Cabinet has approved the release of the strategic outline case (SOC) for a long term residential mental health facility, which has the potential to end the practice of sending persons overseas for such treatment.

Part of the management process for major capital projects required by the Framework for Fiscal Responsibility (FFR), the SOC outlines a number of project options that must be considered in the development of the outline business case (OBC) which will determine the most feasible option.

Some of the options identified by the Committee and included in the SOC are: maintaining the existing situation with no changes, or keeping things as they are, but hiring clinical case managers to monitor patients in the United States and Jamaica. Other options are: an on-Island facility with 30-40 beds for local patients only, or, a larger one that would cater to local and overseas patients, or simply tendering the service.

Government will shortly publish a request for proposals for a consultant to develop the OBC which will work strategically, and through public consultation, to identify the preferred option for going forward with the procurement.

Following the award of this contract, work on the OBC is scheduled to begin in late 2015 and continue into early 2016, with the procurement process for the facility itself, should the OBC indicate viability for the project, potentially beginning later that year.

A technical subcommittee comprised of representatives from the Ministry of Health, the Ministry of Finance, the Chair of the Mental Health Commission, as well as the Departments of Public Works and Counselling Services continue to oversee this process and provide regular updates to the larger steering committee, which is made up of a wide cross section of stakeholders.

The group will be guided in its work by a number of objectives agreed by the steering committee and the Cabinet Policy Guidance for the project. In particular the SOC suggests that any facility developed should be developed as a regional centre of excellence in the rehabilitation and provision of care for the mentally ill.

It also envisioned that the provision of vocational, educational and social skills training would enhance patients’ ability to live independently, and integrate into society.

A recent World Health Organisation survey on the provision of mental health services in the Cayman Islands identified the lack of a local long term residential facility as a gap that needed to be addressed. It also found evidence of an increasing local demand for mental health services.

Government is presently paying for approximately 15-20 patients to receive long term care overseas. Meanwhile a similar number who remain on the Islands are expected to benefit from the facility.

It should be noted that while the proposed facility would focus on the treatment of adults, the Ministry of Health and the Mental Health Commission will give separate consideration to the treatment of children and youth requiring similar services as part of the formulation of a Mental Health Policy later this year.

The Premier and Minister of Health, Hon. Alden McLaughlin, commented that the construction of a long term residential mental health facility would contribute to a number of Government’s core objectives.

“The ability to receive treatment on Island will allow patients to maintain personal contact with family and friends, and hopefully improve their outcomes. If we are able to indeed construct the facility via a public private partnership this would simultaneously help us to keep our costs low. I further believe that such a facility would strongly contribute to increased wellness among a vulnerable section of our population”, Mr McLaughlin stated

Persons who are interested in reviewing the SOC may visit the Ministry of Health website, www.ministryofhealth.gov.ky.

For your convenience we have published the SOC here after FAQ’s.

Strategic Outline Case (SOC) for the Long Term Residential Mental Health Facility (LTRMHF) Frequent Asked Questions: FAQ’s
What is a Strategic Outline Case (SOC)?
The Strategic Outline Case is an official document that provides a situational analysis and background information before a major project is undertaken by the Cayman Islands Government (CIG). The SOC frames the strategic context of the proposed investment and provides stakeholders with an early indication of what is being considered in moving forward with the project.

What is the purpose of the Strategic Outline Case?
The purpose of the SOC is to inform all stakeholders about the relevant facts surrounding a particular project. It is one of the first steps in the Framework for Fiscal Responsibility (FFR) process.

What is Framework for Fiscal Responsibility (FFR) and why do we have to have a Strategic Outline
Case done on our need for a long term residential mental health facility?
In 2011, the Cayman Islands Government and the United Kingdom Government reaffirmed their commitment to work in partnership and to respect the rights and responsibilities specified in the Framework for Fiscal Responsibility (FFR) and the revised Public Management and Finance Law (PMFL).

The FFR ensures effective medium-term planning, to ensure that the full impact of fiscal decisions is understood, by: putting value for money considerations at the heart of the decision making process, the effective management of risk, and delivering improved accountability in all public sector operations.

There are five key stages that must be undertaken by the Cayman Islands Government in the planning, development and execution of a project of the size and scope of a long term residential mental health facility. These stages are: 1 – appraisal and business case; 2 – procurement; 3 – contract management; 4
– delivery; and 5 – evaluation. The SOC is required in the first stage.

The Strategic Outline Case refers to a “Long Term Residential Mental Health Facility” (LTRMHF), what exactly is that?
Long term residential mental health treatment facilities are often needed to provide services that allow
for an extended period during which the individual can be closely monitored to provide accurate diagnosis, to help adjust or stabilise medications, or to manage health during and post- acute episodes where a person’s mental illness temporarily worsens. At present, no such facility exists in the Cayman Islands.

