Agenda item

In attendance for this item were:

Avril Wilson, Director of Adult Services

Michael Hudson, Chief Financial Officer

Mark Astbury, Interim Head of Finance

Adrian Hardman, Cabinet Member with Responsibility (CMR) for Adult Social Care

The Chairman advised that members of the Health Overview and Scrutiny Committee (HOSC) had also been invited to attend the discussion and Cllr John Gallagher was welcomed to the table.  

Year-end Budget Monitoring

The Chief Financial Officer (CFO) introduced the Panel’s consideration of year end budget information for 2018/19 for Public Health and Adult Services and pointed out that from the start of the following year it was hoped to bring forward the timescale for publishing financial information to be aligned with the Scrutiny timetable.

The Panel’s attention was drawn to the key headlines set out in the agenda for Adult Services (page 23) and Public Health (page 25). The year-end position for Adult Service was an overspend of £12.420m, which did not sound good, although members were reminded that the figure had originally been £17m, and that regular reports had been submitted to Cabinet and to Scrutiny regarding lessons learned. For Public Health there was an underspend of £0.100m.

Questions were invited and the following main points were raised:

·       When asked about the variance for Learning Disability Services, the CFO believed that rather than a change in demand, this was more related to previous underfunding and increasingly complex needs, therefore the budget had been increased over successive years, as reported previously. It was confirmed that budget pressures in this area continued and had been factored in to the 2019/20 base budget.

·       A member asked about the use of internal reserves and was advised that there wasn’t any.

·       A member asked whether the acknowledged need for more capital investment at Howbury House was factored in to the budget. Officers advised that of the three elements of works involved, only one was not included in the current figures for Adult Services, and there would be a report to Cabinet about this.

·       It was confirmed that there was approximately a £2m difference between the net expenditure for Older People and Learning Disabilities services, but this would be higher in 2019/20.

·       Referring to the changes made within Learning Disability Services, a member asked what savings would have been made and the CFO advised that £7m was outstanding, so it was known that the September base budget figure was incorrect, and the base budget would be adjusted for 2019/20 to just under £66m. A range of savings projects had also been designed and the net budget for Learning Disabilities would be £65.977m

·       The Director of Adult Services confirmed there were no new savings plans for Learning Disabilities at the moment, apart from progressing earlier plans for the redesign of day opportunities and respite.

·       The HOSC member present asked whether the 12% overspend was a continuing trend from the previous year and the Interim Head of Finance pointed out that three contributing factors had made 2018/19 a very different year, namely the accumulation of savings targets, the increase in growth of complex needs and the previous use of reserves; this exceptional situation had been addressed by review of the budget.

·       Referring to the year-end budget monitoring for Public Health, a member asked why Adult Services featured as three separate services. Officers believed this depended on the way in which contracts built up and whether they related to services paid for directly by Public Health or invested in through Adult Services.

·       When asked what services came under ‘other services’ listed against Public Health, across the Council, and the CFO said there would be a range of services, for example libraries.

·       A member suggested it was fair to say that the Directorates (of Adult Services and Public Health) were holding it together regarding the budget, and both the Directors agreed it would be very tough this year; the lack of information year on year about funding, amounting to around 22% of the Adult Services Budget, made it impossible to plan for the long-term or to contribute to NHS forward plans. The delayed Green Paper on social care was also referred to.

·       The CFO advised the Panel that the overspend in Worcestershire was not out of the norm.

Performance Monitoring

The Director of Adult Services referred to the performance information which had been circulated and reported pleasing progress relating to Adult Social Care Outcomes Framework (ASCOF) 2d (% of people with no ongoing social care needs following reablement after hospital discharge) and ASCOF 2b (% age 65+ at home following rehab). However, improved performance would therefore have been anticipated against ASCOF 2a (1) (Admissions to permanent care per 100,000 (18-64) and ASCOF 2a (2) (Admissions to permanent care per 100,000 (65+), and this had not been the case, which was puzzling and now subject to ‘deep dive’ analysis and case audits to try and understand why.

It was already known that the average age for entering permanent care was 84, that 800 days was the approximate length of stay in a nursing home, with the likelihood of an individual surviving a second year increasing if they survived the first year. It was known that around 30% of activity was being driven by hospitals - between October 2018 – March 2019, 92 people aged 65+ went into a care placement, of which social care was the lead decision maker in 19 cases, 9 cases were self-funders who no longer had funds, and the remainder were continuing healthcare. Therefore, a great deal more work and conversation was needed with health partners about how to manage the money being spent.

Referring to the other performance indicators, the Director advised that managers had been strict about completion of annual care packages and the number of new referrals which had resulted in a person receiving long term services was consistently lower where the Three Conversation (3C) model had been introduced.

In the discussion which followed the following main points were raised:

·       When asked whether some sort of proportionality could be the solution to the issues referred to around more integrated social care and health funding, the AS Director said that there were some integrated care packages, which may be the way forward. She felt that strategic discussions were needed around pooling funds to better effect, which would be difficult but was necessary and would also be innovative. She pointed out that no criticism of current working was implied, which was a national problem - advice had been sought from ADASS and the Director confirmed she was aware of two other areas which were engaged in similar discussions.

·       A Panel member asked whether seasonality played a part in performance figures and was advised that this was the case with older people and the transfer from college over the summer may also affect those of working age.

·       Figures for the last quarter of 2018/19 were confirmed as 662 per 100,000 for admissions to permanent care for those 65+ and 20.5 per 100,000 for those of working age.

·       A Panel member suggested that the Panel needed more information, in particular about adults of working age, to really understand the lack of improvement in Admissions to Permanent Care (ASCOF 2a(1) and 2a(2) despite improvement in the percentage of people with no ongoing social care needs following reablement after hospital discharge (ASCOF 2d) and percentage of 65+ at home following rehab (ASCOF 2b). The Director agreed and would be happy to inform the Panel about the outcomes of the investigative work which had begun.

·       A member asked about the length of time people spent in hospital and the AS Director said that research showed how extended hospital stays were not healthy and led to loss of muscle tone etc, however analysis was also being done to verify that people weren’t being placed inappropriately into care homes to avoid delayed transfers of care.

·       The AS Director would look into a member’s query about the percentage of those 65+ at home following rehab (ASCOF 2(b), specifically a member’s query about the drop from 88% in March 2016 to 78 a year later and whether lessons could be learned?

·       A member asked how the baseline for area team conversions had been arrived at and it was explained that this was established from the previous social work model used.

In summing up, the following information was requested:

·       un update on the investigative work to understand underperformance of targets for admissions to permanent care ASCOF 2a (1) and (2)

·       an update on the investigative work to verify whether people were being placed inappropriately in care homes to avoid delayed transfers of care

·       detail about the drop in numbers relating to %age 65+ at home following reablement (ASCOF 2b) from March 2016 to March 2017

·       for Adult Services provided for adults of working age to be incorporated into the work programme.