions: • Wellbeing and Access – supporting people to be treated earlier in community and primary care settings. Over 90% of people with mental health problems are treated in primary care by their GP. • Urgent and Inpatient Care – responding to people in crisis and providing high quality inpatient care and home treatment. The Trust admits approximately 2000 people to hospital each year. • Recovery and Independent Living - working with a range of community organisations to support people to live as independently as possible.

The benefits of the integrated networks of care for people using the services, commissioners and GPs are: • A single point of access to services at a local level • Clear co-ordination throughout the care pathway • Greater ability to be flexible with resources, based on need not age • More people treated at home or in community settings • Reduced use of hospital The four networks areas are:

North Devon The network covers a large rural area. The main towns are Barnstaple, Bideford and Ilfracombe. North Devon has the highest proportion of older people in its population. There has been historical underinvestment in services for older people in north Devon and the Trust has support from commissioners to reinvest some of savings from reduction in hospital services to redress this imbalance.

Exeter, East Devon and Mid Devon The network area covers the cathedral city of Exeter. East Devon is a mixture of small market towns and is a largely rural and coastal area and Mid Devon covers a large rural area including parts of Dartmoor. Following the closure of two large psychiatric hospitals in the early 1990s Exeter now has a higher proportion of resources than other parts of the county and, as the major urban centre; it also has a greater incidence of mental health problems than other parts of Devon.

South and West Devon The network area covers Teignbridge, South Hams and West Devon. The Trust contracts, on behalf of Devon PCT, with Plymouth Primary Care Trust mental health services for inpatient services for people in South Hams and West Devon.

Torbay Torbay is predominantly an urban area, with many of the challenges which face many seaside towns such as higher incidences of drug and alcohol problems and homelessness.

Activity and budget for main service areas – 2010/11

£ Staff Beds Occupied Community Service 000s % WTE Bed days Contacts Funded 000s 000s 52350 40 995 110 34 226 Mental health – adults 22487 17 427 70 24 59 Mental health – older people Drug and alcohol 2499 2 47 8 5

12493 9 195 10 3 58 Learning Disabilities

11408 9 220 70 25 0 Secure Services 3134 2 47 12 4 Specialist services

Other including 27324 21 100 0 39 31 Individual Patient Placements) TOTALS 131695 100 2032 280 131

Adult mental health services

These are the Trust’s mainstream services and provide care and treatment to approximately 16,000 people each year The Trust mainly provides services for people with more severe and enduring needs although a significant proportion of activity relates to common mental health problems (such as depression and anxiety disorders).

The Trust’s reorganisation of its community teams to create more cohesive networks of care has increased their productivity. This efficiency improvement has enabled the Trust to be more responsive to General Practitioners who are the main referrers to its services.

Substantial improvements in length of hospital stay, occupancy and admission rates have been achieved. Average occupancy rates (excluding patient leave) in 2009/10 were 79% for adult inpatient units and 80 % for older peoples’ units, indicating there is further scope to reduce overall inpatient capacity in line with the strategic shifts to community care. The Trust’s occupancy target is 85%.

The Trust’s community services operate at below national reference costs and this position continues to improve. The savings which have been achieved from development of the networks and the reform of inpatient services have contributed to the Trust ongoing cost improvement programmes and enabled investment to strengthen community services. The Trust provides psychological services to two of the main general hospitals in Devon and has plans to enhance and expand these services. There are many areas of physical health care where it is now recognised that specialist psychological services can make a significant difference to the well being of patients and the success of treatment (e.g. obesity, trauma, pain relief, cancer care etc). These interventions are also likely to ensure that outcomes of medical intervention are effective and will reduce overall costs. The Trust provides a liaison psychiatry hospital service at the Royal Devon and Exeter Foundation NHS Trust in Exeter and at Torbay General Hospital. At present it does not provide this service at North Devon District Hospital in Barnstaple. The Trust has also been awarded contracts worth over £4m by NHS Devon and Torbay Care Trust for improving access to psychological therapies and these expanded services are being introduced in 2010 and 2011. These provide for people with common mental health problems such as depression and anxiety. The Trust is ale to use its network structures to ensure the services are provided in an integrated fashion.

