Agenda item

Purpose of report: To provide details of the budget for scrutiny prior to Cabinet and Council meetings.

Witnesses:

Wil House, Strategic Finance Business Partner for Adult Social Care and Public Health

Ruth Hutchinson, Director of Public Health

Nick Markwick, Co-Chair, Surrey Coalition of Disabled People

Sinead Mooney, Cabinet Member for Adults and Public Health

Kate Scribbins, Chief Executive, Healthwatch Surrey

Simon White, Executive Director of Adult Social Care

Rachel Wigley, Director of Financial Insight

Key points raised during the discussion:

1. With the Equality Impact Assessment (EIA) having been distributed to Members only the day before the formal Select Committee meeting, the Chairman emphasised that lateness could hinder the Committee’s ability to scrutinise. The Director of Financial Insight responded that the Finance department would have liked to have distributed the budget earlier, but this was delayed by the general election in December 2019, coupled with late public funding announcements.
2. The Cabinet Member for Adults and Public Health introduced the item by stating that the budget gave cause for positivity with a note of caution. This budget aimed to ensure financial sustainability and investment for residents. The 2020/21 period constituted the first year for some time that the Council had received additional funding from central government; this was a recognition of the funding pressures that Local Authorities (LAs) had faced. The transformation project had been very significant, and Adult Social Care (ASC) and Public Health (PH) had played an important part in it. Due to increased financial stability, the Council was looking forward to delivering an ambitious capital programme, including investment in supported housing.
3. The Director of Financial Insight informed the Committee that:
   1. significant progress had been made in moving from financial recovery to stability;
   2. the budget proposed significant investment in Surrey;
   3. the transformation would continue to deliver efficiencies;
   4. and investment in areas such as extra care accommodation were aligned with the Council’s 2030 vision.
4. The Executive Director of Adult Social Care noted that when creating a budget envelope for ASC, the vast majority of spending was on provision of care. Surrey County Council was trying to change the model of care in order to contain spending within the budget envelope. This could be summarised with the phrase ‘strength-based approach’, which was a focus on how the Council could facilitate residents living how they wished, and assessing people at their best. The performance information of the department indicated that the strength-based approach had been successful: the number of contacts turning into assessments was falling, 5,000 people had been taken off the caseload and the percentage of people going into residential nursing care had been reduced. This approach was not focused on saving money, but it did so as a by-product, and the average cost of care in Surrey had fallen. The 2020/21 budget was more realistic than the previous year’s, although this still presented a challenge. In 2019/20 there had been a slight increase in spending for the first few months, until the last three months, when there had been reductions month-on-month. Finally, the Executive Director wished to commend the absence of closures of care services in the budget.
5. The Executive Director indicated that, as older people usually used services for a shorter amount of time, the savings impact there would manifest relatively quickly. Meanwhile, changing from residential care to an independent living-based model would deliver savings in learning difficulties (LD), as well as providing many residents with a service that they would prefer.
6. A Member expressed concern at the notion of assessing people at their best, because the package agreed for a person might not be what they would actually need. The Executive Director recognised this point but emphasised that mental health issues and physical disabilities varied in severity over time. People could access different levels of care using the direct payments system if they were going through a ‘rough patch’. The strength-based approach took into account the emotional impact that temporary factors could have on a patient.
7. A Member highlighted the importance of patient outcomes and enquired how outcomes were measured. He stated that 5,000 people had left the list of people requiring care, and he wished to know what happened to them after they had left this service. The Executive Director acknowledged that there were cases of patients who had repeat entries into the care system. However, as hospitals were often under strain, there were reasons outside the remit of ASC where patients might leave hospital and then be readmitted soon after. Members should talk to individual patients wherever possible and find out if care had a positive impact on them individually.
8. A Member asked whether the consequences of some residents self-funding care were that those residents paid more and, in effect, subsidised Surrey County Council. The Executive Director responded that this was a controversial topic, and that self-funders often did pay more. However, it was understandable that care providers might want to sell services to the Council for less than they would to a private company, as the Council might offer more security as a commissioner.
9. Members expressed concern about Surrey’s PH spending in 2019/20, which, at £29 per head, was significantly lower than the England average of £56 per head. The 2020/21 budget report itself noted that ‘any further reduction in PH spend in Surrey could have very serious long-term impacts for Surrey residents, especially considering how much of an outlier Surrey already is in terms of low PH spending’. The Chairman questioned whether the funding available was adequate to support the prevention programme, as prevention should be at the heart of the service. The Director of PH confirmed that PH funding was indeed low; Surrey’s PH funding had been reduced by 9% since 2013. The reason for this was that the allocation of PH funding was based on historical spends prior to 2013, and this amount of funding could bring challenges for Surrey in the present. It was important to use PH funds in the most efficient way possible and there were tight criteria on how funding could be spent. The Cabinet Member explained that central government had committed to more PH funding, but without detail specific to Surrey. She asserted that all Committee Members had a responsibility to raise this concern with their MP. The Chairman expressed his intention to raise this issue with the Surrey Health and Wellbeing Board.
10. A Member requested more information on the projected timings of care package savings in 2020/21. The Executive Director acknowledged that abiding by projected timings was challenging, but it had been managed in ASC in the last 12 months, so they would attempt to repeat this. Every year ASC had to manage around £5 million of additional costs from young people transitioning from children’s social and education services, as well as price inflation (budgeted at £7.4 million in 2020/21) and demand pressures across all other client groups. The Executive Director said that ASC’s transformation plans were designed to achieve the savings required in 2020/21, but also said that Surrey County Council was reliant on the outcome of central government’s three-year spending review in order to ensure ASC was sustainable in the medium to long term. Amongst other things, this would help the Council to maximise relationships with care providers.