What are the Cayman Islands Government’s goals with this project?
The goal is ensure stakeholders and CIG are getting best services as well as value for money in the treatment and care of those who requite long term residential care for mental health illnesses. A present, most of these patients are sent to facilities in the USA or Jamaica. The CIG seeks to have consultants prepare the Outline Business Case (OBC) to see if the project is viable so that patients can receive this care locally within their own country of residence.

Why does the Cayman Islands need a “Long Term Residential Mental Health Facility” (LTRMHF)
There is currently no long term residential mental health facility in the Cayman Islands, yet the number of patients needing this type of facility ranges between 10-20 persons, who must at present be treated abroad. In addition to those patients overseas, there are a similar number of patients living here who would benefit from a long-term residential facility. Many of the patients here are unable to access overseas care because of their criminal history that prohibits them from being accepted. This makes of total of approximately 20-40 persons in need of such a facility currently.

This facility would provide the islands with a therapeutic setting providing counselling, psychiatric care and management, comorbid treatment, vocational, educational and social skills training. This will allow for adequate clinical oversight of patients, increasing chances of positive long-term outcomes. It would support and develop independent living skills allowing patients to rebuild their lives through the development of new employment skills to enable them to return to a functional level through various means.

Additionally this facility would enable patients to be close to their family and friends; remaining in the community which enhances their social structure and quality of life. Proximity of family will enable the opportunity to mend family dynamics, as well as to provide a greater possibility for a change to a healthier lifestyle with the support of family. It would also facilitate appropriate after-care for the patient and the family, including on-going support and clinical resources.

What steps are necessary by the Cayman Islands Government for it to achieve the LTRMHF?
 Pre Procurement Stage: Preparation of a Strategic Outline Case (SOC)
 RFP for Procurement of Consultants
 Preparation of an Outline Business Case (OBC)
 Tendering Process
 Contract & Performance Management – Implementation Phase / Project Delivery
 Operations – Performance Management.

Where can the public obtain further information about the Strategic Outline Case, once it has been finalised?
The public can obtain further information by doing the following:-

•Visiting the Ministry of Health & Culture website at www.ministryofhealth.gov.ky
•Visiting the Ministry of Health & Culture Facebook page at:
https://www.facebook.com/MinistryHealthCultureCaymanIslands?ref=hl
•Emailing the Ministry of Health at h&[email protected]
•Telephoning (345) 244-237

Project Title: Long-Term Residential Mental Health Facility (LTRMHF) Sponsoring

Ministry: Ministry of Health and Culture
Senior Responsible Officer: Jennifer Ahearn

Section 1: Project Overview

There is no long-term residential mental health facility in the Cayman Islands. Patients requiring long-term care are transferred to Jamaica and the United States of America. Currently, the number of adult patients overseas fluctuates between 15-20 persons; most of the patients are sent to Jamaica and the majority of those in Jamaica have been there for several years. In addition to those patients overseas, there are a similar number (15-20) of patients living here who would benefit from a long-term residential facility. Many of the patients here are unable to access overseas care because of their criminal history that prohibits them from being accepted.

Since the middle to the late 1990s, there has been a need for a long-term residential mental health facility. At that time, there were approximately 30 men and women with chronic severe psychiatric illness who would benefit from a residential facility. These persons in the community were known to social services, police, courts, and the prison authorities. This need has become increasingly urgent as the government continues to spend large amounts of money for overseas care of these patients.

Recently, the media reported that a member of the Judiciary stated that the criminal justice system is faced with a marked increase of defendants with serious mental issues and this must be addressed as a matter of urgency. He went on to say that he believed it’s a chronic problem and should be dealt with in Grand Cayman, rather than sending people overseas for treatment.

A long-term residential mental health facility will remove patients from the streets, thereby reducing the likelihood of them committing any criminal or antisocial acts; families will get relief and respite from the burden of taking care of their loved ones.

The goals of the facility when established would include the following:

 To achieve the status of a Centre of Excellence in the rehabilitation and the provision of care of the mentally ill in the region.

Establishment of a residential facility in a therapeutic setting providing counselling, psychiatric care and management, comorbid treatment, vocational, educational and social skills training. This will allow for adequate clinical oversight of patients, increasing chances of positive long- term outcomes.

 Support and develop independent living skills allowing patients to rebuild their lives through the development of new employment skills to enable them to return to a functional level through various means.

 Patients are close to their family and friends; remaining in the community which enhances their social structure and quality of life. Proximity of family will enable the opportunity to mend family dynamics, as well as to provide a greater possibility for a change to a healthier lifestyle with the support of family.

Enhance and develop new social and interpersonal skills offering a higher degree of successful integration.

 Achieving optimal outcomes while at the same time realising significant cost savings.

