Agenda item

Attending for the discussion of the draft 2018/19 budget for Adult Services and Public Health, were the Director and Assistant Director of Adult Services, the Director of Public Health, the Strategic Commissioner of Adult and Health Services, as well as the Senior Finance Manager for Adult Services, and Senior Project Manager.

The Cabinet Members for Adult Services and Health and Wellbeing were also present.

A presentation had been circulated and the officers highlighted the main points, including key headlines from the budget report included in the agenda, key investments, new proposed reforms or other ways to fund, the Public Health Ring-fenced Grant, risks and cost pressures.

·         There were a number of demand pressures, especially on services for adults and children. Around 85% of the budget for adult services was spent on external providers.

·         The proposal for 4.94% Council Tax increase included a 3% Adult Social Care Precept, ring-fenced for Adult Social Care services in order to contribute to cost pressures. Since an extra 2% had been raised the previous year for Adult Social Care services, this would mean that the extra amount allowed for 2019/20 would be 1%.

·         The Adult Social Care budget would be strengthened by £7.2million in 2018/19; £3m in response to demographic growth and increasing complexity of support for vulnerable older people and adults with disabilities, £3.2m to meet rising costs of inflation, for pay,pensions and prices. £1m would go towards meeting the requirements of the Deprivation of Liberty Safeguards (DOLs) legislation – government reforms were due, which the Director welcomed since the current requirements were frustrating and not the most effective method.

·         Measures to achieve a balanced budget included maximising use of the Better Care Fund Grant, other monies, income for client contributions, also maintaining challenge on savings targets and trying to keep them at the same level, as well as use of accountancy adjustments where necessary.  An example was capitalising expenditure to maximise the use of revenue.

·         New proposed reforms, or other ways to fund included £4.2m from optimising use of the Better Care Fund and new Directorate reforms such as:

Ø  review of Learning Disability (LD) Day Services (£0.3m)

Ø  maximising benefits (£0.2m), by working with the voluntary sector and the Department of Work and Pensions. There was evidence that people were not always maximising use of the benefits they were entitled to, which was detrimental to them but also to the Council

Ø  review of Replacement Care (previously called Respite) for LD (£0.1m)

Ø  Advocacy joint commissioning with neighbouring councils (£0.1m)

Ø  Transport provision (£0.1m)

Ø  External Provider Training (£0.1m)

Ø  Housing Support (Mental Health (£0.3m)

·         Reprioritisation of Public Health was earmarked to save £0.5m. Existing plans for Public Health were based on cautious estimates of assured grant levels from 2018 and following confirmation of the Public Health Ring-fenced Grant (PHRFG) further reprioritisation of spend would follow.

·         Nationally, there were significant risks and cost pressures on services for adults, including demand and demographics, workforce (particularly nursing and social care recruitment within home care providers, which had led to some care home closures and in Worcestershire the number had reduced from 68 to 64 care homes) and pressures on contracts (National Living Wage etc).  The Council was looking at how it could help across the system.

·         Discussions continued with the NHS over responsibility for funding expenditure around Continuing Health Care and Section 117 placements. The number of 'Self-funder pick-ups' had also increased due to individuals living longer and their income being insufficient to pay for their own care.

·         The Three Conversation Model of social work was the main area of focus to address increased demand and complexity of need.

·         The PHRFG had continued to reduce over successive years. The 2018/19 notification was £29.1m, compared to the Council's budged estimate of £28.3m. The £0.5m savings target was achievable; however there would be a number of challenging savings targets moving forward since there remained a degree of uncertainty around continuation of mandated services beyond 2020. The Council would need to review mandated areas, such as reviewing contracts where statutory duties may sit with other organisations – for example housing. However the Council would monitor very carefully the effect of any reduction of services, and do all it could to strengthen the prevention element. The indicative grant for 2019/20 was £28.3m, a reduction of £0.8m.

·         In reiterating the number of challenging financial risks, the Director of Adult Services referred to the long-awaited Green Paper for social care, which it was hoped would bring more clarity for the future.

A discussion took place and the following main points were raised:

·         The Panel and HOSC considered that every opportunity should be taken to communicate honestly with communities and all levels of Government about the challenges being faced in adult social care as well as about the positive actions being taken.