Mental health services for older people

Devon has a higher than average proportion of older people in its population and a projected 40% increase in the population aged over 65 by 2021. The Trust treated over 7,500 older people in hospital and the community in 2009/10.

Improving services for older people is a key service development priority. The Trust is investing over £4m in its capital programme to ensure all its inpatient units meet modern standards of privacy and dignity. It is also working to reduce variations in performance and inequalities in access to services by increasing the investment in community services and the expansion of some services for adults to meet the needs of older people (e g crisis resolution and home treatment)

The most significant area for development is the care and treatment of older people with dementia where the Trust is working to enhance its response to the needs in acute hospitals and in primary care for a more rapid response to assessment and access to specialist expertise in the care and treatment of dementia. Drug and alcohol treatment services The Trust provides specialist community teams which treat people with drug and alcohol addictions. It also provides some detoxification beds on its adult acute inpatient wards. The services are commissioned by the Devon and Torbay Drug and Alcohol Action Teams (DAATs) which includes health, social care and criminal justice agencies.

The Trust, in partnership with Exeter Drugs Project, a voluntary organisation, was awarded a three year contract (2010/11- 2012/13) by the Devon DAAT to provide an integrated treatment service. This is a good example of how the Trust and a partner organisation are working together to redesign services to increase the number of people accessing treatment whilst helping to reduce overall costs. This is being achieved by increasing the support to GPs to treat more people in a shared care arrangement between the specialist drug service and primary care.

NHS Devon also prioritised investment in alcohol treatment services in 2009/10 and provided an additional £630k to the Trust to expand these services

Learning disability health services

The Trust provides services for adults with learning disabilities in its specialist inpatient units, residential care homes and integrated health and social care community teams. Its aim is to ensure its mainstream services provided in the networks have the capacity and capability to meet the needs of people with learning disabilities and mental health problems.

Secure services

The Trust is the main provider in Cornwall and Devon of secure services for male patients and has plans for additional services at Langdon Hospital in Dawlish.

The Trust is also currently bringing one of the units at Langdon Hospital - Chichester House – up to low secure standards which will also increase the number of beds from ten to fifteen. When the scheme is completed the Trust will be able to provide an additional service for patients who currently are treated outside Devon.

NHS Devon awarded the Trust a five year contract in 2009 to provide health care services to the three prisons in Devon. The contract is worth over £4m a year. The Trust works in partnership with Devon Heath - a primary care social enterprise - to provide the service. The intention is to provide a network of care in the prisons that mirrors those available in the community and to build on the existing links between the Trust’s secure service and the prisons.

2.2.9 Specialist services

These services are mainly purchased by commissioners on a price per patient basis and are provided for patients from Devon and other parts of the south west. The Trust will continue to invest in and expand these services by developing ‘centres of excellence’ and building their regional and national reputation. The Trust provides: Eating disorder services Building on the reputation of the Haldon inpatient unit in Exeter, the Trust developed a day service in 2009 to increase capacity and treat patients who do not need hospital admission. The Trust is already providing a service for patients in the south west as well as attracting them from other parts of England and Wales. Personality disorder services The Trust provides some specialist psychological and psychotherapy services for people with personality disorders. It is planning to expand its day treatment programme in Exeter to provide more local services for people who are currently treated outside Devon and funded from the individual patient placement budget. Gender identity services The Trust runs one of only three services in England which specialise in assisting people with gender identity problems. It already provides a service to people from Cornwall, Plymouth, Devon and Torbay and is expanding its capacity to assess and treat people across the south west and beyond. Autistic spectrum condition services NHS Devon and Devon County Council have commissioned the Trust to set up a specialist team to work with people with autistic spectrum conditions in 2010/11. This is in response to the Autism Act. The team will provide a diagnostic, assessment, consultancy and training service to support mainstream mental health and learning disability services in meeting the needs of people with autistic spectrum conditions more effectively. At present any individual who needs a specialist assessment has to be referred to a service outside Devon and funded as an individual patient placement. Individual patient placements