 Facilitating appropriate after-care for the patient and the family, including on-going support and clinical resources.

Approximately, 40-60 percent of mental health patients have a dual diagnosis and 10 percent of the population suffers from a mental illness. The staff of Caribbean Haven are trained substance abuse counsellors and not mental health professionals, hence, patients who are dual diagnosed and are in residential care at Caribbean Haven are unable to get the appropriate care needed.

Section 2: Background, Needs, Objectives & Constraints

Background

There are various reasons for embarking on this project. Some of the reasons include:

 Prior to the mid-eighties mental health services were predominantly outpatient care provided by a part-time psychiatrist. The more severe patients were transferred to the Bellevue Hospital in Jamaica for further treatment or, if they were violent they would be sent to the police lock-up in Cayman.

In the mid-eighties a visiting psychiatrist from Jamaica came once monthly and a full time psychiatrist nurse was employed who provided most of the community care.

In 1988, the mental health services department was established with the appointment of a full time resident psychiatrist. This was to develop a comprehensive community mental health service delivery system for the Cayman Islands. One of the goals was to evaluate the current service, utilize existing resources to establish programmes and services, and to meet the current mental health demands. Data was being gathered to support the need for appropriate mental health personnel and facilities.

 At that time, the mental health services were decentralized from George Town, and were made available at the district clinics and included a comprehensive community mental health service. The public health nurses did most of the visits and case finding throughout the Islands.

In 1993, Dr Franklyn LaHee prepared a Mental Health Services development 10 year plan focusing on a comprehensive, client centered community based, public treatment and service system for patients with severe mental illness. At that time the Mental Health Services Department comprised a consultant psychiatrist, a psychiatric social worker, a community psychiatric nurse and a receptionist/secretary to serve a population of 27,500. At that time,

there were about 130 patients suffering from chronic mental illness throughout the Cayman Islands.

Dr. LaHee also spearheaded the building of the eight-bed inpatient psychiatric unit at the
Cayman Islands hospital. The 10 year plan would include the following:
a) Hospital and Crisis Services
b) Residential Treatment Services c) Treatment Services
d) Rehabilitation Services
e) Support Services

 In 2001, the then Ministry of Health and Information Technology commissioned a report on the Review of the Mental Health Law. The report was completed by Dr Bradley and Dr Palmer, Consultant Psychiatrist and Medico-legal Consultant respectively.

 In 2010, Ministry of Health established a mental health taskforce to develop a National Strategic Mental Health Policy and Plan for the Cayman Islands. The taskforce completed their first and most important task of revising and amending the mental health legislation. Since then, the Mental Health Commission has been established and has been working diligently to achieve its mandate.

In July 2014, the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) survey was conducted in the Cayman Islands and the findings have revealed the need for a residential mental health facility. The Mental Health Commission will continue to work with the Ministry to ensure that this project comes to fruition.

Cayman Islands Government Strategic Aim and Policy Objective
The Cayman Islands Government has identified ‘A fit and healthy population’ as one of its 12
Broad outcomes of the Strategic Policy Statement (SPS). Included in this outcome is the following:

 Development of a mental health facility, in conjunction with the private sector;

 Encourage fitness and healthy lifestyles in schools and in the community generally; and

Work with the Health Services Authority, private sector partners and Cayman Islands National Insurance Company to lower the cost of health care and improve the quality of medical services available in Cayman.

Needs

Demand for Services
The preliminary figures from the World Health Organisation Assessment Instrument for Mental Health Systems (WHO-AIMS) study highlight an increasing demand for mental health services. Currently, 15-20 patients are overseas, and a similar number are on island that would benefit from this facility. We anticipate needing a facility with 30-40 beds, and including opportunities for future expansion. There are no local facilities to provide long-term care for chronic and/or dual diagnosis patients, despite the demand. The Royal Cayman Islands Police Services recently noted that the lack of adequate mental health facilities and care has placed an additional burden on the police services and social services. The absence of such a facility represents a significant gap in the continuum of care.

Objectives

Project Objectives
The objectives of the project are as follows:

 To achieve the status of a Centre of Excellence in the region in the rehabilitation and provision of care of the mentally ill.
 Establishment of a residential facility in a therapeutic setting providing counselling, psychiatric care and management, comorbid treatment, vocational, educational and social skills training.
This will allow for adequate clinical oversight of patients, increasing chances of positive long-term patient outcomes.
 Providing treatment and maintaining clinical stability in a safe environment for patients requiring long-term care, increasing their self-esteem and self-reliance, and ameliorating the impact of their life challenges.
 Support and develop independent living skills allowing patients to rebuild their lives through the development of new employment skills to enable them to return to a functional level through various means.
 Patients keeping close to their family and friends; allowing them to remain in the community which enhances their social structure and quality of life. Proximity of family will enable the opportunity to mend family dynamics as well as to provide a greater possibility for a change to a healthier lifestyle with the support of the family.
 Enhance and develop new social and interpersonal skills offering a higher degree of successful social integration.
 Providing care in a nurturing environment to enable patients to achieve a level of independence.
 Achieving optimal outcomes while at the same time realising significant cost savings.
 Provide appropriate support to the patients and their families when the patient is preparing to transition back into the community and through the transition process.
 Facilitating appropriate after-care for the patient and the family, including on-going support and clinical resources.

