Agenda item

Purpose of the report: To receive an update on the progress of the Adult Social Care transformation programmes.

Witnesses:

Karl Atreides, Chair, Independent Mental Health Network

Jonathan Lillistone, Assistant Director of Commissioning (Adult Social Care)

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

Sinead Mooney, Cabinet Member for Adults and Health

Kate Scribbins, Chief Executive Officer, Healthwatch Surrey

Liz Uliasz, Deputy Director of Adult Social Care

Simon White, Executive Director of Adult Social Care

Patrick Wolter, Chief Executive Officer, Mary Frances Trust

Ernest Mallett joined the meeting at 10:34am.

Key points raised during the discussion:

1. Members enquired whether the scope of the Market Management work mentioned in the report included market frailty and the actions the Council would take to prevent market failure. The Executive Director of Adult Social Care (ASC) confirmed that it did include market frailty. While Surrey County Council had a particular interest in protecting parts of the care market with which it did business, it also had a more general duty to ensure the care market in Surrey was successful. Moreover, the Covid-19 pandemic had brought particular challenges to the care market.
2. A Member noted that in the report, Practice Improvement had been ‘RAG’ rated as amber/red, and expressed concern that this programme had been slow in implementing the strengths-based approach. He asked what impact that had had, including impact on the budget. The Executive Director of ASC responded that the Council had been taking steps on the strengths-based approach since 2018 and the strengths-based approach was still central to its philosophy. Unfortunately, the Covid-19 pandemic had had an impact on the service and shifted the focus towards hospital discharges and funding requirements, which had somewhat overshadowed the strengths-based approach. The Deputy Director of ASC added that training on the strengths-based approach had started again virtually and tools for implementing the strengths-based approach were being rolled out, so after the difficulty of the pandemic, the approach was now back on track.
3. A Member asked for a general update on care package reviews and queried whether the reviews had resumed yet following the Covid-19 lockdown. The Executive Director of ASC said that reviews were still taking place and the most challenging area was Learning Disabilities (LD). The Council was not reaching the level of savings from the review process that it had anticipated; this may be because the reviews were being conducted virtually.
4. A Member expressed concern about the topic of rates of pay for domiciliary carers. He asserted that some contractors paid one rate of pay for the time spent caring and another for the time spent travelling between clients, which could mean carers are paid below minimum wage. The Executive Director of ASC responded that there was no evidence that any of Surrey County Council’s contractors were using different rates of pay to subvert the minimum wage. Moreover, different businesses treated travel times differently. The Assistant Director of Commissioning (ASC) added that the Council was very clear from a commissioning perspective that providers were expected to comply with legal obligations, and if they did not comply, this would be investigated.
5. The Co-Chair of the Surrey Coalition of Disabled People remarked that during the Covid-19 pandemic, the use of technology to support clients had become more widespread. However, the section on technology enabled care (TEC) on page 21 of the report did not include details of how the Council would use TEC going forward. The Cabinet Member for Adults and Health said that during lockdown the use of TEC had improved and the Council was scoping a project to identify opportunities to further improve its offer to residents, working with districts and boroughs and NHS colleagues. The Cabinet Member would keep the committee updated on this.
6. The Co-Chair of the Surrey Coalition noted the possibility of moving the Direct Payments (DP) function in-house. He asked whether there had been examples recently where DP support had been removed from a number of people and they had had to go directly to the Council for support. At the moment, independent support was available for people looking for carers; however, bringing the service in-house may make this more difficult. The Assistant Director of Commissioning (ASC) stated that the service’s approach was to collaborate with external partners – like the Surrey Coalition of Disabled People – who played an important role. The Executive Director of ASC indicated that the Council had increased the hourly rate that people on DPs could pay their personal assistants so that was now linked to the London Living Wage and would be automatically uplifted each year.
7. A Member asked whether the Council was tracking care homes’ use of the infection control funding that had come from government and what the outcome of this funding was for care homes. The Executive Director of ASC replied that the use of the infection control grant was tightly controlled by government. Three-quarters of the funding had to be spent directly on infection control, while the Council had more discretion on the remaining quarter. The infection control grant was linked to the Care Home Resilience Plan submitted to government, which included a tracker where care homes had to update their status. The plan covered elements including personal protective equipment (PPE), staff moving between homes, and whether staff had the right guidance. The rate of infection and number of deaths in care homes were decreasing, indicating that this plan was effective. Moreover, the Executive Director emphasised that as the pandemic was easing the Council was reintroducing visits to care homes.