In 2006 Devon Primary Care Trust and Torbay Care Trust delegated to the Trust the budget for commissioning care and treatment for all patients whose mental health needs could not be met locally. This budget is known as the individual patient placement (IPP) budget. The expenditure for the period 2006/07 to 2010/11 was:

2006/07 2007/08 2008/09 2009/10 2010/11 £000s £000s £000s £000s £000s Devon • Secure 6,912 8,802 7,734 0 7,823 • Non 2,285 2,417 3,611 6,145 4,752 secure Torbay • Secure 1,879 2,019 1,992 0 0 • Non 1,383 1,065 1,402 1,600 1,593 secure

The Trust oversees the care and treatment of these patients – the majority of whom are placed with independent sector providers - to ensure that the services they receive are clinically appropriate, high quality and represent value for money. Between 2006 and 2010 the Trust was able to make cost reductions for commissioners through its improvements in procurement and purchasing of individual patient placements from other providers. The arrangement has enabled the Trust to reinvest money previously spent outside Devon to provide more local services. The management of the budget has also provided the Trust with valuable information about the market for specialist services.

The contracting of medium and low secure services is handled by the regional specialist commissioning group (hosted by NHS Bristol) who managed the budge directly in 2009/10. In 2010/11 NHS Devon has transferred the secure IPP budget management back to the Trust who work directly with the SCG. The Trust remains responsible for arranging and agreeing any patient placements and for managing the care pathway. The Trust also contracts for all non secure services itself.

Workforce

Total Numbers By 31 st 31 st 31 st 31 st Total Staff Groups (WTE): March March March March Changes 10 09 08 07 Medical Staff 54 55 56 70 -8 Consultant Psychiatrists 60 55 57 57 3 Senior Managers 72 78 81 74 -9 Admin & Clerical 280 273 237 227 43 Clinical Support Staff 553 573 591 598 -30 Nursing 643 624 619 651 24 Psychology, Psychotherapy & other Scientific staff 130 79 65 60 64 Allied Health Professionals 101 109 120 129 -18 Other 13 10 15 22.00 -9 Total Staff in Post 1906 1856 1841 1888 60 Total Funded WTE 2074 2042 2106 2214 -148

The table illustrates how the Trust workforce has changed since 2007. These changes have supported its cost improvement and service development programmes. The significant changes in 2009/10 were the transfer of a number of staff in learning disability services from the Trust to third sector organisation, the transfer of health care staff working in Devon prisons to the Trust and the recruitment of additional psychological therapists through the IAPT initiative.

The Trust has been able to reduce the overall number of funded posts through a programme of service change and staff redeployment. This has enabled it to manage changes in the workforce in a way which has enabled staff to be retained and retrained in order to retain expertise and experience and to achieve a more appropriate skill mix.

The increase in administrative and clerical staff between 2007 and 2009 is mainly due to the Trust taking on direct management and employment of a number of people previously employed by other local NHS Trusts in shared service functions (e.g. payroll, IT and accounts payments).

Properties

The Trust has teams and hospital beds in 20 different towns in Devon and Torquay. It owns and leases approximately 70 properties and its assets are valued at £51.9m (as at 31.3.2010). Forty eight assets are protected (see Appendix 6 for details).

The Trust’s hospital services are in Exeter, Barnstaple, Dawlish and Torquay and it also has inpatient units in Bideford, Exmouth, Honiton and Newton Abbot.

In the main the Trust’s inpatient services are provided in modern, purpose built facilities which do not need major capital expenditure. The main exception is the secure services at Langdon Hospital in Dawlish where the Trust has plans for a major rebuild and upgrading of the facilities.