Constraints
There are several constraints facing this project:

Financial
Currently, there are no funds allocated for the project in this financial year’s budget; the Ministry will need to allocate appropriate funding for consultancy for the Outline Business Case and legal fees in 2015. If the preferred project delivery model is for it to be constructed, owned and operated by the Cayman Islands government, it would require increased operational expenditure and head-count, as well as capital funds to construct the facility.

Staffing
Under the current financial constraints, there may be some difficulty in recruiting appropriate staff and at the same trying to reduce head-count. International best practice requires as a general rule one registered nurse per 12 patients, per shift. The primary role of the registered nurse is to administer and monitor medication. A minimum of two psychiatrists will be required, one of which could be employed as a part-time employee.

Public perception
The Committee believes that the majority of persons will support the project. One concern is where the facility is to be located as this may lead to the “not in my backyard” issues.

Timing Issues
The need for the facility is immediate as the demand for services increase, as well as the complexity of the cases.

Legal requirements
The current legal requirements of the Local Companies Control Law (LCCL) regarding Caymanian ownership may make the project less attractive to overseas investors if a public- private partnership is pursued. In addition, if the facility is designed to offer medical tourism services, there may be immigration issues for patients requiring a long-term stay. These concerns should be addressed when developing the Outline Business Case.

Health Insurance
While the minimum coverage for health insurance that must be provided by approved insurers has a maximum of $25,000 lifetime benefit for inpatient, there are many insurance plans that do not provide cover for mental illness in an outpatient setting or the patient is required to pay 50 percent of the cost rather than the standard 80/20 co-pay.

Professional Standards
CPAM and the other Health Practice Councils will need to work with the Mental Health Commission to ensure that appropriate scope of practice and code of conduct are prepared for all categories of practitioners employed to the facility.

If medical tourism is pursued, it is recommended that the facility become Joint Commission International (JCI) accredited.

Planning
Since this facility would be the first of its kind, the Committee may encounter challenges going through the building permit/building code processes.

Size of project
The projected size and scope of the project may make it unattractive as a public-private partnership.

Other populations
Currently, the facility proposed would accommodate adult patients only. While the greatest need is for adults, there is also some need for inpatient treatment for children and youth which will need to be considered separately from this project.

Section 3: Stakeholder Issues

The stakeholders and their roles are as follows:

1. Ministry of Health
The Ministry of Health is the lead agency for this project and has a high level of commitment to move it forward. The funding for this project is likely to come from the Ministry’s budget.

2. Mental Health Commission
The Mental Health Commission is charged with a broad remit relating to all aspects of mental health in the Cayman Islands. The Commission will have a high level of interest and commitment to this project. They will be a key stakeholder in terms of advocating for the project, providing expertise in the development of policy guidelines and operational guidelines for the project.

3. Health Services Authority
The H.S.A will have a high level of interest in the LTRMHF. As a potential provider of services and a potential contributor of providers, they will be a key stakeholder in the project. The development of the LTRMHF will help to reduce the burden on the HSA’s Mental Health Unit while enhancing overall patient outcomes

4. Ministry of Community Affairs, Youth & Sports – CAY&S
Ministry of Community Affairs, Youth & Sports is responsible for social services, counselling (including substance abuse), youth and sports. A high level of involvement will be required, and a high level of commitment is anticipated.

5. Children and Youth Services (CAYS) Foundation
The interest/involvement of CAYS Foundation would be minimal to moderate unless a decision is taken to include the older adolescent population, i.e. beyond mandatory school age, in the LTRMHF clientele.

6. Department of Children and Family Services(DCFS)
The Department of Children and Family Services is likely to be a referral source, as some of their clients also require mental health services. The role of DCFS is to provide assistance to children and families in crisis – child welfare and protection, the elderly and other social work interventions. It is anticipated that DCFS will have an interest in the long-term residential mental health facility. While not a key stakeholder, the department will have a moderate level of involvement in the project process. It is expected that they will be willing participants in the process as needed.

7. Department of Counselling Services
The Department of Counselling Services could be a major stakeholder given that there is discussion/consideration of locating the long-term residential mental health facility at the Caribbean Haven site. Their buy-in and participation is critical to the success of this project. Currently, patients with dual diagnosis are admitted to the Caribbean Haven Residential Centre, but the staff will require additional training to care for patients with dual diagnosis.