·         When asked about flexibility on the budget remaining for social care, given that such a high proportion (85%) was tied up in costs of external providers, and contract costs may increase, the Director explained that a detailed round of negotiation took place each year with providers and it was a fine balance between balancing budgets and not significantly underpaying providers, which would not be viable. A two year deal had been struck with providers the previous year which meant that increases to hourly rates were not expected for this year. When asked for further information, the Director offered to provide information on investment in social care providers over recent years. The remaining 15% was mainly for staffing but there were no redundancies being suggested and the Directorate would look at other efficiencies. Front line staff were very important.

·         A member referred to new expenditure budget information for 2018/19 in the agenda report and sought clarity that the £3m allocated for Adult Social Care and £1m for Deprivation of Liberty Safeguards – Social care Assessments equated to an additional £4m spend? The Director explained that these two figures related the overall £7.2m strengthening of the Adult Social care budget, along with £3.2m additional funds to meet the rising costs of inflation, for pay, pensions and prices.  The Cabinet Member for Adult Social Care pointed out that in effect demand and inflation was consuming the additional budget and so the funds for strengthening were really to provide a stabilising effect; to be clear, there was no extra £3m

·         The member sought further clarity on inflation for pay, pensions etc and where this featured in the overall budget, and the scrutiny officers would re-circulate this information.

·         Referring to the recent addition of social care to the role of Government Minster for Health, a member asked what projects was the Council involved in to prevent people needing care? The Directors felt there was now a much bigger focus on prevention and strong strategic progress, starting with the Sustainability and Transformation Partnership (STP). Social care and health integrated on a daily basis, including at Directorate Leadership Team level. Schemes of work included social prescribing, digital inclusion, making every contact count, behaviour change programme and strokes and falls.

·         When asked how the Better Care Fund, which was a specific grant, could be optimised, members were advised that the Council was trying to use the grant more effectively including trying to apply the grant to services which replaced some of the Medium Term Financial Plan expenditure.

·         Members asked about what was being done to attract more nurses to the profession and officers spoke about the considerable pressures on the Acute Trust and the Health and Care Trust. Brexit had also brought uncertainty since a high proportion of social care staff came from Eastern European countries. This was a national issue, which locally partners were trying to tackle through the STP, and trying to attract good quality care staff who would progress. The STP had a Workforce Action Board and despite concerns, applications for the nursing degree had in fact increased.

·         It was clarified that the complexity of supporting vulnerable older people had increased because people were living longer but were not necessarily healthy and often had multiple conditions. The Director of Adult Services could provide an indication of numbers affected.

·         Referring to the budget figures, a member suggested that the budget uplift of £3.2m for 2018/19 was generous; providers should be doing well but they were not and therefore what would the Council do if more care homes continued to close and what about the suggestion for the Council to run care homes? The AS Director agreed that this was a good point and although for the Council to run care homes would be too high risk, his personal view was that it should look to intervene regarding areas such as complex dementia care. He also pointed out that the Council could not directly employ nurses, but although a number of nursing homes had closed, there were other types of settings. The Council was doing a lot to prevent people needing care and kept abreast of the situation and gaps.

·         A member referred to problems when people were discharged from hospital, and asked where in the community integrated care would take place. The AS Director felt that Worcestershire did quite well on integrated working, and continued to look for new areas. The Grange was an example of community settings. One option was the 'step down' unit which was close to hospital yet also a step towards going home. Studies showed that a person's own home was the best place and so a lot more needed to be done to facilitate this.

·         Cllr Oborski (the Council's lead scrutiny member for Children and Families) was subsequently invited to the table, and requested clarification about closure of The Grange, highlighting the plight of those discharged from hospital who were on their own and isolated. The AS Director acknowledged that while some people were able to receive intensive care at home, there would absolutely always be a need for a bed for some, which was part of the reason for the step down unit.  However it was important to move away from providing a bed where it was not needed. A paper with proposals for The Grange was anticipated and it may be that closure was not the best option. The CMR for Adult Social Care felt it was important not to jump to the conclusion that people could not cope, and the question of continuing care would be addressed by the CCGs at the Health and Wellbeing Board. He referred to research indicating that every 10 days in hospital equated to 10 years ageing.

