Agenda item

Purpose of the item: Scrutiny of the Draft Budget and Medium-Term Financial Strategy

Witnesses:

David Lewis, Cabinet Member for Finance and Resources

Sinead Mooney, Cabinet Member for Adult Social Care

Mark Nuti, Cabinet Member for Health, Wellbeing & Public Health

Rachel Wigley, Director of Finance Insights and Performance

Nicola O’Connor, Strategic Finance Business Partner (Corporate)

Louise Lawson, Strategic Finance Business Partner for Resources, Land and Property and Economy and Growth

William House, Strategic Finance Business Partner for Adults, Wellbeing and Health Partnerships (AWHP)

Clare Matthews, Acting Principal Strategy and Policy Lead

Claire Edgar, Executive Director of Adults, Wellbeing & Health Partnerships (AWHP)

Jon Lillistone, Director of Integrated Commissioning

Sarah Kershaw, Strategic Director of Transformation, Assurance & Integration

Ruth Hutchinson, Director of Public Health

Kathryn Pyper, Chief of Staff (AWHP)

 

Prior to the discussion witnessed provided a slide presentation on the Draft Budget 2025/26 and Medium-Term Financial Strategy to 2029/30 (See Item 6 in the Agenda, pages 41-49)

 

Key points raised during the discussion:

 

1. The Vice-Chair expressed concern around the heavy reliance on technology within the transformation programme, particularly with issues this could create for rural areas with internet connectivity problems. The Vice-Chair asked for reassurance on how Artificial Intelligence (AI) and other remote technology could be delivered and accessed by residents. The Vice-Chair addressed the ageing population and the increased demand for AI and technology this would create and wanted to understand what is happening within Surrey to enhance the ability for residents to access technology appropriately as they age. The Cabinet Member for Adult Social Carereassured the committee that there was a lot of work being undertaken in the Adults, Wellbeing and Health Partnerships (AWHP) directorate to successfully deliver and prepare its residents around digital inclusion.

 

Cllr Robert Evans and Cllr Abby King joined the meeting at 10.08am

Cllr Mark Nuti joined the meeting at 10.24am

 

2. The Strategic Director of Transformation, Assurance & Integrationacknowledged the reliance on digital solutions but noted it was not the only means to deliver efficiencies. The Office of National Statistics reported 50,000 people in Surrey lacked internet access, which was about average compared to other counties. AI and its requirements had to be built into the transformation programme, as well as insights such as data and modelling. AWHP was mindful of digital exclusion to ensure that does not happen, and its impact on efficiencies. A corporate digital exclusion programme looked at this work and its potential across all council activities. The programme’s action plan could be shared with the committee. Public libraries were doing work on digital exclusion such as the public computer network and an independent skills programme more generally.

 

3. Regarding digital exclusion, the Director of Integrated Commissioning reaffirmed that Surrey compared reasonably favourably to other authorities. Significant work was being done with Mole Valley District Council in the broader digital switchover, with a focus on how there could be alternatives to broadband such as mobile technology when switching from analogue to digital solutions. There was a national toolkit, and work was done with national networks to progress through that. Detailed work was being undertaken, specifically to enable certain localities. There were positive uses for AI, but there was a focus on data security and its appropriate use within the work.

 

4. In reference to the £50.1 million (m) of pressures identified, the Chaimanraised concern around the risk that those could be higher than anticipated and asked what the key risk areas were. The Chairman highlighted that the Care Quality Commission (CQC) assessment had marked the needs assessment as requiring improvement, and the Chairman noted it was an area under pressure, and it would be a key area to robustly deliver efficiencies against the pressures. The Strategic Director of Transformation, Assurance & Integrationnoted there was a substantial efficiency programme with principles of improving the care and support to deliver statutory functions and deliver efficiencies. The efficiency programme was based around prevention and earlier intervention, as well as improving the efficiency equipment provision and looking at the ‘front door’ to help address demand and get better outcomes. Plans were in ongoing to address the areas highlighted in the CQC inspection.

 

5. The Executive Director of AWHP acknowledged concerns around the required efficiencies, which were expected due to the budget size and need for efficiency. Despite having received a ‘good’ CQC rating, there were areas AWHP could alter care delivery and care offers to ensure further efficiencies. This would be challenging and needed focus in terms of the pace of delivery, but efficiencies can lead to better outcomes for people. People often wanted less intrusion and more ability to live independently. AWHP’s plan was to get this right from a practice perspective and listen to residents regarding their care needs and options available. There was evidence to suggest that Surrey was not quite operating in this way, for example, people had been moved into residential or nursing homes prematurely when care could have occurred in the home. AWHP’s transformation plan was partly to ensure this was not repeated and ensure there was a strong home care market so people could stay in their homes for longer and move to residential and nursing homes at the right time for them. Once people entered residential and nursing homes, it was likely it would be for a long period of time, which was evident for working age adults such as those with learning disabilities and neurodiversity and nationally the direction was to place these people into residential or nursing home settings. This was a substantial cost to the Council. AWHP’s aim was to get this right from both a financial position and from a position of independence for the individual, so people could live in and contribute to their local communities. Demand was a challenge and transformation work would involve reviewing the ‘front door’ approach, and how AWHP communicated with Surrey residents, ensuring consistency in the approach around how ‘conversations’ around social care were offered, to ensure the right people were being assessed at pace and in a timely, good way and achieving good outcomes, and issues were resolved earlier in the process where possible. These issues could partly be linked to aids and adaptations such as grab rails and access to the disabled facilities grant that help to intervene earlier and keep people at home for longer. Best practice had informed AWHP to be least restrictive and ensure efforts to reduce complexities through early intervention, which was part of the transformation plan.

