Agenda item

The Health and Social Care Scrutiny Sub-Committee is asked to:

1.    To note 2023/24 Period 6 (September 2023) budget and savings position.

2.    To note the updated performance position for the Directorate against the newly published Use of Resources report.

3.    To note the update on strategic transformation, including the progress of the Strategic Delivery Partner.

The Sub-Committee considered a report set out on pages 15 to 22 of the agenda which provided the Adult Social Care and Health (ASCH) Directorate’s financial performance at period 6 (September 2023), and current transformation progress in relation to the 2021/2024 Medium Term Financial Strategy (MTFS) and future 2024/2027 MTFS.

Annette McPartland, Corporate Director for ASCH, introduced the report, during which it was highlighted that the quality of information collected in the borough had been improving. It was also added that the Directorate was coming to the end of its original three-year MTFS transformation programme and had been meeting the savings objectives set at the outset of this programme. It was also stressed that the impact of inflation and austerity alongside the increasing demand for services made the delivery of savings even more challenging. However, it was also emphasised that it was very important to ensure that savings delivery did not compromise the safety and wellbeing of residents.

Following the introduction, the Sub-Committee was provided the opportunity to ask questions on the information provided. The first question asked for further information on the increase in the Directorate’s net budget from £129.8m to £141m. In response, it was explained that the budget increase was a result of moving a team and the associated budget from the Housing Directorate to the ASCH Directorate. A supplementary question asked about the rationale behind this move. It was explained that the funding associated with that team was assigned to and fit with the ASCH area, with many members of the team being social workers. Therefore, it was beneficial from the perspective of their supervision, accountability and learning & development opportunities. It was also highlighted that the ASCH Directorate was accountable for ensuring that the Council’s Care Act responsibilities were met. Thus, it was decided that it would be more appropriate for this team to be located within the ASCH Directorate.

The next question asked about the governmental intention to reduce the number of asylum seekers and refugees placed in the hotels, and its potential impact upon ASCH. It was explained that the numbers had been increasing. The Council had set up a multi-agency board to determine and monitor how the additional grant had been spent. It was stressed that there were risks associated with the grant, particularly whether it would be renewed. A supplementary question asked whether there was only one grant available or whether the funding was coming from different sources. It was explained that the Council also had a budget for people with no recourse to public funds, but the grant had been provided by the Government to cover the additional pressures councils had been facing. It was agreed that further information on the origin of the additional pressures grant would be circulated after the meeting.

An explanation of what no recourse to public funds meant was requested. It was explained that it referred to care recipients who did not have permission to work in the UK or claim benefits. Therefore, there was no direct funding available for them and they received minimal support.

The Sub-Committee raised concern about the risk of a provider potentially exiting the market, with further information request on how this was being mitigated. It was explained that Croydon had a large market for both domiciliary, residential and nursing care. Although there had not been many cases of market failure in the borough, there were many risks associated with budgeting, accounting for inflation and the National Living Wage. It was also added that the commissioning team regularly met with market providers through the Providers’ Forum. If a large provider decided to leave the market, the Council would have safeguarding responsibilities and need to ensure that residents who were not funded by the Council were also supported. It was stressed that most of the providers in the borough are classified as either good or outstanding, with the Cabinet Member providing additional reassurance on the monitoring of care homes and the wider market. 

The next question asked by the Sub-Committee highlighted the risks associated with the increasing cost of care packages, and whether there were any contingency plans. It was explained that the Council used CareCubed system to determine whether value for money was being achieved, with the system used by both the Council and its providers. It was highlighted that there was evidence that the system supported negotiations with providers, although it did not work as well for determining the cost of care for older people. It was explained that it was important to work with the market to accurately determine inflationary uplifts and there was a Market Sustainability Investment Fund to support this work. Reassurance was given that even though some providers asked for significant increases, the Council had been successful in its negotiations with them. There would be a further uplift in April that had already been agreed.

As a follow-up, it was questioned how the Council reviewed care packages and whether it was the correct course of action to reduce the cost of these packages. It was acknowledged by officers that the review had been a demanding process. However, it was essential to review an individual’s needs regularly, as these changed over time. Another important area was to review the transition for young people in care to support them to live as independently as possible as adults.

The next question considered the influence of housing on ASCH. Officers explained that the impact of housing was immense, therefore, it was very important to strengthen the link between these two directorates. It was highlighted that it was particularly important from the mental health perspective, for instance a priority was to ensure that tenancies were sustained (e.g. in case when a resident was admitted to a hospital). There was also work ongoing on the pathways available to residents to ensure they were supported and that the provision of accessible housing was very important. As a follow-up, it was questioned whether the demand for accessible housing was higher than the supply, and if so, how this was being managed. It was explained that it had been identified with the ASCH Housing Strategy, that demand had been rising and there was a need for more accessible housing.

