Coming Home Implementation: report from the Working Group on Complex Care and Delayed Discharge

6. Community Change Fund

6.1 Purpose of the Community Change Fund

It was the view of the members of the SLWG that most people with learning disabilities and complex care needs require a radical redesign of services in their local community. In order to facilitate this, the group proposed a short-term Community Living Change Fund which was accepted as an early and priority need and distributed by the Scottish Government following receipt of Barnett consequentials for similar work by UK Government.

£20m was allocated to Integration Authorities in February 2021 and can be held in reserve for up to 3 years. The Scottish Government is working with local areas to monitor the use of this funding.

The purpose of the Community Living Change Fund (referred to as the Fund) is to drive the redesign of services for people with learning disabilities and complex care needs. The goal is to provide high-quality, local, community-based services where, regardless of complexity of need or behavioural challenge, people's right to live a full and purposeful life, free of unnecessary restrictions can be realised.

The Fund is available to accommodate the re-provisioning of long-term hospital and inappropriate out-of-area care and to create a powerful lever to a longer-term shift from institutional care. The Fund is not intended to replicate current inappropriate arrangements but rather act as a facilitating mechanism to bring about change.

Specifically, the purpose of the Fund is to help people with learning disabilities although this could be extended to support people with enduring mental health conditions where this was deemed appropriate. The Fund should be used to support people to:

• Be discharged from hospital quicker, and not face any unnecessary delays to their discharge;
• Come home back to their local area if they have been inappropriately placed out of Scotland;
• Feel better connected to their communities through an increase in local community service provision for when they have been placed in inappropriate or institutional out-of-area placements;
• Receive better services through redesign of existing provision that is better tailored to the specific needs of the person.

6.2 Use of the Fund

The Fund should be broadly used to improve community-based support to people with complex care needs with the aim that by March 2024 out-of-area placements are only made through individual family choice and people are only in hospital for genuine short-term assessment and treatment.

This includes ensuring that no one is admitted to hospital because of behaviour that challenges, and that where individuals are admitted to hospital, this is short-term and for a clear clinical purpose of assessment and treatment, rather than due to lack of appropriate community placements. The Fund should also be used to ensure that out-of-area placements are only made based on the choice of the individual and/or their family.

It is recognised that this has been a long-term challenge for the sector in Scotland and across the UK, and that service redesign requires whole system change. This may be a lengthy process and will need local leadership and vision for the changes required in local areas. The challenges facing each HSCP may be slightly different, depending on a range of factors such as current local services, geographical challenges, and/or workforce issues. The specific solutions may also therefore be slightly different and as such guidance for use of the Fund has not been specifically prescriptive.

However, it is clear that the overall aim of the Fund is to support redesign of services in order to achieve the above objectives. It is therefore important that the Fund is used in this way, rather than to simply make up for a shortfall in local services.

“This has been a long-term challenge for the sector in Scotland and across the UK, and service redesign requires whole system change.”

Equally, the Fund should not be used to develop institutional services which lack connection with the community and do not allow for people to live a full and rewarding life.

Some of the suggestions for how the Fund could be spent in order to achieve the overall objectives are noted below. These are supplied in order to help local areas think through how best to achieve the overall objectives of the Fund. It is recognised that HSCPs remain best placed to decide how best the Fund should be spent:

• Use the money from the Fund collaboratively, for example linking with other HSCPs with similar challenges (remote, rural, or island communities may have similar needs).
• Take a board-wide approach to use of the Fund, in order to achieve more fundamental and systemic change, i.e., local HSCPs within the same board area may find it more useful to take a board-wide approach.
• Provide bridging finance in order to support the closure of inpatient beds.
• Invest in collaborative local commissioning solutions, bringing together third sector partnerships.
• Develop a 'place of safety' or crisis service to provide short-term accommodation options for people experiencing significant challenges or approaching crisis in their current service.
• Consult with social care providers to determine their workforce development needs, with an aim to achieve a wider range of providers able to develop successful community-based services for people with challenging behaviours and complex needs.
• Provide specialist training to commissioners to enable them to feel more confident in commissioning services for people with the most complex and challenging needs.
• Develop a local complex needs 'Change Champion' role, with responsibility to oversee the Fund's objectives.
• Develop local expertise and resource in Positive Behaviour Support or other similar person-centred approaches, recognised as effective evidence-based approaches to supporting people with learning disabilities and behavioural challenges.

Case Study Teviot Court, Midlothian

Midlothian is one of the fastest growing Local Authorities in Scotland with a rapidly increasing population. It is fairly small geographically, covering the 9 miles from Dalkeith to Penicuik. Therefore one housing development is local for everybody. Midlothian has land, and a well-established local authority house building programme. It is close to Edinburgh, and therefore issues around recruitment and retention are not as acute as other areas.

Early discussions took place about a cross-HSCP regional approach but ultimately it was easier to build alone.

The first step was to build the houses. It took five years until the properties were completed. Without the properties everything else was felt to be compensating for the wrong environment. The appropriate houses cost twice as much as a usual council house but can be used variously and independently as design allows for differing needs. The design is 12 council tenancies in a cluster of four flats around three courtyards. This allows for efficiencies of support, provided in a town centre location. Properties are twice the size of standard housing and a pleasant place for people to live in a high quality environment. These properties were suitable to support people who may have been at risk of having to live out of the local area or of being admitted to hospital. The design is safe, comfortable and a homely environment. The designs are physically robust, single storey, barrier free and non-institutional. The layout is designed in a simple clear manner so that, intuitively, it requires less effort for people with complex needs to use and inhabit the environment.

Various capital approaches were considered but Midlothian ultimately settled on utilising the Housing Revenue Account. This was supported by Phase 2 of the Housing Build Programme plus 50% from the General Fund. Placements are supported through rent charges. Complementary properties in Phase 3 are currently being built as part of the house building programme.

6.3 Monitoring of the Fund

The Scottish Government should actively monitor spending from the Community Change Fund to ensure that the Fund is being used to meet the objectives noted above.

Informal monitoring will be carried out collaboratively and co-operatively through partners such as the Social Work Scotland Learning Disability Network.

However, the use of each Integration Authority's share of the £20m must be recorded in their annual financial statement and the outcomes delivered detailed in their annual performance report.