The Trust approved a business case in 2009 to invest £4.5m in improving its inpatient units for older people. This programme is due to be completed by the end of 2011.This is a central element of the Trust’s reform of services for older people and the service redesign resulting from the changes to the function of some of the inpatient units contributes to the Trust’s overall cost improvement programme.

The Trust has completed an estates review with NHS Devon and Devon County Council to identify opportunities for co-location of integrated health and social care teams and to rationalise use of office accommodation. As a result of the review, and as part of its cost improvement programme, the Trust has identified those properties which are no longer fit for purpose and which are surplus to its longer term requirements. These properties are valued at £7.3m and will be sold, when the market conditions are right, to generate additional resources to support the Trust capital programme (see section six).

The Trust is planning to invest £31.9m in its capital programme over the next five years. The priorities are:

• Older peoples’ inpatient services • Secure services at Langdon Hospital

Finance

The Trust has a strong record of achieving its financial plans, including managing a challenging financial turnaround between 2006 and 2008. All capital and cash targets have been met during the last four financial years It has generated surpluses in 2007/08, 2008/09 and 2009/10 and implemented cost improvement programmes designed to make its services cost effective, competitive and financially sustainable in the longer term.

The Trust’s improvement programme for older peoples’ services in 2010 and 2011 is designed to reduce the overall number of beds and units to enable a strategic shift of resources to community services and will improve the overall reference cost.

Performance

The Trust has historically been measured against key performance targets set by the Healthcare Commission and more recently the Care Quality Commission. Performance against each key target is monitored and reported to the Trust Board every month.

Until 2008/09 the annual health check was the system for measuring performance within a framework of national standards and targets set by the Government. This assessed NHS organisations ‘use of resources’ and ‘quality of services’.

The table below sets out how the Trust performed in 200/08 and 2008/09:

Use of resources Indicator 2007/08 2008/09 Financial Reporting 2 3 Financial Management 3 3 Financial Standing 3 4 Internal Control 3 3 Value for money 3 3 Overall Use of 3(good) 3 (good) Resources

Indicator 2007/08 2008/09 Meeting core standards Fully Met Partly Met Existing national targets Fully Met Good New national targets Excellent N/A Overall Quality of Ex cellent Fair Services

The decrease in the rating for quality of services in 2008/09 was due to the failure to meet performance on the target for ‘best practice in mental health services for people with a learning disability’.

The Trust also had four core standards that formed part of the Care Quality Commission’s Standards for Better Health that were not being met at year end in 2008/09. These related to medicines management, supervision, records management, and clinical governance. The Trust has implemented action plans to meet these standards.

The previous performance regime has now been replaced by a national registration system for all care providers. The Trust registered with the Care Quality Commission in April 2010, with one condition relating to outcome area 14 (Regulation 23) which concerns support to staff.

Given this condition the Care Quality Commission has required the Trust to put in place systems to ensure the supervision and appraisal of staff and for keeping appropriate records it was been implemented effectively. This remains a high priority across the Trust and is one of its top three corporate risks.

Summary of Contractual Relationships

The table below details the contracts the Trust has in 2010/11.

Commissioners Duration Type £000s % NHS Devon and Torbay Care Trust Mental Health / Learning Disability 3 years Block 78, 738 60 Secure services Price per 3 years Case 5,765 4 Specialist services Price per 3 years Case 807 1 Other Individual Patient Price per Placements 3 years Case 14,169 11 Devon Drug and Alcohol Action Team Drug / Alcohol 3 years Block 6,434 5 NHS Devon

Prison Health Care 5 years Block 4,412 3

Other income 21,370 16 TOTAL 131,695 100

Most of the Trust’s services are funded on a block contract basis. The remainder (mainly forensic and eating disorder inpatient services) are purchased on a price per case in anticipation of moving to a tariff system for Payment by Results.

NHS Devon is the co-ordinating commissioner, on behalf of Cornwall, Plymouth and Torbay and also with the regional specialist commissioning group, for the Trust’s secure and specialist services.