8. A Member remarked that he had heard cases where some care homes had been charging residents high fees for PPE provision. The Executive Director responded that PPE was not free in all cases and, whereas towards the beginning of the pandemic there had been supplies of PPE from the government and public donations, care homes were now expected to purchase PPE in the normal way from suppliers and could therefore legitimately charge residents for PPE. Some unscrupulous suppliers had taken advantage of the demand for PPE and increased prices. The Council would only provide PPE to care providers for free in a short-term emergency. However, the Executive Director said that if the Member had encountered cases where self-funders had experienced very high prices for PPE, this should be taken up with care homes on a case-by-case basis.
9. A Member queried whether the Council was putting in place measures to alleviate the mental health problems that some residents may develop due to self-isolation during the pandemic. The Deputy Director of ASC acknowledged that the Council had seen an increase in mental health referrals, particularly Section 136 referrals (removing to a place of safety by police under the Mental Health Act). Visits to clients had continued throughout the pandemic where necessary, and the Council had been working with external providers such as Mary Frances Trust. Moreover, staff were being trained to recognise mental health symptoms through helplines. The Council was continuing to respond to referrals as they came in. All the relevant information and resources were available in one place on the Healthy Surrey website.
10. A Member enquired what the remit of the Surrey and Borders Partnership (SABP) reference group was. The Deputy Director of ASC replied that the remit was psychological first aid, and the group had been formed in response to concerns about the mental health of shielded people and people who were self-isolating. One example of a response was that psychological first aid training had been set up for helpline staff. The Deputy Director agreed to send the Terms of Reference of the group to the Chairman of the Select Committee.
11. A Member asked for more information on the budget for mental health – what efficiencies had been identified? The Deputy Director of ASC said that the Council was working through the budget plan at the moment, including the staffing budget, setting up a reablement service and prevention work. These could all help achieve efficiencies. The Member questioned whether the plans for the staffing budget would equate to fewer staff. The Deputy Director responded that this was not the case and that the service would struggle to operate with fewer staff. Rather, efficiencies would be made by ensuring resources were in the right place.
12. A Member asked what phase one of the mental health programme had consisted of and what phase two looked like now it had been revised. The Deputy Director of ASC replied that phase one had been ending the Section 75 agreement and moving staff into locality teams. Part of changing this structure was ensuring all staff were trained in the care act and using recording systems correctly. Phase two involved embedding the strengths-based approach, ensuring teams had the right line management structure and developing a hospital discharge process and working effectively with mental health colleagues to secure the right outcomes for residents. Other focuses included ensuring people had access to employment and working with commissioners.
13. A Member asked what the ambitions were to work in a multidisciplinary way with other services, giving the example of children’s services, which had a family safeguarding model bringing together multiple other services. Regarding adults’ services, there was a ‘toxic trio’ of poor mental health, drug and alcohol abuse, and domestic violence, and multidisciplinary work could help with this. The Deputy Director of ASC said that adults’ services were building multidisciplinary relationships, by working with GPs, for example. The service had been working with Helen Rostill (Director of Mental Health, Surrey Heartlands/Chief Innovation Officer & Director of Therapies, Surrey & Borders Partnership) to connect community services to mental health services. There was also room for partnership working with districts and boroughs on housing, as that could have a significant effect on mental health.
14. A Member enquired what support was given to young people for the transition from children’s mental health services (CAMHS) to adults’ mental health services. The Deputy Director of ASC explained that she had been in contact with the Assistant Director of Disabilities, Autism & Transition about this. There had been some referrals from CAMHS to adults’ mental health services on someone’s 18^th birthday, which was deemed too late to do effective transition work. As work was transferred from SABP to the Council, the Council was aiming to improve the transition process.
15. A Member expressed concern that more young people were developing mental health issues, and that the service did not have sufficient funding or staffing to cope with this. She also was concerned about the medium-term psychological impacts of Covid-19, such as ‘brain fog’. The Executive Director of ASC acknowledged that some people, particularly those with learning disabilities (LD) or mental health issues, would suffer psychological damage due to Covid-19. The service was anticipating more referrals on this and would respond to them accordingly.
