Written evidence submitted by East Sussex County Council [SOC 012]
Adult Social Care Inquiry
Thank you for giving us the opportunity to make a written submission to the Adult Social Care Inquiry launched on 9 June 2016. This submission is made on behalf of East Sussex County Council and reflects views from across Adult Social Care. It also includes developments being made through East Sussex Better Together (ESBT), our 150-week programme to transform health and social care services and the Connecting 4 You programme.
Executive summary
East Sussex County Council’s Adult Social Care and Health Department
East Sussex has a population of 539,800 residents (mid-2014 estimates). This has increased by 7% over the last ten years and is projected to increase by 4% over the next ten years to 561,700 by 2024.
East Sussex has had an older age profile compared to England & Wales and the South East for at least the last 30 years. 61% of residents are aged between 18 and 64, and 23% aged 65 years or older (134,000), of these around 21,000 people are aged 85 years old or over. In ten years’ time it is estimated the population aged over 65 will increase to around 160,000.
Conclusion
An ageing population, growth in demand and complexities in health service provision, together with a very challenging local authority funding position in the next few years, mean that social care will have to make significant decisions about future service provision unless additional funding is made available. The evidence submitted demonstrates the challenges currently being faced in East Sussex and the potential for achieving efficiencies and positive outcomes for people through innovation when resources for investment are available.
1.1. East Sussex County Council (ESCC)’s Medium Term Financial Plan for Adult Social Care (ASC) indicates that by 2020/21, unfunded pressures will be in the region of £56m. Given that the base budget for ASC in 2016/17 is £163m, this is a challenging and unsustainable position.
1.2. As part of negotiations with providers for 2016/17 fee rates, the Residential Care Association, as the representative body for nursing and residential providers in East Sussex, presented a paper that argued the impact of the introduction of National Living Wage (NLW) would require a 5% per annum increase in fee rates for the years leading to the full NLW rate being set. This is a significant potential pressure that is partially being mitigated through ongoing negotiation; but the financial impact has been calculated in the region of £6m per annum.
1.3. The NLW is only one element of what is a very challenging position for the market. Within East Sussex, there are critical pressure points whereby there are insufficient nursing beds available to meet demand; with the consequential impact on hospitals. However, there is oversupply of low level ‘traditional’ residential places, which are not required to meet assessed client need, as clients are living independently with support. The challenge for the local authority and providers is how to incentivise the market to change to meet demand; whether this is through fee rate incentivisation or longer term capital investment, the challenging financial climate makes this a long term issue.
1.4. The announcement of £1.5bn allocation through the Better Care Fund is a welcomed recognition of the pressures faced by ASC services. However, without confirmation of the phasing conditions (if any) or mechanism for allocating this funding, it is proving difficult to factor into longer term planning. As we progress joint financial planning with our Clinical Commissioning Groups (CCGs), clarity of funding is essential to ensure that we are making the right decisions within the known resource envelopes to manage the whole system changes required.
1.5. Deferral of the introduction of the cap on care costs until 2020 has provided a breathing space for the authority to focus on the implementation of the Care Act 2014. Planning for the cap highlighted a significant potential financial impact, with a medium level risk currently assessed at £8m in 2020/21, prior to any national funding allocation.
1.6. The authority actioned the council tax precept/levy at 2% for 2016/17; raising £4.657m allocated to adult social care. However, this only partially mitigated the pressures currently being experienced from:
1.6.1. Demography: East Sussex has the highest proportion of over 85 year olds than any other council and an ageing population which is currently growing at 1.5% per annum. The annual pressure arising from the ageing of the East Sussex population is in the region of £3.5m.
1.6.2. Growth in demand: an increasing number of clients, with increasing acuity of care and support are placing considerable strains on services. The annual pressure from service growth is in the region of £1.8m.
1.6.3. Care Act 2014: since the Care Act came into force with a new national eligibility criteria, a higher proportion of people now meet the eligibility threshold. We saw in increase from 68% to 78% in the first six months of 2015/16 and are supporting more people as a consequence. In addition, the wellbeing principle means that assessments are more complicated and take longer to complete.
1.6.4. Providers: increasing costs of service provision from external providers, plus a challenging market which currently does not have the resources to be able to adapt to meet changing demand.
1.6.5. Local authority funding reductions: the requirement for the Council to deliver services within a reducing financial envelope, is far outstripping what can be mitigated by the 2% Council Tax Levy. ESCC’s ASC savings target for 2016/19 is £40m, having already been required to make savings of £28m for 2013/16.
