Agenda item

To consider and make recommendation to the Executive Member for Adult Social Care and Health and the Executive Member for Public Health on the departmental transformation to 2019 savings proposals and public consultation feedback.

The Director of Adults’ Health and Care spoke to the report and presentation, which set out the departmental transformation to 2019 savings proposals and public consultation feedback (see Item 6 in the Minute Book).

Members heard an overview of the key findings of the balancing the budget consultation held by the County Council the previous summer, and noted that all of departments in the Council had been asked to proportionately contribute a further 19% saving of their budget by April 2019, as part of the next ‘Transformation to 2019’ (T19) programme.  For Adults’ Health and Care, this resulted in an overall requirement of £55.9m.  An overview was provided of the Department’s ‘Transformation to 2017’ (T17) savings, which would see a total of £43.1m achieved by the end of the 2017/18 financial year.  With the proposed T19 savings, this would bring the cumulative total to £191m by the end of 2020.

There were four principles that underpinned the Departmental approach to T19:

·      Prevention: strengthening the prevention strategy to reduce and/or contain demand.

·      Independence: increasing the number of clients living independently and reducing the cost of care.

·      Productivity: improving the efficiency and productivity of the Department’s operations.

·      External spend: increasing outcomes and service efficiency from commissioned services.

Within these principles were four main blocks, which centred on the use of additional health and social care integration funding; living independently (older people’s and physical disabilities); learning disabilities, children’s to adults transition, mental health and social inclusion; and working differently.  All of these were underpinned by the theme of demand management and prevention.

There were approximately 3,000 staff employed within Adults’ Health and Care, and in due course it was expected that the Department would need in the region of 150 fewer full time equivalents, through natural attrition, redeployment and potentially voluntary redundancy.  Through the T17 programme, it was expected that there would be a staffing reduction, but the requirements of the changes implemented required additional growth in staffing in some areas, and this may be the case for T19.

An additional £18.9m was being made available in 2019/20 through the Integration and Better Care Pooled Fund, which would offset some of the savings required by the Department.  These funds would be used to invest in joint and integrated service delivery programmes, and to protect core social care services.

The living independently proposals were centred on creating options so that people can live independently for as long as possible.  Through intermediate care, such as reablement (both home and bed-based), individuals can be supported to re-learn the life skills that enable them to remain independent, and to need less ongoing support.  As a result of this work, the number of people being admitted into acute care should reduce, which should improve flow through hospital and enable the limited social care resource to be targeted at those with higher needs.  There were also greater opportunities for exploring how technology-enabled care can be used to reduce cost; innovative devices already in use in Hampshire had helped to reduce social isolation, reminded individuals to take their medication, and had sensors which alerted care staff if an individual had experienced a fall.  Such technologies also allowed for care staff resource to be aimed at those with higher needs.  The Council would also be continuing to invest in extra care, particularly focusing on younger adults with learning disabilities.

The proposals for the living independently programme would include a re-consideration of client contributions, particularly around what percentage of contribution the Council takes for providing care.  Hampshire was unique in the south east, as currently only 95% of the maximum contribution was charged to clients.  This area was considered under the T17 proposals, and it was determined at that stage not to move to 100%, but this would need to be reconsidered for T19.  This work stream would also be reviewing and potentially redesigning day opportunities for clients, as these currently followed a traditional format of travel, activity in a day centre, and then travel home.  There may be an opportunity to explore how more activities and groups can be supported in local communities, reducing the need for travel, improving social contact, and building community resilience at the same time.

The proposals around learning disabilities, children’s to adults, mental health and social inclusion were also focused on choice and living independently, moving away from long term institutional care to, where appropriate, extra care and living independently.  Taking this approach would open up other life opportunities for individuals, for example enabling employment.  Joint work would be undertaken under this heading with Children’s Service on the transition pathway, where previously there has been a potential for a cliff edge of service delivery between the two Departments, where services were previously delivered by Children’s, which may not be there in Adult Services.  The Department would be working with colleagues to create opportunities to experience greater independence and make choices about where support can be offered as teenagers, to make the transition process smoother.  The Department would be working in partnership with District and Borough Councils to redesign services around social inclusion, and a working group of the Committee would aid this work.

The working differently T19 work stream would focus on the entire workforce of the Department, making better use of technology, rolling out greater modern and flexible working, making business processes more efficient and ceasing some activities.  Through this, it was believed that approximately £4.1m could be saved, and a reduction of 150 full time equivalent staff.  Annually the Department experienced around 300 staff leaving through natural churn, such as resignation and retirement, so this would provide the space to restructure teams and identify which areas needed additional support, and where posts would not need to be filled.

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Demand management and prevention was an underpinning work stream and impacted on all areas of the Department, therefore no sum of money had been placed against this area, as any further efficiencies released would be realised under the other key T19 areas.  Work had already started under T17 in investing in initiatives that help individuals and communities to help themselves, with an example of this being the health and wellbeing centres being supported by the Council across Hampshire to provide services, information and a space for communities to use.

The Public Health grant continued to be ring-fenced, and this was due to be reduced by £4m by 2019/20, to bring the cumulative reduction to £8.3m.  From 2019/20, Public Health would receive a grant of £49.5m.  As these savings were on a different timescale to the rest of T19, these proposals would be brought forward in separate papers.

There were a number of risks inherent in changing the Department’s offer, in managing these messages and ensuring outcomes are maintained.  The Department had learnt from previous transformation programmes, and the importance of ensuring that staff are communicated with at the right time.  The Council continued to have a clear duty to meet eligible needs, but it was not mandated as to how these are delivered, and therefore there was scope to review how services are organised.  The Director was clear that he would not fetter discretion, and would always be cognisant of individual needs and circumstances, and changes in case law.