16. A Member expressed concern that GPs were overprescribing medication to patients in order to mask mental health problems, rather than tackling the problem itself. He suggested that the Healthy Surrey website link (which contained details of many services in one place) should be cascaded to GPs. The Executive Director of ASC highlighted the fact that GPs did not come under the Council’s ASC services remit. Nonetheless, primary care was playing its part in mental health services. The Council was trying to shift away from severe and enduring mental health problems such as psychosis towards services like SABP, IAPT (Improving Access to Psychological Therapies) and community services.
17. A Member enquired why the RAG rating for hospital discharge was amber in the report. The Deputy Director of ASC replied that this was because of lockdown, which had led to the pausing of multiple areas of work. These had now been un-paused and details were being finalised. However, the rating was still amber, as the service had not achieved everything it would have hoped to have achieved.
18. A Member asked how the review of mental health structures was being conducted and how residents, Healthwatch Surrey and the Adults and Health Select Committee could be involved. The Deputy Director of ASC stated that the review involved looking at caseload numbers, staffing and other resources issues. Once models were developed, user representatives such as Healthwatch Surrey would be involved. The Member suggested working with other external organisations too.
19. The Chief Executive Officer (CEO) of Healthwatch Surrey asked witnesses to comment on the number of complaints recently. Also, what themes had been identified in complaints and what advocacy support was available for those pursuing complaints? The Executive Director of ASC responded that the Council did use complaints as a source of learning and that the Select Committee had received the annual complaints report that analysed complaints received and detailed learning from ombudsman cases. Since 2019 there had not been any major shifts in the level of complaints. The Chairman of the Select Committee also informed the CEO of Healthwatch Surrey about the dashboard that the committee was developing, which would show complaints data.
20. The Chair of the Independent Mental Health Network (IMHN) expressed concern about mental health supply and demand throughout Surrey. He declared that prior to the pandemic the supply had not kept up with the demand, and the pandemic had worsened this situation. Organisations such as Surrey Police had noticed an increase in death by suicide amongst young people. Moreover, people with secondary mental health issues were often rejected from mental health services as they were deemed not to reach criteria, as these criteria were always changing. Apart from GPIMHS (GP Integrated Mental Health services), what provision was in place to reach increased demand for mental health services? The Executive Director of ASC said that the responsibility for this lay with SABP, so they would be the best people to answer this question. The Chair of the IMHN replied that the IMHN was already working with SABP. He added that he had gone through the service himself, and praised the enabling independence service. However, the pandemic’s impact was not to be underestimated and there was a burden on the voluntary sector to fill in the gaps. The Deputy Director of ASC thanked the Chair of the IMHN for his feedback and expressed a wish to develop reablement services and relationships with external organisations.
21. A Member queried how Surrey County Council compared with the market leader in ASC and what could be learnt from them. The Assistant Director of Commissioning (ASC) said that the report pointed to a number of measures by which the Council could compare itself to other LAs. For example, other LAs often did well when it came to consistency across the market, including quality, pricing and confidence in being able to secure placements. A more strategic, centralised approach was one mechanism by which Surrey County Council could achieve that. The Member responded by asking who the market leader was and why Surrey was not leading with them. The Assistant Director of Commissioning (ASC) expressed a wish to avoid commenting on specific history, but with regards to near neighbour LAs, they had a similar approach to Surrey County Council. However, the Member stated that near neighbours such as West Sussex, Essex and Hertfordshire offered better services at a lower cost, and asked why Surrey was not achieving the same. The Assistant Director of Commissioning (ASC) replied that Surrey County Council only purchased about 25% of beds in Surrey care homes; Surrey had a larger self-funder market than other LAs. Surrey faced a greater challenge in achieving good value pricing and good quality.

Recommendations:

The Select Committee:

1. Requests that a report on the Mental Health programme of work is presented at its next meeting on 15 October 2020, and that this outlines the review process and planned actions in more detail;
2. Recommends that key stakeholders and partners are involved in the Mental Health review;
3. Recommends that there is better publicity of the mental health services and resources available to residents;
4. Requests that a detailed report on the Practice Improvement programme is presented at a future meeting.

The responses to recommendations 2 and 3 as above are annexed to these minutes.

Actions/further information to be provided:

1. The Deputy Director of ASC to send the Terms of Reference of the SABP reference group to the Chairman of the Select Committee.