Written evidence submitted by South East Strategic Leaders [SOC 172]

 

 

  1. South East Strategic Leaders (SESL) is a partnership of 15 County and Unitary Councils across South East England, committed to nurturing the UK’s economic engine room and promoting public service excellence.  SESL represents the unique voice of upper tier authorities, supporting its members to create the conditions in which individuals, communities and businesses can thrive.  Its membership comprises Buckinghamshire, Hampshire, Kent, Oxfordshire, Surrey and West Sussex County Councils, all the Berkshire Unitary Councils and extends beyond the ‘traditional’ South East to include Essex County Council, Central Bedfordshire Council and Swindon Borough Council.  SESL represents more than 8 million residents and accounts for almost 15% of UK GVA (£247bn).

 

 

Executive summary

 

 

 

1 - Funding

 

  1. The Care Act. SESL strongly supports the Care Act, with the principle of wellbeing at its heart and its strong emphasis on prevention, early intervention and the rights of carers. However, there is concern that the current funding settlement, coming on top of historical levels of underfunding and demographic and other pressures, means that it may not be possible to fully live up to the expectations the new Care Act has created (in terms of improved and more personalised care and support) and that front line services might be put at risk.

 

  1. The approach of SESL member authorities. SESL member authorities continue to make great efforts to meet the needs of people who need care and support and their carers by working with them effectively and efficiently. This includes significant investment in carers’ services, development of community assets, greater use of prevention and enablement services, and transforming the way services work with people and the way in which they provide care and support. Services fully understand the need for, and are committed to, working with partner agencies to deliver on integration with health to ensure people’s needs are met and their wellbeing improved.

 

  1. Local authority funding reductions. In 2016/17 local authorities face substantial reductions in Revenue Support Grants (RSG).  This has impacts on the grants subsumed into the RSG and not protected such as the Learning Disability and Health Reform Grant and the Care Act Grant.  Reductions in grants have a significant impact on adult social care which takes by far the largest proportion of the budget of councils with social services responsibilities. Adult social care services in the South East have to make substantial savings, on top of the significant savings of previous years. Examples of the scale of savings to be made are:-

 

 

 

  1. The basis of funding allocation.  Individual local authorities in the South East have raised a number of concerns about the basis for the funding allocation. A request has been made to the Government for a fundamental review of the basis for funding allocations and to move to base allocation on a needs-led analysis of current and future spending demands across all types of local authority, factoring in all sources of additional income. The Department for Communities and Local Government has set up a task group to look into needs–led redistribution.

 

  1. Spending pressures. Local authorities in the South East face many         significant spending pressures.

 

    1. Demography and ageing populations with increasingly complex needs.  Some authorities face significant additional annual spending pressures from demographic pressure alone; for Buckinghamshire County Council that amounts to £3m.

 

    1. Growth in demand. There are increasing numbers of clients with greater awareness and expectations of care and support. The Care Act has increased the number of people meeting the eligibility threshold. One authority, for example, saw an increase from 68% to 78% in the first 6 months of 2015/16. The wellbeing principle has resulted in longer and more complex assessments.

 

    1. Learning disabilities. More young people with learning disabilities are making the transition from children’s to adult services. This adds high costs as people with a learning disability move from residential care to supported accommodation.

 

    1. Safeguarding.  Authorities are dealing with an increased number of alerts and investigations since implementation of the Care Act.  The rate of safeguarding contacts per 100,000 population increased from 577 in 2014/15 to 859 in 2015/16.

 

    1. Delayed transfers of care. Authorities are, to an increasing extent, struggling to meet demand and avoid delays to hospital discharge. In one South East local authority in 2015/16 the average monthly snapshot showed 56 delays (15 were attributable to adult social care). In the first quarter of 2016/17, the average was 71 delays per month (19 were attributable to adult social care).

 

    1. Care market pressures. Rising costs, due to inflation, the National Living Wage and market forces, are leading to cost pressures and price increases. Local authorities’ ability to meet budgetary targets can be largely determined by price uplift negotiations with market providers. Market capacity and sustainability are crucial considerations and concerns.

 

    1. Deprivation of Liberty Safeguarding (DoLS). The Supreme Court Ruling (early 2014) has led to all significant increases in DoLS workloads with significant resource issues and cost implications.  For example, Buckinghamshire County Council has seen an increase of 542% in referrals received since 2010/11.