There was concern raised about the possible effect from any reduction in an individual’s support and how residents could communicate with the Council if they felt the support they received did not meet their needs. It was explained that in the first instance the Council would look to engage with any residents who disagreed with their assessments or the level of support they received. However, if no agreement could be found, there was a complaint process that could be escalated to Local Government Association. It was added that if there was a change in an individual’s needs, their support would always be reviewed.

It was questioned who had the responsibility for the care costs of individuals placed in Croydon from other boroughs. In response, it was explained that the placement cost would be the other local authority’s responsibility when placing a person within the borough. However, there were other costs to the Council such as those relating to safeguarding. It was stressed that the circumstances would be different if an individual moved to the borough and required care, which would be the responsibility of the local council. The ordinary resident funding rules were clearly stated in the Care Act. It was noted that although some people moved into Croydon, conversely at the same time many people chose to leave the borough and move to another local authority area.

Considering the forthcoming report from Local Government Association Peer Challenge Review, it was questioned whether the Council could expect the budget to require change depending on the findings. The officers explained that there would not be any financial implications and that the budget had already been set based upon the demographics and need assessments. Should the result of the Review indicate areas of improvement, this might result in the reallocation of resources rather than requiring additional resources being added to the budget. Reassurance was given that improvement work was being constantly monitored within the directorate with resources reallocated as required.  In addition to that it was assured that the report, once factually checked, would become a public document. The Cabinet Member stressed that it was crucial to ensure that both the ASCH directorate and the Council were transparent and open about its challenges and plans.

Further information was sought on the development of digital service and what efficiencies could be anticipated. The officers explained that there were already some digital services in place, such as the virtual ward. It was also envisioned that digital workstreams would help to deliver savings through bringing a greater focus on prevention and early help. It was added that there was a portal available to residents and partners that could be used as a referral mechanism. It was confirmed that there was currently a review underway to map out the opportunities for the use of technology within the directorate.

The Council was working with other South West London boroughs and the Improvement & Assurance Panel on the procurement of a transformation partner who would advise the Council on best practice and where the Council should invest its efforts. It was also added that in order to increase productivity, the use of artificial intelligence (AI) to support staff increase efficiency and productivity, was being explored. Officers explained that a current focus was on the information, advice and guidance available on the Council’s website, and ensuring that the referral system worked as expected. It was explained that the anticipated improvements would ensure the right level of care whilst simultaneously decreasing cost. An example of Swindon Borough Council was given, where they had worked with a large technology provider to develop an AI tool which produced an easy-read document within 10 seconds. It was added that for an officer it would take around a week to develop a similar report. Reassurance was given by the officer that it was crucial to ensure that nobody was excluded from any services and that residents knew how to use and access the technology.

The Sub-Committee asked a further question on the timeline for the technology review and what technological solutions were available for residents, including telecare. The officers explained that the technology review was going through the final stage before commencing the procurement process. It was also assured that telecare was available through the careline, alongside other, more modern, solutions. There had been a significant piece of work around the careline to ensure that all relevant stakeholders were connected to it digitally.

It was flagged that there may be some fear of AI amongst residents and the potential effect it could have on the services, such as accessibility for some residents or that the AI would be used for diagnostic purposes. The officers provided reassurance that AI would only be used to support the process and it would continue to be the responsibility of the practitioner to own the decisions or recommendations. It was also explained by the officers that increasing productivity through the use of AI would allow practitioners to spend more time with residents. The Cabinet Member highlighted that there were great opportunities coming from the use of AI and that in some cases it could be used to detect human error.

It was questioned how the voice of residents would be fed into the development of new digital innovations and how any of their concerns would be addressed at the trial stage. The officers reassured the Sub-Committee that residents and their experiences were always at the forefront of their thinking when solutions were being designed and implemented. It was highlighted that on various occasions the Resident Voice Group had met to provide their feedback on proposed solutions. It was also added that there were many other bodies comprising of relevant stakeholders, such as the Learning Disability Partnership Board and Carers Partnership Board, that could feed into the process. It was stressed that whenever possible, the directorate looked to deliver coproduction with residents and other relevant stakeholders.

It was questioned whether staff shortages were having an impact on core areas like the review of care packages. It was explained by officers that there were particular practitioner groups that were particularly difficult to recruit. For instance, occupational therapists who helped people become more independent and as a result required less care and support. Therefore, the shortage of staff within this area delayed various processes and savings. There was also a challenge in recruiting people in commissioning, who supported the directorate in identifying more cost-effective solutions. It was highlighted that for social workers the Council had developed an Assisted Supported Year in Employment programme. This competitive scheme provided extra support for newly qualified social workers and helped to improve retention in Croydon. Officers also explained that recently the Council had undertaken a significant piece of work around performance management and data systems. This would support the Council in targeting resources to complete its customer base reviews by early next year.