11. Noting that the press often reported on the fragility of the care market and high-profile care failures, a Member asked how fragile the care market was in Surrey. The Executive Director said that he did not have with him facts and figures, but that he did not think that the rate of failures was increasing. However, failures did occur regularly – usually about once or twice a month. He informed Members that the Council worked closely with the Care Quality Commission (CQC). The Cabinet Member also stated that the Council had good communication with providers and there was a platform for providers to raise any concerns. The Cabinet Member suggested that it might be helpful to add this issue to the Forward Work Programme.
12. The Chairman enquired whether there was an audit to examine cases of people who were being cared for by failing companies. The Executive Director confirmed that there was such an audit, and the Chairman asked for assurance that the audit was adequate. The Executive Director replied that this audit was routine and that in the time he had been in-post there had not been any problems.
13. A Member raised concern that a distinction had not been made between care packages for older people, people with LD and other groups, nor had a distinction been made between domiciliary and residential care. Anecdotally, it was difficult to retain domiciliary care staff because the working conditions were not attractive; for example, they sometimes were not paid for travel to and from patients’ homes. She enquired whether Surrey County Council could have an impact on that. The Executive Director appreciated that the practicalities of providing domiciliary care were challenging. The Council’s policy was to pay for travel, so the Council was not responsible for that issue. Care providers struggled, though, to retain care staff for many reasons, one of which was that the Council could not afford to pay domiciliary care staff as much as it wanted to. Even reablement paid considerably better than some domiciliary care providers, making working in domiciliary care unattractive for many people.
14. A Member expressed concern about the use of the phrase ‘market management’ in the report. According to the Member, the Council was still trying to reduce spending on residential care, even though providers were in a precarious position. There seemed to be a view that some providers would come back under the Council’s control, but the Member was concerned that while this was seen as an easy answer, it was in fact not realistic. The Executive Director confirmed that some care homes had returned to the Council’s jurisdiction, and that all would be reviewed and decisions would be made by Cabinet where applicable. Regarding the precariousness of the market, he said that while pressures did exist, Surrey had an advantage in that there were many more self-funders in Surrey than in other LAs. Therefore, providers were willing business partners to the Council, and the Council would continue to do business with providers in a way that engendered confidence and safeguarded income streams for providers.
15. A Member remarked that since, according to the report, 80% of ASC costs were care packages, presumably that is where savings could be made. With that in mind, he asked what levels of reductions in care packages were being made and what the outcomes of this were. The Executive Director indicated that the Council did not aim to reduce care packages by a high percentage. From his point of view, there were more cases where the level of care was increased after review than decreased. A short-term increase in care tailored to an individual could enable the individual to be more independent in the long term, thus decreasing costs while enabling residents.
16. A Member questioned why a graph in the report showed that Surrey’s spending on ASC was significantly higher than comparators. He asked whether this implied inefficiency or was due to differences between the demographics of the Surrey and other counties. The Executive Director stated that this had been examined and the results would be provided to the Select Committee. He asserted that discrepancies between Surrey and other councils were not related to efficiency problems but rather to the fact that Surrey was a relatively wealthy county that spent more than average on all its services.
17. A Member requested more information about debts owed to ASC by residents and what was being done with regard to direct payments. The Executive Director responded that the level of debt was increasing, but it was doing so broadly in line with income increase. A sizeable proportion of the debt was secured – in other words, it was held against a property and would eventually be recovered. Responding to this assertion, a Member asked what debt was secured and what was being written off for historic reasons. Also, he wished to know how Surrey County Council compares to other councils with that percentage. The Cabinet Member replied that she would find the answers to these questions and feed back to the Committee. Perhaps this could go on the forward plan for consideration as its own item. The Director of Financial Insight added that a review had been done on the provision for ‘bad debts’ (debts unlikely to be paid back), and that had been built into the budget. However, the Finance team was not proposing to increase the provision for bad debts, as there was currently a balance between secured debts and non-secured debts and sufficient provision for bad debts.
18. A Member observed that the EIA for the 2020/21 budget found that there might be increased demand placed upon the voluntary, community and faith sectors (known collectively as ‘the third sector’) in some areas. She wished to know what the Council was doing to support those groups. The Executive Director replied that third sector organisations were not a first resort, but were only relied upon after personal assets, friends and family, and neighbours had been looked into. It was important that the Council put residents and third sector organisations in contact with one another.
19. A Member asked how the Council was lobbying for increased funding from central government for mental health, and asked for the witnesses’ points of view on this. The Executive Director responded that nationally, Surrey County Council was amongst the councils that spent the least per head in PH on mental health services. It would be beneficial to spend more on preventative and support services, rather than acute services and financial overheads. However, it was too early to predict what funding would come from central government, and it was worth bearing in mind that mental health services had not contributed at all to savings made in the last 18 months.