1.6.6. Delayed transfers of care (DTCs): working across the whole system continues to be a challenge, particularly in relation to hospital discharge. DTCs are at levels higher than in previous years as social care struggles to meet demand (see 1.3). In 2015/16 the average monthly snapshot showed 56 delays (of which 15 were attributable to ASC). In the first quarter of 2016/17 the average monthly snapshot was 71 delays each month (of which 19 were attributable to ASC). The main areas for delay are around intermediate care and independent sector provision in relation to care homes and home care.
1.6.7. Safeguarding: since the introduction of the Care Act, the level of safeguarding activity has increased significantly. In 2014/15 we received 3,260 alerts and started 847 investigations. By comparison, in 2015/16 we received 4,653 concerns and started 1,868 safeguarding enquiries. This represents a 42% increase in the number of concerns received and a 121% increase in the number of enquiries started.
1.6.8. Following the Supreme Court ruling in early 2014 relating to the Deprivation of Liberty Safeguarding (DoLS), we have experienced considerable pressures resulting from the significant increase in the number of people in hospitals and care homes whose deprivation now needs to be authorised. The table below shows the number of referrals received in East Sussex over the last three years:
Year | Number |
2013/14 | 166 |
2014/15 | 1,493 |
2015/16 | 2,643 |
2.1. ESCC recognises the value of carers’ contribution to the health and social care economy and recognises carers as expert partners in providing care to people with care and support needs. ESCC commissions a wide range of support services for carers and is committed to both protecting the funding for carers and to continuing to provide these services at no charge to carers. Examples of some of the services are given in section 4 below.
2.2. Pressures on funding for services for adults with care and support needs however (as described above) are having a real impact on carers. Where there is insufficient funding to support the ‘cared for’ person, there is always a knock-on effect for carers.
3.1. We have produced a Commissioning Intentions and Market Position Statement for 2016/17 to communicate our intentions to providers and help the market contribute and respond to emerging need, required service developments and pathway reconfiguration. It will also support ongoing discussion and debate in the coming year, to ensure that we meet our market shaping duties and can develop a sustainable service offer and continue to deliver quality outcomes for our local population.
3.2. It is the first jointly produced document to support the East Sussex Better Together (ESBT) transformation programme (see 5.1), and our vision for a fully integrated health and social care system in East Sussex. You can read it here: https://new.eastsussex.gov.uk/socialcare/providers/funding/market/
3.3. The financial situation described in section 1 is having a significant impact on local care markets. The local authority has a significant impact on the home care market in particular where we hold 80% of the business.
3.4. It is difficult to have a robust social care market when funding is so tight. Recruitment of experienced and qualified staff (such as registered nurses) remains an issue and there are significant concerns about recruitment and retention in the independent sector workforce where low wages and ‘zero hours’ contracts are contributing factors.
3.5. The Care Quality Commission’s new inspection regime is also impacting on the market and providers’ ability to meet inspection standards remains a concern. There are a large number of homes rated inadequate and suspended across the South East and this is affecting our ability to make placements.
3.6. We are introducing a new approach to quality improvement and supply development which will help to shape and sustain the market. We have also established a virtual Care Home Provider Support team which is focusing on current suspensions, incoming suspensions and providers of concern.
Some examples of innovative approaches are set out below:
4.1. Telecare – investment in the development of Technology Enabled Care Services is a priority for ESBT. Since April 2013, the Telecare client base has increased from 3,200 to 6,500. Telecare packages have seen an 80% increase in the complexity of devices ‘prescribed’, such as falls detectors and bed and chair sensors which support older and disabled people to live at home for longer. Referrals for GPS devices have increased from 1 to 3 per week to support and reassure unpaid carers who care for people who are prone to wandering. Currently, 27% of ASC packages include a Telecare component, and this is expected to grow to 35% by March 2017.
4.2. ESCC has demonstrated an approximate cost avoidance value of £32 per client per week by using Telecare to delay clients’ need for admission to a care home. The Department estimated a preventative savings of £589,000 in 2014/15 through the better use of Telecare.
4.3. A project to switch from rented to ESCC owned Telecare equipment is underway which is expected to ‘free up’ resource in the medium term to part-fund some of the following developments:
4.4. Occupational therapy clinics – The ASC Occupational Therapy Service has launched a new project where selected clients were offered an assessment in a clinic environment, rather than in their own home. The clinics offer a more proportionate approach and enable a greater number of people to be assessed. This reduces the time that clients have to wait, and offers a more personalised and preventative approach through prescriptions for low risk equipment, information, advice and carers assessments.