8. Needs Assessment Unit(NAU)
This agency is relatively new with responsibility for providing temporary and permanent financial assistance (poor relief) to residents, including indigents. Some of the indigents suffer from serious mental illness and could benefit from the LTRMHF. The NAU will have a moderate level of involvement in the project and is expected to be a willing participant as needed.

9. Ministry of Home Affairs
This Ministry is responsible for national security, public safety, crime reduction, and offender rehabilitation. The Ministry of Home Affairs will have a significant interest in the project, and a high level of commitment is anticipated.

10. Department of Community Rehabilitation(DCR)
The Department of Community Rehabilitation is expected to play a significant role in this project and would be an asset through a collaborative approach. Although DCR’s role will mainly be for the supervision of persons with mental illness who are involved in the criminal justice system, support and guidance may also be extended to others from a preventative approach to avoid entry into the criminal justice system. Further, DCR could be utilized as liaison/case managers between the client and various agencies, as well as family and community to allow for a smoother reintegration into the community, and a more successful continuum of care. It is anticipated that DCR’s community support, supervision, and guidance, will lessen the chances of persons being placed in facilities such as the prison. The LTRMHF will improve the support and services needed for DCR’s clients, which should enhance the success rate and increase public safety.

11. Her Majesty’s Cayman Islands Prison Service
There is a perception that a significant number of the prison population who have mental illnesses are held “unjustly”. The Prison Service’s rehabilitative team currently has a Correctional Counsellor with mental health and substance abuse experience, as well as a Clinical Psychologist who liaises with community based mental health professionals in an effort to meet the needs of those inmates with both serious mental illness and co- occurring disorders. It has been acknowledged that future estate planning must include a psychiatric unit in order to provide stabilization to inmates upon reception or at any point during their incarceration, as well as ongoing therapeutic interventions that may be required. Whilst the prison currently works to prepare all inmates for re-entry into the community, some who have been identified with serious mental illness may require admission to the LTRMHF upon release for further treatment. Re-entry plans will take this into account and all efforts will be made to ensure that they are well prepared for the same, as the Prison Service is committed to working with allied professionals within the continuum to ensure the best possible outcomes for all inmates including those with mental illness.

12. National Drug Council(NDC)
The National Drug Council is an entity under the Ministry of Home Affairs and will have an interest in the project. The NDC will be active participants in the project development process and will be in a position to assist with research into best practices and other areas. As they conduct regular surveys of the adult prison population, they can also contribute current relevant data to inform programme development and assist with ongoing evaluation and monitoring.

13. Royal Cayman Islands Police Services (RCIPS)
The RCIPS will have a significant interest in the project, but it is anticipated that they will have a moderate level of involvement in the project development process. The RCIPS have made statements in the press about the high level of mental health-related calls they receive, and the increasing burden it has put on their resources and facilities, thereby lowering their ability to respond to crime fighting issues. It is anticipated that once the LTRMHF is operational, the number of calls that the RCIPS will need to respond to for mental health issues should decrease, as it is often the same patients they are called on to deal with.

14. Courts (Judicial)
It is expected that the Courts/Judicial will have a significant interest in the LTRMHF due to the significant number of dual diagnosis cases before the court with increasing difficulty in adjudication due to a lack of appropriate facilities. In addition, the Courts have been operating a ‘Mental Health Court” which is on-going and functioning. It is anticipated that they will have a moderate level of involvement in the LTRMHF project process; however, they will likely be active participants when called on to contribute to the project development process.

15. Ministry of Education, Employment & Gender Affairs
The Ministry is responsible for education and employment. It is expected that they will have a significant interest in the project as it relates to young people and identifying employment/vocational opportunities for persons with a mental illness. A moderate level of commitment is anticipated from the Ministry.

16. Department of Education Services(DES)
It is anticipated that the DES will have a significant interest in the LTRMHF, but a moderate level of involvement in the project process as this will be a facility for adults.

17. National Workforce Development Agency (NWDA)
The National Workforce Development Agency has responsibility for helping people to get into employment, to remain in employment, and to progress within their careers. Some clients may have significant barriers to employment, including mental illness, which may create difficulties in getting employed, or remaining in employment once hired. It is therefore anticipated that, part of the focus of this project will be the development of employment skills; the NWDA will have a significant level of interest in the establishment of a LTRMHF, but a minimal level of involvement in the project process.