Angela Goodwin left at 11:54am.

20. A Member expressed concern about reductions to ASC spending. Changes would not always be welcomed by residents, and efficiencies (which could be seen as ‘cuts’) would be likely to reduce the number of residents to whom services were available or accessible. The Executive Director understood the Member’s concerns about residents becoming removed from care services, and he noted that residents’ records would still exist in case they came back into the service, and perhaps the service could outreach to residents where appropriate. However, he wished to convey to residents that ASC services could paradoxically shorten residents’ lives if over-relied upon. Residents should approach the service when they felt they needed it, not the other way around.
21. A Member asked what the current vacancy rate in ASC was, and what the target for this was. The Executive Director replied that while there was not a significant vacancy margin in ASC, the underspend in staffing was an issue, which was projected to amount to £1 million. In order to tackle this, the service needed to recruit more staff, which would be the means to make savings. The Cabinet Member added that the recruitment process for this had started.
22. In 2020/21, £5.4 million of the PH grant would be spent on PH services provided by other parts of the Council. A Member queried where this would be spent. The Director of PH responded that the service kept track of exactly where this money was spent, and examples included the Baby-Friendly Cafes, Eat Out Eat Well programme and Safe and Well visits. All this spending was in line with the principles of the PH grant, and was similar to how other LAs made use of the grant.
23. The Co-Chair of the Surrey Coalition of Disabled People expressed concerns that the budget unfairly impacted people with LD and people with sensory disabilities.
24. The Co-Chair observed that reducing the Council’s ASC expenditure would increase pressure on unpaid carers. The Executive Director expressed his appreciation for the work done by unpaid carers. The ASC service would continue to spend on travel for unpaid carers as part of the strength-based approach. The Strategic Finance Business Partner added that one efficiency mentioned in the budget came from the shift from residential care towards independent living for people with LD. Also, the 2020/21 budget was larger overall than that of the previous year, so the Council would not reduce the overall spend, but rather would try to offset certain pressures with suitable efficiencies. The Cabinet Member highlighted the emotional, financial and mental impact that being an unpaid carer could have, and suggested that the Co-Chair work with Healthwatch to see if more could be done to help unpaid carers.
25. The Co-Chair was of the opinion that residents should be assessed on their worst day, not their best, especially if they were known to fluctuate. He asked for comment on direct payments and expressed concern about the ‘climate of optimism’ for care workers and social prescribing. On the latter, the Co-Chair stated that a lot of money was being put into social prescribing but very little help was being given to the third sector so that they could assist with social prescribing, and he was concerned that it was being used as a method to remove residents from health or care registers. The Executive Director responded that what was meant by a climate of optimism was the belief that people’s lives could improve and were not on a downward trajectory. The Director of PH added that outcomes were a key part of social prescribing, and work was being done nationally to discover what outcomes it produced. Currently, the evidence base showed that it produced good outcomes, but Surrey is undertaking work on measuring how it compared to other parts of England. She emphasised the importance of working with the third sector.
26. The Chairman requested more detail on how information in the EIA on the impact of changes was gathered. The Executive Director responded that performance data, the volume of complaints and provider failure were all indicators for ASC of notable impact on residents. The Chairman said that it would be useful for the Select Committee to receive feedback once or twice a year on the complaints system. It would also be useful to examine the whole range of indicators and how the Select Committee could guide improvements.

David Mansfield and Darryl Ratiram left at 12:22pm.