·         The Panel was pleased by use of technology to support people's independence at home and welcomed the recent approval of £199k funding of new technologies in care for Howbury House by the Cabinet Member with Responsibility for Adult Social Care, which formed part of the new Technologies in care project endorsed in 2015, to which Cabinet allocated £2m from directorate reserves.  The Panel was keen to see progress in this area, which was on the work programme.

·         Reassurance was given that the proposed reform for transport provision was a project about working with individual service users and families; it was not related to community transport.

·         With reference to the proposed review of LD Day Services, a member asked what options the Directorate was considering to support people who used the daytime centre for adults with learning disabilities in Bromsgrove, since he was aware that staff were talking openly about redundancies? It was confirmed that engagement, not consultation, was about to start to look at how services could be shaped in the future. The Directorate may look at whether there were providers within the community. The Resource centres were very valued and vibrant in Bromsgrove, however numbers attending the Connect centres were reducing and therefore no longer financially viable, which would need to be looked at. Wherever possible the Council re-deployed staff involved. The timetable for engagement was for a report and proposals for formal consultation due to go to Cabinet in June 2018, looking at service changes in 2019.

·         The way in which the Better Care Fund worked was explained, although it was important to distinguish between the BCF and the one-off input to it. BCF funds came into the Council before being passed on, which was done very collaboratively with the health sector.

·         A member asked at what point people's needs would outstrip people and resources, and the AS Director felt that nationally things were coming to a point where more money was required, rather than just working differently; the tipping point was very, very close. However, the directorate had a legal duty to provide services and nationally it was important to look at the picture for how services could be provided.

·         Assistive technology, such as that used at Howbury House, had had a positive impact on stabilising pricing within the market place for care, and the Council's brokerage team provided very good market intelligence. The AS Director felt it right for more standard services to be provided by external providers, of which Worcestershire had some very good ones, but for non-standard care the Council may need to consider intervening.

·         When asked whether there were any radical solutions which could help with future care provision, the AS Director pointed to the areas such as the 'Three Conversation' model for social work, technical equipment and maximising benefits. Both Directors pointed out that although the number of people requiring social care was escalating, the vast majority of people would not need it. Care homes and visits from homecare staff were not an inevitable part of ageing and it was important to have a degree of optimism and to focus on creating a world where people are encouraged to age well and remain independent. There were examples of other countries with a better preventative approach, for example Scandinavian countries did not have higher numbers of Winter deaths. Across the system, there were people who could impact on prevention health and social care and the County Council could influence that.

·         Members were excited by this degree of optimism and saw a role for councillors in encouraging people to be a part of their communities.

There were people who could impact on prevention health and social care and the County Council could influence that.

·         A member who was also the Vice-Chair of Hereford and Worcester Fire and Rescue Service asked whether discussions had taken place about the potential for the Service to help discharge people from hospital and it was confirmed this was a live area of business.

·         Several members raised concerns about Disability Facilities Grants, which were administered by district councils, and were not always spent; it would be helpful to understand how district councils and other agencies worked together to deliver this service, and any opportunities to maximise effectiveness of the grants.

·         Recruitment and staffing difficulties in social care settings and in nursing was highlighted as an issue which the Panel would continue to monitor.

·         When asked to comment, the Chair of Worcestershire Healthwatch felt that the debate had been robust, honest and challenging. He flagged up the importance of communicating budget messages to the public and also suggested asking the leadership present if there was anything which would help?

·         In response, the AS Director sought support in continuing to push the agenda for social care and reiterated his view that the best outcome was for someone to be in their own home, which may require a change in mindset. It was also important to fly the flag for social care as a vocation.

Following the discussion with officers and the CMRs, Panel and HOSC members agreed comments on the draft Budget 2018/19 which would be highlighted to the OSPB for its meeting on 30 January, which would form part of the OSPB's response to consultation on the Budget.

The Panel also wanted to highlight its concern to both the Overview and Scrutiny Performance Board and Cabinet that pressures from finance and demand meant a number of 'tipping points' were in danger of being reached when there may be a risk of services not being delivered; how close were they? The potential risks to services would need to be closely monitored and the Overview and Scrutiny Panels would require regular information in order to fulfil its monitoring role.

In relation to the budget scrutiny process, the combined discussion of Adult Services and Public Health budgets had worked well, however it would be more helpful to consider the budget within the context of the Medium Term Financial Plan and longer term plans. It was important to have sufficient meetings to deal with the volume and detail of information involved.