 

  1. National Living Wage. Introduction of the National Living Wage has added significantly to the costs faced by providers and, therefore, faced by local authorities of purchasing services. In 2016/17, this has added £5.6 million to the amount Kent County Council pays its residential and domiciliary care providers (estimated to rise to £6.6 million by 2020).

 

  1. Council Tax precept of 2%. Reduced funding and spending pressures have led to significant funding gaps for local authorities.  The additional social care Council Tax precept only goes a small way towards addressing this gap.  For example, in Kent this will raise £11.2 million which represents only 20% of the combined budgetary pressure.

 

  1. Better Care Fund. The announcement of the allocation of £1.5bn is welcome recognition of the pressures faced by adult social care services. However, timing is an issue as the additional funding is not set to start trickling through before 2017/18 and the bulk of this new funding will not be available until 2018/19 and 2019/20. Long-term planning requires greater clarity and certainty of funding but there is no confirmation of phasing conditions and no defined mechanism for funding allocation.  Concern has been expressed that the indicative allocations are based on a flawed relative needs formula that produces inadequate allocations for some types of local authority.

 

  1. Care Act part 2 deferral. Local authorities understood the reasons for deferring the “Dilnot” aspects of the Care Act. However, the uncertainty over their introduction makes it difficult to plan for future services and costs.  Planning by local authorities for the cap on customer contributions highlighted significant potential financial impacts prior to any national funding allocation.

 

 

2 – Carers

 

  1. Importance of carers. Local authorities recognise the vital role that carers play in providing support and care, their role as “expert partners” and the need to promote the wellbeing of carers. Support provided by carers prevents and delays needs from increasing and leading to higher costs.

 

  1. Supporting carers. Local authorities invest substantially in services to support adult carers and work with carers’ organisations to ensure that effective support is delivered. This includes providing specific information and advice, elements of assessment and support planning, peer support networks, training for carers, outreach, and promotional work to help identify carers earlier. Whilst authorities are committed to providing comprehensive support for carers, funding pressures mean that they are not able to provide as much support as necessary. In practice, this has led to reductions in support for carers.  One example is the reduction of non-statutory early intervention and preventative services for carers, such as the flexible break payment scheme.

 

  1. The increasing demand and limited resources for the “cared for” lead to delay in support and provision for the carers, which has a real impact on carers and their wellbeing.

 

 

3 - Commissioning and market oversight

 

  1.                   Managing and shaping the market. Local authorities work closely with providers to ensure the market responds to emerging need, required service developments and changing practices. This involves contract reviews, ongoing discussion, events and workshops, joint work and mechanisms such as the production of Market Position Statements. In this way, a sustainable local service offer is developed and maintained and quality outcomes are delivered for local people.

 

  1.                   Contract compliance is monitored and discussed, and the results of visits and information received are discussed and acted upon with providers, along with Care Quality Commission involvement as necessary.  Local authorities proactively work directly with providers to help improve practice, training and the quality of care provided. For example, the Quality in Care team in Buckinghamshire is multidisciplinary and supports care homes to strengthen their management, invest in skills development and leadership, as well as improving policy and practice on the ground through specific training. Innovative work is being undertaken by local authorities with providers, including changing to more outcomes-based service models through co-design.

 

  1.                   Market share. In some markets, local authorities purchase a large percentage of the business. A significant proportion of local authority adult social care expenditure is with external providers and, therefore, the ability to meet budgetary targets is largely determined by price uplift negotiations.

 

  1.                   Market and the financial situation. The financial situation described in paragraphs 2-10 is having a significant impact on local care markets. Local authorities in the South East have identified that “it is difficult to have a robust social care market when funding is so tight”. The challenge for the local authorities and providers is how to incentivise the market to change to meet demand. Whether through fee rate changes or long-term capital investment, the challenging financial climate makes this an issue which is not easily addressed.

 

  1.                   Increasing costs. For one local authority, during the last 4 years, average price increases for residential care have been about 12% and for nursing care the price increases have totalled 24%. For nursing care, an increase in activity and cost has resulted in average weekly expenditure increasing by 37%. The increased costs produced by the National Living Wage have been covered in paragraph 7, however they particularly affect home care provision as a high percentage of the costs are wage costs.

 

  1.                   Market capacity. There is a range of capacity issues faced by South East local authorities, but nursing market capacity is a particular concern.  Local care markets are under pressure from challenging workforce and quality issues, such as recruiting experienced and qualified staff (registered nurses for example).  In the independent sector, low wages and zero hours contracts are contributing factors. Local authorities work with providers to assist in attracting a workforce sufficient in number, quality and motivation but this is a particular problem across the South East given the very stiff competition from other sectors for staff.