27. The Chief Executive of Healthwatch Surrey welcomed witnesses’ tone of transparency and the acknowledgment from witnesses that residents would not welcome some changes and there could be difficulties in implementing this budget. She remarked that many efficiency programmes would have an impact on the most vulnerable residents, and enquired how those people were identified, how risks were mitigated, how assurance could be provided that the EIA would be effective, and whether the EIA was open to public scrutiny. It was important that the Council engaged directly with those most affected by efficiency programmes and that the most vulnerable people had access to information about their rights and access to advocacy. The Cabinet member stated that the Health and Wellbeing Strategy was attempting to ensure that vulnerable people were not left behind. She emphasised the importance of the Council working with organisations like Healthwatch to ensure that challenging decisions produced positive outcomes.
28. The Chief Executive of Healthwatch further asked how the Council ensured that the complaints system was open and accessible to those most vulnerable. The Executive Director was keen for the service user’s voice to be at the forefront of the service, but at the moment, this was not the case; he was currently working with frontline staff in the service to change this. He encouraged the Chief Executive of Healthwatch to hold more specific parts of the service to account in partners’ forums.
29. A Member expressed her support for the changes to the ASC service, particularly the emphasis on residents being independent and living in their own homes. She asked for clarification on to what extent some of the activities labelled ‘new’ in the budget report had been tested and proven as reliable. The Executive Director acknowledged that newly introduced services had not all been perfect. There had been hopes that changes to commissioning would deliver a positive impact for service users as well as financially for the Council. The service was working with the local university, experts, and districts and boroughs to improve technology. The Cabinet member added that technology-enabled care was important because it could help to deliver efficiencies. This technology was tried and tested - it was known to help residents live independently in their home and act as a support to unpaid carers. The Chairman stated that ‘new’ technologies had been used to help with looking after older people for two or so years, so they had been tried and tested for some time. Another Member praised the use of the word ‘new’ and expressed a belief in innovation and evidence-based evaluation.
30. A Member asked how confident witnesses were that recruitment was functioning effectively. The Executive Director informed Members that recruitment had started in the LD service to amend caseloads being too high. The ASC service had also worked with HR to cut bureaucracy in appointments, and the service was committed to making improvements throughout recruitment in 2020/21.
31. A Member asked for comment on how PH overall would fit within the accountable health system. The Director of PH responded that this was already being demonstrated through the Health and Wellbeing Strategy, whereby metrics and outcomes were being worked towards over a 10-year period. The work will be reported to the Health and Wellbeing Board every quarter.
32. A Member noted that there was a comment in the EIA on the abandonment of the Surrey disabilities register and asked for more information on this. The Executive Director stated that the register was not statutory and that it had had no pretentions of including everyone in Surrey with disabilities. The register had not delivered savings, but could easily be reinstated if necessary. The Cabinet Member added that despite this, the Council should note that some residents did consider the register important and felt that it had benefits. The Cabinet Member would distribute further information about the register to the Committee, and would meet with the Coalition of Disabled People for discussion.

Clare Curran left at 1:01pm.

33. A Member asked whether the increase in people with dementia should be of concern, what the impact on the budget of the increase was, and whether the service was capable of coping with the increase. The Executive Director said that the challenge the Council faced was to try to help people with dementia to live at home or in supported living. The Technology Integrated Health Management (TIHM) project – a study that worked to improve the lives of people with dementia in Surrey – was especially effective when the person had a live-in carer. The budget was constructed to try to contain demographic pressures; however, unlike LD, with dementia there was not a known group of people coming into the service. It could be hard to reach people in some communities. The Chairman enquired whether there was an estimate of how many dementia cases were likely to occur in the next few years. The Cabinet Member replied that the most recent national figures indicated that the number of dementia cases was due to double in the next 20 years, and that data on dementia had been built into the budget.

Recommendations:

The Select Committee:

1. Recognised the difficulty of formulating this year’s budget given the announcement of a general election in December. However, effective scrutiny requires more time to prepare draft in order to make reasoned, specific recommendations. Select Committees should be involved in budget setting from late 2020 to enable effective scrutiny of the 2021/22 budget.
2. Requested that the Cabinet Member for Adults and Public Health confirmed that they considered the Public Health budget to be adequate to support the Surrey Health and Wellbeing Strategy’s emphasis on prevention; and to take appropriate action, including lobbying government, if they were not able to confirm this view.

Actions/further information required:

1.     For the Cabinet Member for Adults and Public Health to distribute further information about the disabilities register to the Committee;

2.     For the Committee to receive a report on the fragility of the care market in Surrey;

3.     For the Executive Director of ASC to provide details of why Surrey’s spending on ASC was significantly higher than comparators;

4.     For the Committee to receive a report on vacancies and difficulties in recruitment;

5.     For the Committee to receive a report on ASC debt, including comparisons between Surrey County Council and other councils;

6.     For a report on complaints feedback to be presented to the Committee twice a year.

The Chairman adjourned the meeting at 1:03pm for a short break, during which Tina Mountain and Rachel Turner left the meeting.

The meeting reconvened at 1:26pm.