18. Sunrise Adult Training Centre (SATC)
The Sunrise Adult Training Centre is a department under the Ministry of Education, Employment & Gender Affairs, which provides training and therapeutic services to adults with disabilities. The SATC is likely to be a referral source, as some of their clients require mental health services. Research demonstrates that individuals with disabilities, which include but are not limited to, intellectual disabilities, physical disabilities and neurological disorders, are at a higher risk for developing mental health issues as they progress through older adulthood. The complexity of the individual’s mental disorder and mental illness can require specialized treatment interventions. The SATC provides services in occupational therapy, vocational training, and life skills development, which can provide informational support in the development of programmes. The Sunrise Adult Training Centre will have a moderate level of involvement in the project and is expected to be willing participants as needed. It has several clients with mental health issues, some of which require long term treatment in an overseas facility.

19. Public Works Department(PWD)
The PWD will provide project management services for the delivery of the project.

20. Private sector mental health providers
It is anticipated that these stakeholders will be very interested in this project as they are on the front-lines treating and caring for clients/persons who may benefit from the LTRMHF. They may also be potential partners if a public-private partnership delivery of the project is pursued. They will likely be active participants in the stakeholder consultation opportunities through the project development process.

21. Consumers and families
As the primary beneficiaries of the project, it is expected that there will be a high level of interest in the LTRMHF project from this stakeholder group. Their involvement in the LTRMHF project process will likely be on an “as needed” basis. The Minister with responsibility for Health would be asked to identify a suitable person to serve on the Steering Committee.

22. Non-Governmental Organizations (NGOs)

Loud, Silent Voices is an active NGO dedicated to mental health issues and concerns, and serves as a support group for patients and their families. This group would have a high level of interest and commitment to seeing the development of a LTRMHF. Their involvement in the project will likely be on an “as needed” basis.

Alzheimer’s and Dementia Association of the Cayman Islands (ADACI) may have some interest in the project, though their members would likely have a greater interest in the facility and services offered by the Pines Retirement Home.

The Special Needs Foundation Cayman is a non-profit organization of parents, educators and professionals committed to supporting children with a range of special needs. This group may have some interest in the project, though their members are children and adolescents.

Bridge Foundation is a non-profit organisation that provides accommodation and support for recovering addicts at its campus in Hell in West Bay.

23. Private health insurance providers
It is expected that the private health insurance providers will have a minimal to moderate interest and involvement in the LTRMHF project, as it is felt that they have very few clients with benefit packages that would cover the cost of patient care at the LTMHRF. Many persons with mental illness are sent overseas for care and have insurance coverage through CINICO.

24. CINICO
As the insurance provider responsible for most of the patients with serious mental illness that require inpatient treatment, it is anticipated that CINICO will be a key stakeholder with a high level of interest in the project. CINICO’s involvement in the project process will likely be towards the end of the project process.

25. Cabinet
Cabinet has a key role in the project process and will provide the Cabinet Policy Guidance. This Cabinet Policy Guidance will give the guiding parameters of the project and Cabinet will need to commit the funding for the project. Cabinet will have a high level of interest and will be involved in the procurement process in accordance with the provisions of the Framework for Fiscal Responsibility (FFR). The Cabinet Policy guidance for the LTRMHF is attached as Appendix One.

26. Outstanding stakeholder issues
The Ministry of Health will continue to engage the Ministry of Home Affairs to discuss the need for the treatment of prisoners who become mentally ill while incarcerated and/or the treatment of the mentally ill who have committed a crime. The physical infrastructure of Northward Prison will require a separate wing for the mentally ill whether they are remanded in custody or have been convicted. Some of those persons in the prison suffering from a mental illness and have completed their sentences will require placement in a long-term residential facility.

The Deputy Chief Officer in the Ministry of Home Affairs confirmed that while the prison has increased its staff complement for the rehabilitation team which include a clinical psychologist, a correctional counsellor, a case manager, and an assistant case manager, there are some prisoners for whom the appropriate response is a long term residential mental health facility in order to access a continuum of care and to prevent the cycle of recidivism. More community mental health nurses are required to assist families and the correctional services to ensuring that prisoners are compliant with their medication and the appropriate level of support is available. This will help to reduce the demand on the court and prison, thereby improving family relationships.

As part of its function, the Mental Health Commission will continue to provide mental health training, sensitization sessions and training on the mental health legislation for prison officers, constables, counsellors, social workers and health care providers.

Section 4: Management & Implementation

A Steering Committee has been established to finalize the Strategic Outline Case for submission to Cabinet. Once the SOC has been granted approval by Cabinet, a technical subcommittee consisting of the Chief Officer, Ministry of Health; Max Jones, Public Works Department; Karen Rivers, Ministry of Finance; Dr Lockhart, Mental Health Commission; and Esther Taylor, Department of Counselling Services will be formed.