 

  1.                   Quality issues. The Care Quality Commission’s new inspection regime has led to a large number of homes across the South East being rated inadequate and suspended. This reduction in market capacity has had an impact on the ability of local authorities to make placements.

 

  1.                   Market sustainability. Many providers face a difficult situation in that they are struggling to manage within the funding available from local authorities and the additional pressures including the National Living Wage.

 

 

4 – New ways of working

 

  1. Technology enabled care services (TECS). Maximising the use of technology as a cost effective alternative to, or to support, traditional care services is a strategic priority for local authorities. The use of TECS is being embedded at the heart of the assessment process and future service provision. As a result, there are substantial increases in: take up by clients; use in care packages; and the range of  devices used - Telecare packages include Lifeline alarms, different sensors, and GPS tracking devices to help people who may wander and those with a learning disability to travel. There is a range of standalone technology (such as epilepsy sensors, carer call alarms, bed/chair sensors, and entry/exit check and call services) in use or being developed.

 

  1. TECS are a cost effective way to: enable vulnerable people to remain independent in their own homes; support carers to look after loved ones; remind people to take medication, eat or drink; help people feel reassured; check on people’s welfare; and keep people safe.  In terms of cost effectiveness, monitoring and research indicates a cost avoidance value of £32 per client per week using Telecare to delay the need for admission to a care home with preventative savings in one County of £589,000 in 2014/15. Effective use of this technology is being championed within authorities, providers and other partners.

 

  1. Environmental control systems. Working in partnership with NHS Specialist Commissioning, one local authority has commissioned an Environmental Control Systems service which provides highly specialised equipment and technology for people with complex disabilities who would otherwise require 24 hour support or a residential placement.

 

  1. Preventative services.  Local authorities are making innovative changes to the design and delivery of their services through developing and strengthening prevention work in community settings. This involves identifying people who would benefit from earlier intervention to support their wellbeing and prevent unnecessary hospital admissions.  Best use is made of preventative community resources available, and linked are made with local assets such as organisations, community groups, businesses and community centres.

 

 

5 – Integrating health and social care

 

  1. Health and social care are intrinsically linked in terms of strategic objectives, accountability and responsibilities, activities and performance, and the outcomes delivered for service users, patients and carers. South East authorities work closely with health professionals, services and organisations to deal effectively with key issues such as hospital discharge or the closure of acute and community services but this needs to be on the basis of the on-going development of a whole systems approach.  Health and social care need to be treated as equal partners, adopting a long-term perspective with adequate funding in place, underpinned by fair, consistent, certain and aligned funding allocations.

 

  1. Current and immediate cost pressures in health and social care can necessitate short-term actions and create difficulties in developing and maintaining a whole system approach which should underpin effective and efficient partnership working.

 

  1. At a local level, health and social care have worked for a number of years on the Better Care Fund and, more recently, on the Sustainable Transformation Plans (STPs). Local authorities are also working towards full integration of health and social care commissioning functions, as well as making significant progress towards health and social care integration in terms of provider services. However, a number of key factors need to be in place to ensure that: the advantages associated with integration are realised; better outcomes for people are delivered; an appropriate delivery model for this is put in place; and this is sustainable.  It is important to ensure that the STP process does not have adverse budget implications for social care.

 

  1. In order for local authorities and their partners in health and social care to successfully reshape services towards new models of care, expectations need to shift. While local authorities play an important role in reshaping expectations, the Government needs to set the tone nationally and show leadership in terms of explaining its vision for the future of health and social care, the subject of an earlier letter from SESL to the Secretary of State which can be seen at:

 

http://sesl.org.uk/health-and-social-care-integration-letter-august-2016/

 

  1. Social care needs to be recognised and treated as an equal partner and the requirements of the Care Act and the duties for all partners should be fully recognised.

 

  1. Sufficient funding should be available to ensure that local authorities can deliver: the duties of the Care Act; the prevention agenda at a local level; and can work with providers from the private and voluntary sectors to change service models to ensure changing needs are met and that service and individuals’ outcomes are achieved.

 

 

6 – Concluding comments

 

  1. The information gathered on the financial sustainability of adult social care from the association of directors of adult social services (ADASS) in the South East used in this submission is more completely reported in the ADASS 2016 budget survey which can be seen on-line at:

 

https://www.adass.org.uk/media/5379/adass-budget-survey-report-2016.pdf

 

  1. The headlines of this submission include:-

 

 

 

August 2016