The outcomes of the balancing the budget consultation did show a high level of support for raising existing or levying new charges for services, although the Director was mindful that if this question had been posed solely on care contributions the response may have been different.  Broadly, however, the strategy of the Council and Department had been supported.  The Department were also keen to increase income in other ways where possible, such as through selling services such as that on client affairs, which provides advice on issues relating to those individuals who do not have capacity to make decisions.

The proposals had been discussed in co-production meetings and the Director was due to attend a number of meetings with stakeholders, including clients, to understand their views on the proposals and deliver messages around the T19 programme.  Additionally, there was likely to be a new green paper on social care and how it is funded financially, so the Council would be alive to this when drafted.

The report contained Equality Impact Assessments for each saving proposal work programme, and some areas may require further consultation.  The next steps after Select Committee would be for the Executive Member to consider the proposals and to submit them to Cabinet for further review.  A final form of proposals would then be considered by County Council in November, and the further development of the proposals, and timetable for their implementation, would take place after this time, subject to any consultation work.

In response to questions, Members heard:

·         Part of the focus for T19 is on communities, as Hampshire hosts over 5,000 community organisations and the Department can help to corral and bring these together, which would result in being able to access a more holistic approach to care.

·         The Department were clear that meeting needs wasn’t just about providing personal care, but also about a wider approach to reducing isolation and social need.  The World Health Organisation had recently suggested that the impact of social isolation had the equivalent impact on health of smoking 15 cigarettes a day.  Therefore, it was important that care plans accounted for reducing social isolation.  In addition, most referrals to the Department were concerns about individuals living alone and being isolated, rather than physical care needs such as assistance with eating or dressing.

·         That part of the exploration of new technology was to understand how devices might replace tasks that currently lead to the inefficient use of staff.  For example, carer visits in order to ensure that service users have taken their medication, yet technology exists on the market that reminds individuals to take medication, and alerts carers if this has not been done.  Similarly, the work being proposed around increasing community resilience may enable more voluntary assistance with issues such as these, such as neighbours undertaking a check to ensure an individual has eaten.

·         That the Director accepted that social workers and other professionals don’t always get it right, and that a further culture shift needed to take place to ensure that family wishes and those of the client are always at the centre of care decisions.  There had been a number of serious case review enquiries nationally recently which presented similar findings around professionals not always listening to families, or sharing information, and Hampshire along with all other areas needed to learn lessons from these.  The Department were undertaking work with health partners around independent personal commissioning and this will focus on giving younger adults greater choice about what support they have, and when.  Additionally, work with co-production groups, which have membership made up of clients, families, previous service users as well as community representatives, is instrumental to the Department in learning how to do things better.

·         There was a cohort of service users supported by the Department who could not live independently due to the complexity and severity of their needs.  However, institutional long-term care was not the right approach to meet these individual’s needs, as outcomes from reviews such as that focused on Winterbourne had shown.  A significant amount of work is being undertaken with health on transforming care for people with profound disabilities, ensuring that care can be delivered locally, and individuals can be part of the wider community, should they wish to be.  One of the steps taken by Hampshire County Council to realise better integration between services for those with profound disabilities was the decision to integrate the learning disability and mental health services into a single line management support structure, which would ensure better co-working.

·         There continued to be challenges and risks associated with the care market workforce, which at best would be described as fragile.  This sector experienced high turnover and issues with retaining staff, and Hampshire County Council was continuing to work with partners to increase the attractiveness of ‘care’ as a career choice.  In tandem, the exploration of technology to replace care workers where the use of staff was inefficient would release precious domiciliary care capacity.

·         Reablement and intermediate care was generally for a period up to six weeks, but there were some exceptions where additional time was needed.  This care was universal and not means tested, and it had been evidenced that investing in this type of care impacted positively on health and social care, with approximately 70% of service users returning to independence rather than further care.

The Chairman then moved to debate, where discussion was held on the information received to date and whether the Committee was able to take a view on the proposals at this stage.  Some Members expressed their desire to defer taking a view on the proposals until a working group had been formed to consider each work stream in detail.  Other Members noted that the proposals were still in a draft stage, and had been drawn together by officers who had the subject expertise to take a view on where the savings could be delivered.  The Chairman noted that the Committee would have a further opportunity to consider the T19 proposals, once they had been through Council, in greater detail.

There was some concern from Members that some of the Department’s aims of promoting independence and lessening social isolation would be impacted by savings proposed by other areas of the County Council.  The Executive Member for Public Health assured the Committee that the Corporate Management Team had worked together on proposals to mitigate potential impact on other areas of the Council, but the Director of Adults’ Health and Care agreed to hold further discussions in this area.

The Director noted that some of the T19 proposals were a continuation of what the Department were already doing, and that some might be subject to stage two consultation.  Additionally, a working group was being formed to look at social inclusion.

The Chairman noted the possibility that Cabinet may make changes to the T19 proposals submitted by each Department, although the level of savings would need to be the same.

The Chairman moved to the recommendation as set out in the paper:

That the Committee support the submission to Cabinet of the proposed savings options contained in the report and its Appendix 1

A vote was taken on the proposed recommendation:

For:                                    8

Against:                 4

Abstained:                        0

RESOLVED

That the Committee support the submission to Cabinet of the proposed savings options contained in the report and its Appendix 1.