The functions of the technical subcommittee are as follows:
 Provide updates to the Steering Committee
 Draft the Request for Proposal(RFP) documents to request the consultancy services for the Outline Business Case
 Lead the procurement process for the OBC and the delivery of the project

Proposed project management structure and key personnel
General: the choice of procurement method will affect the level of project management required. The base requirement is for project management personnel with strong project management skills and general procurement expertise. It is recommended that this project be managed by PWD, either through its major projects office or PWD’s general project management office. When the procurement method and scope of project are defined, the decision can be taken on which of these two offices will be responsible for the project management.

Reporting Structure: The Project Manager (PM) will be supervised on a daily basis by the Senior/Chief Project Manager. The PM will also have a reporting function to the Senior Responsible Owner (SRO), and to the LTRMHF Steering Committee.

A Project Manager should be appointed to represent the LTRMHF interests during the project and acting as the “Owners Representative”.

The proposed key personnel anticipated for each project stage is as follows:
1) Pre-Procurement Stage
 Preparation of SOC, Outline and Full Business Case; key personnel – Project
Manager, Administrative Assistant
 Consultant support – financial, legal, technical, environmental

2) Tendering Process
 Preparation of tendering and contract documents and contract award; Key personnel- Project Manager, Administrative Assistant
 Consultant support – financial, legal, technical, environmental

3) Contract & Performance Management – Construction Phase Project Delivery
 Key personnel – Project Manager, Administrative Assistant
 Consultant support – financial, legal, technical, environmental

4) Contract & performance Management – Operation Stage
 Monitoring and assessment by CIG/Project Steering Committee

Legal, contractual or procurement issues
Adherence to the Cayman Islands legal framework is required at every stage of this project. The Public Management and Finance Law (2012 Revision) clearly sets out the key stages for projects of this nature and the various procurement requirements to ensure value for money. Public Private Partnerships to the extent contemplated for this project is a fairly new area for the Cayman Islands Government. Relevant external expertise may therefore be necessary to review and advise on potential contractual arrangements prior to execution, if this method of delivery is pursued.

Outstanding management/implementation consideration
The appointment of a Project Manager as soon as practical is a recommended course of action. This will afford a dedicated resource to the advancement of this project should the Government decide to pursue it. The adequacy of existing funding to retain a Project Manager, consultant support for the preparation of the RFP documents and Outline Business Case should also be considered.

A consultancy report will be prepared by the Ministry, and the financial consultants will be required to complete the Outline Business Case. If the Public Works Department is unable to provide architectural and engineering support, these services will have to be outsourced for consultancy. It is anticipated that technical consultants will need to have the experience and expertise in the design of mental health facilities. Legal consultants will be required if the government decides to pursue a public-private partnership. While the Foreign and Commonwealth Office (FCO) could provide independent technical advice, other consultants i.e. environmental and mental health experts may be required.

Under the terms of the Framework for Fiscal Responsibility (FFR), government is not allowed to borrow funding for any project; therefore, in order to ensure the success of the project, a commitment will be required from Cabinet for the continued financing of the project/facility.

If the project is developed to attract medical tourists seeking care, then it’s likely there will be increased revenue for the Cayman Islands.

Anticipated Project Timeline

CIG confirms that the succeeding dates in the schedule for the Strategic Outline Case and the Outline Business Case set out below are indicative only of the overall time. The timeframe for the procurement of the project will depend on the delivery method chosen.

 

Section 5: Consideration of Options

There were five options identified:

Option 1: Status Quo

Currently, overseas providers are utilised for long-term care, and acute care is available on Grand Cayman. However, the local provider has no clinical oversight of the patient whilst overseas, and there is no formal policy that will require reporting from the overseas providers. In addition, many families find it difficult to visit their loved ones whilst they are overseas receiving care and this creates a burden on the family and in some cases affect the patient outcome.

Option 2: Enhanced Status Quo

In order to achieve this, it will require hiring clinical case managers in Jamaica and the United States to monitor patients sent there. The number of case managers hired is dependent on the location and number of patients. The role of the clinical case manager is to provide supervision of the ongoing care of the patient and liaise with the providers of care. A major drawback of this option is the overseas providers of care do not always make themselves readily available.

Option 3: Building a Long-Term Residential Mental Health Facility for the local population

This facility would accommodate the local population estimated to be 25 to 30 patients. Currently, half of these patients are overseas and the other half is those persons locally who would benefit from this facility. If persons with a dual diagnosis are included, this number would increase.

The long-term residential facility will offer clients medical and social supervision in a therapeutic environment where clients and therapists are involved in working to achieve optimal outcomes for the clients.

Option 4: Building a Long-Term Residential Mental Health Facility for local and overseas patients

This facility would accommodate our local population as well as medical tourists. It will be designed as a centre of excellence in the rehabilitation and the provision of care of the mentally ill for the region. The proposed facility may provide opportunities for other small United Kingdom Overseas Territories (UKOTs) to use our facility, thereby becoming a potential revenue generator.