Given there was a challenge with recruiting staff, it was questioned whether the use of higher cost agency staff was having an impact on the budget. It was acknowledged that the level of agency staff was currently high due to winter pressures. However, it was assured that many agency workers would only be employed in the short term, the cost of which would be covered through the additional pressures funding. There was ongoing work with other London boroughs to benchmark staffing costs to ensure that agency staff were not being overpaid. The Council had also been actively trying to convert agency staff members to permanent ones. Assurance was given by officers that the Council was actively looking at options to increase the number of staff in hard to recruit areas, such as through apprenticeship schemes. Another area being looked at was ways to improve staff retention, which included appointing the Principal Social Worker to support the profession and other career progression opportunities. It was highlighted that the turnover of staff within the directorate was not particularly high, especially amongst the heads of service and newly qualified social workers.

The Sub-Committee challenged officers on the potential impact of staff shortages on the transformation programme and whether this was sufficiently resourced. The officers explained that this had been identified as a concern and agreed that the transformation process should not be impeded by staff shortages. Therefore, it was assured that, if necessary, staff resources would be reallocated to the area of transformation to support the process. Further reassurance was given by the Cabinet Member who confirmed that the reallocation of staff resources was regularly used by the Council to support the delivery of priorities.

The number of people between the ages of 18 and 64 who were living in nursing care was highlighted by the Sub-Committee, information requested on the work to reduce the numbers of younger adults placed in nursing care. It was explained that there were different kinds of nursing home and not all of them were for older persons’ nursing care. It was assured that placing a resident in a care home was usually a last resort. However, it was stressed that there would always be a need for nursing homes to accommodate the complexity and severity of care needs.

Further information was requested on the key performance indicators that would be used to monitor the delivery of the new Transformation Programme. The Sub-Committee highlighted that it would be very challenging for Scrutiny to monitor delivery without the right indicators being in place and robust data collection processes. Officers explained that the new reporting framework for the Department of Health and NHS England was going to require more client level data to be submitted monthly, which would be reported on a quarterly basis. As such, it would improve the collection of data and allow better comparison with other boroughs. It was confirmed that the Government was in the final stage of the implementation process and that it was currently in the testing phase. It was also confirmed that this reporting framework would be used by all local authorities. 

The final question considered the impact of inflation on the transformation programme and what was the Council plan to mitigate the negative impact of inflation. The officers provided reassurance that the directorate worked closely with governmental bodies, Local Government Association and finance department to manage these risks. It was explained that the greatest impact would be through the increase of the National Living Wage. It was also added that it would be very important not to damage the market and give significant uplifts. It was highlighted that the Council used a star chamber each year to identify budget savings. The star chambers included finance and commissioning leads, and their task was to estimate demand, review different scenarios and prepare for inflation and related market changes.

Following its questioning of the information provided, the Sub-Committee Members debated whether it was sufficient reassurance by the information provided on the ASCH 2024-25 Budget. It was concluded that although there was a certain level of assurance could be taken from the ongoing delivery of the in-year budget, there were areas in the budget for the forthcoming year, such as the transformation programme, where there were still some unknowns that would only be finalised after the budget setting process had been completed. As such, the Sub-Committee agreed that these areas would be scheduled in their work programme for a deep dive later in the year.

Actions:

Following its discussion of this item, the Sub-Committee agreed the following actions for follow-up after the meeting.

1.     That further information would be requested to explain the source of an additional pressures grant funding.

2.     It was requested that the report arising from the LGA Peer Review of Adult Social be circulated to the Sub-Committee, once available.  Consideration would be given to scheduling the item on the agenda for the next Sub-Committee meeting on 12 March 2024 for discussion.

3.     It was agreed that the members of the Sub-Committee would meet to review and plan its work programme for its forthcoming meetings to ensure it had the right areas of focus and items were fully scoped to set out the information required.

Conclusions:

From its discussions of the Adult Social Care and Health Directorate 2023-24 Budget, Savings and Transformation report, the Sub-Committee reached the following conclusions: -

1.     The Sub-Committee commended the work of the Adult Social Care team in managing its budget, acknowledging that there was a good level of understanding of and control over the budget for the service.

2.     The Sub-Committee also commended the work of the Practice and Quality Assurance Panel reviewing the packages of care, which was a key to delivering savings within the service.

3.     The Sub-Committee also welcomed a review on the further use of technology within the service, as a means of identifying further savings.

4.     Although, the Health and Social Care Sub-Committee did not have any specific concerns about the Adult Social Care and Health Directorate budget for 2024-25, there were a few areas, such as the transformation partnership workstream, that were still in the early stages of development and would require further in-depth scrutiny over the forthcoming year to provide further reassurance on delivery.