4.5. Primary care pilot – delivered by ASC Community Support Workers, the overall aims of this pilot service are to identify carers not known to primary care and/or not accessing support services and to provide flexible and responsive short term interventions within primary care settings to patients with dementia and other long term conditions and their carers. This enables access to appropriate support, activities and respite breaks. The service receives direct referrals from primary care and has led to the development of close working relationships between the practices and ASC staff.
4.6. Respite Healthcare Appointments – we recognise the impact on carers’ health of their caring role and offer funding to carers to meet the cost of respite care in order that they can attend their own healthcare appointments, counselling and training relevant to the caring role. There is no charge to the cared for person for this and the funding is held in the voluntary sector, enabling any carer to access whether or not known to statutory services.
4.7. Joint Community Rehabilitation (JCR) Service - covering all of East Sussex, this service provides an inter-professional approach to rehabilitation and reablement, to reduce duplication, increase capacity, and ensure a more timely and joined-up service to benefit both referrers and clients. The service is open to any adult with identified goals for rehabilitation and reablement. It’s designed to particularly target clients who would otherwise face unnecessarily prolonged hospital stays or inappropriate admissions to acute inpatient care.
We are increasing capacity and lowering the eligibility criteria for our JCR service so that everyone who gets home care for the first time, or is waiting for a care package, will receive a reablement service.
4.8. Proactive Care Practitioners – these will form an integral part of the Integrated Locality Teams (ILTs) to identify patients who would benefit from earlier intervention to support their wellbeing and prevent an unnecessary hospital admission. The service is designed to enable patients to remain independent through utilising the range of preventative community resources available in their locality and their capacity to self-manage long term conditions. Practitioners will be able to provide a Proactive Care Assessment and prescribe small packages of care.
4.9. Locality Link Workers – these workers are being recruited to bridge the gap between integrated locality teams and communities. Their priorities include ensuring the participation of people who experience health inequalities, including people with care and support needs, in a variety of community activities and identifying and developing connections with local assets such as organisations, community groups, businesses, community centres.
4.10. Informatics strategy – this sets out a vision for the future and the context in which we are working and planning. The strategy includes the vision that from a patient/client perspective, people are confident that all the agencies/professionals involved in their care have instant access to all the information they need about them, within the parameters of their consent and in their best interests. The strategy can be found within this document: http://www.eastbournehailshamandseafordccg.nhs.uk/about-us/publications/?assetdet8760137=435661&categoryesctl10153982=19085
5.1. ESBT is our 150-week programme to transform health and social care services. It’s about making sure we use our combined £850million annual budget to achieve the best possible services for local people. The programme is a partnership between Hastings and Rother CCG, Eastbourne, Hailsham and Seaford CCG, East Sussex Healthcare NHS Trust, Sussex Partnership NHS Foundation Trust and East Sussex County Council. Information about ESBT can be found here: https://news.eastsussex.gov.uk/east-sussex-better-together/
5.2. High Weald, Lewes and Havens CCG (HWLH) and East Sussex County Council are developing a programme entitled Connecting 4 You to coordinate the joint plans of the CCG and the Council with partners and stakeholders, including providers and resident population, to implement the NHS Five Year Forward View and to ensure high quality, sustainable services into the future that best meet the population needs of HWLH, now and for future generations. Connecting 4 You is in its formative phase. The themes reflected in ESBT of healthy living and wellbeing, proactive care, crisis intervention and admissions avoidance, bedded care, discharge to assess and maintaining independence are likely to also be reflected in the Connecting 4 You programme, though they may be delivered differently at a local level.
5.3. Accountable Care: On 24 May 2016, ESCC’s Cabinet agreed to the development of a detailed full business case for Accountable Care in East Sussex, which will be reported to Cabinet in November 2016; and agreed the proposed principles and characteristics for a local Accountable Care model. The full paper can be found here: https://democracy.eastsussex.gov.uk/ieListDocuments.aspx?CId=133&MId=2602&Ver=4
We have developed a set of data scorecards demonstrating key outcomes of the ESBT programme in a range of areas: http://news.eastsussex.gov.uk/east-sussex-better-together/stakeholders/esbt-outcomes/