Option 5: Cayman Islands Government (CIG) to Tender for local Service

For this option, the CIG will advertise a tender for local service provision. The successful bidder will need to provide the facility and services.

Section 6: Costs, Benefits & Risks

6.1 Broad Project Costs

1. The Government’s costs towards this project are expected to be largely centred on the business case and subsequent procurement phase. Thereafter, if it is determined that the delivery will be a PPP model, anticipated expenses will come from the contracting of external consultants, in addition to possible need for emoluments for a project management team, which will essentially act as an owner representative on behalf of CIG. If it is a traditional delivery, then the CIG costs will be for project management and construction.

2. If this project is determined to be best followed in a public private partnership model, the capital costs are expected to be borne by the private sector with minimal CIG financial involvement. The future operating costs will be dependent on the option chosen from the list of options in section 5 and will be further developed as part of a substantive business case.

3. The construction phase will require the monitoring by CIG departments in particular PWD.
The number of people and the amount of time required has yet to be ascertained and therefore cannot been quantified at this time.

4. There will be costs associated with the Project while it is being constructed, including insurance. The potential costs of the above will be borne by different stakeholders and are not available at present.

5. Once the LTRMHF project has been constructed, there will be various operational costs for the Project. The operation of the facility would include management of the facility, high level of security given the nature of the project, insurance, upkeep (cleaning, janitorial), management/services (information, and back office functions HR, finance, IT, etc.). The

extent of the operational costs is unknown at present as the detailed operational requirements of the new LTRMHF have yet to be fully defined.

Non-monetary costs

None have been identified.

6.2: Benefits

1. Improved mental health services for citizens of the Cayman Islands through the establishment of a residential facility in a therapeutic setting providing counselling, psychiatric care and management, comorbid treatment, vocational, educational and social skills training.

2. Better local clinical oversight of patients, increasing chances of positive long-term outcomes.

3. Achievement of a Centre of Excellence in the rehabilitation and the provision of care of the mentally ill for the region. The proposed facility may provide opportunities for other small United Kingdom Overseas Territories (UKOTs) to use our facility, thereby becoming a potential revenue generator.

4. The support and development of independent living skills will allow patients to rebuild their lives through the development of new employment skills, enabling them to return to a functional level through various means.

5. With the facility in place, patients would be closer to their family and friends. Our local mental health patients will remain in the community rather than being sent away, enabling enhancement of social structure and quality of life. The proximity of family will enable the opportunity to mend family dynamics, as well as to provide a greater possibility for a change to a healthier lifestyle with the support of family.

6. Enhancement and development of new social and interpersonal skills offering a higher degree of successful integration for the patients.

7. Achievement of optimal outcomes while at the same time the potential for realising significant cost savings over time, by having this service available locally.

8. Facilitation of appropriate after-care for the patient and the family, including ongoing support and clinical resources.

9. The facility would provide employment opportunities for Caymanians as well as keeping health care dollars in our local economy.

6.3: Risks

In a standard government procurement project, government bears all of the risk. If the proposed structure of the Project is a PPP, risk would be allocated between the CIG and the Private Sector Development Partner. The following are the expected broad risks for the project that have been identified:

1. Financing of Project Costs: The Cayman Islands Government will be responsible for the costs of the pre-procurement stage and preparation for the tender documentation. The costs during these two stages will amount to a significant amount to be identified in an entities’ allocation, especially in a time when budgets are lean and there are requests for further budget reductions.

2. Politics: There is a risk that if the administration changes after the next election (2017) they may not want to pursue this Project.

3. Natural Disasters: The Cayman Islands are located in the hurricane belt and on a boundary between two tectonic plates. Given that the construction phase of the project could span approximately 18 months, depending on the project selected and the start date, this duration could include two hurricane seasons. The impact of a near miss by a hurricane or an earthquake in close proximity would have a severe impact on the progress of the project.

Section 7: Funding & Affordability

Currently under the FFR/PMFL Regulations, Government is unable to utilise conventional borrowing methods to fund major capital projects. As the project scope is as yet undefined, the total cost is an unknown.

 Existing budgetary provisions are in place for the pre-procurement stage. The Cayman Islands Government will seek to utilise in-house expertise as far as possible to prepare the Strategic Outline Case (SOC) to minimise costs. However, as required by the FFR/PMFL Regulations independent financial, technical, and legal advisors are required to prepare the Outline Business Case.

 CIG’s Ministry of Health and Culture should allocate adequate funds in their budget allocations to cover the cost of the professional fees for this project during the 2015-2016 financial year, and also during the 2016-2017 and 2017-2018 financial years. The fees are likely to be in an order of magnitude cost of CI$1.0 million over 2015-16.

 The Outline Business Case will examine all the financial aspects of the project including existing and potential revenue streams, and the best value options to the Cayman Islands for the delivery, implementation and operation.