 

6. The Cabinet Member for Adult Social Care urged the Committee to read the CQC report, which set out both areas of inconsistency and strengths and thanked the previous Interim Executive Director and the staff for their positive work. There was recognition that good practice was highlighted regarding supporting people with short-term social care needs, with 86% of people not requiring longer-term care, which was a good result compared to regional and national partners. Ambitious plans, including for supported independent living to encourage people’s independence, choice and control were also highlighted.

 

7. A Member referred to AWHP’s estimated demand of £620m by 2029 and more specifically the Adult Social Care package. The Member asked how AWHP came up with the predicted figures for the Care Package (page 48 in the agenda) and what the risk was that demand could be higher. The Executive Director of AWHP explained there are various methods used to model for future demand including using ONS data such as population data of people likely to become elderly and frail and young people likely to transition into adult services. Many young people in Surrey were subject to Educational Healthcare plans and AWHP wanted to ensure there was understanding of this demographic that would require the services. This would help build the correct budget concerning likely care costs and inform the design of future services. AWHP needed to be prepared for demographic change, especially regarding younger adults as they moved through the system and those at the edge of The Care Act AWHP wanted to improve the transition service offer, noting the principle around people living at home for as long as possible with the right care and support in place was correct.

 

8. The Strategic Finance Business Partner for AWHP added that predictions were looked at in two ways. Firstly, by reviewing what happened with care package demand change in the past 10 years, minus unusual factors such as the pandemic and using demographics to project forward. Looking at the care package demand pressures, modelling was done on how much more would need to be spent if practice was not changed. Within the efficiencies, modelling around the impact of planned changes, for example, keeping more people at home, increased use of reablement services and technology impacts, to have an alternative target trajectory which the budget was planned around. Robust work had been undertaken and modelled across different care groups within Adult Social Care including on the costs of care, recognising that demand is difficult to predict.

 

9. The Chairman asked what level of risk increases in national insurance, changes to minimum wage and upcoming changes to employment law posed to the budget, and how the risks could be contained. The Director of Integrated Commissioning stated there was a quantifiable impact regarding the increase in employer national insurance contributions. AWHP was in contact with providers. Key things coming from conversations were around demand management, which was focused on the models of care. There was not yet certainty if there would be additional funding from the government to help support this. Continuing conversations with providers around what the models of care would look like could help manage some pressure, and work was being done with providers to try and understand potential impacts and await the local government finance settlement concerning any additional funding in support of that. Continued work amongst the sector is ongoing to try to understand the risks and potential impact that may have.

 

10. A Member asked what mechanisms and measures AWHP would put in place to monitor the risk regarding governance and oversight. The Director of Integrated Commissioning explained that AWHP had regular forums with local care associations, which was positively recognised in the CQC inspections. Relationship managers had been assigned for each commissioned provider, which was key to understanding if there were pressures within services early on, which might prompt further conversations with providers. Conversations had suggested potential consolidation in the sector, where smaller providers merged to maintain financial viability. AWHP would work with providers around this, while acknowledging providers’ autonomy to ensure outcomes for Surrey residents were maintained.

 

11. A Member referred to the Government budget’s announcement of an extra £1.3 billion (b) in grant funding for councils, of which £600m was for social care and whether Surrey County Council (SCC) had any indication if this money would be available for adult services, children’s services, etcetera (etc), and how much of the £600m Surrey would receive. The Strategic Finance Business Partner (Corporate) explained there was not an indication of how much Surrey would receive. It depended significantly on the equalisation of the allocation from the Government. If it was fully equalised for SCC’s ability to raise council tax, SCC would receive a smaller share of the national allocation compared to a partial equalisation although it was difficult to predict.

 

12. A Member highlighted a potential imbalance regarding transformation and care package demand and asked for clarity on the balancing of costs with making reductions and costs that would escalate. They noted that demand would increase if AWHP proposed that more in-home care would stop current levels of spending on care homes and proposed savings of £83m over the Medium-Term Financial Strategy (MTFS) period. The Executive Director of AWHP noted the increase in population and demand for services. Home care was more cost-effective and efficient in managing care needs. Timely placement into residential and nursing homes was important. For example, placing working-age adults in these settings too early resulted in the Council funding them for a substantial length of time. Best-practice approaches were highlighted enabling people to live more independently with a level of care and support such as the supported living model, which was not as restrictive as an institution and was more cost-effective as well. AWHP would review an individuals’ strengths, ability to operate and communicate effectively in the community and what level of care and support was required. CQC best practice- inform that people’s independence should be promoted and Council’s should find ways to enable this. Although the cohort for working-aged people appeared smaller in terms of accessing - services, the costs were increasingly higher. Therefore, AWHP was trying to build in effective ways of working with this cohort in AWHP’s strategies and work with providers in a strength and outcomes-based approach to enable people to live at home for longer. Promoting independence across the whole life course and across different age groups was a key element.

 

Cllr Mark Nuti left the meeting room at 11.07am

Cllr Mark Nuti returned to the meeting at 11.09am

 

13. A Member asked that a report be provided so he could understand how a reduction in the cost of Care Packages would be achieved with an increasing population. The Cabinet Member for Adult Social Care stated she would progress this for the Member and reinforced the importance of residents remaining in their own home, and provided an example of having met a resident who had been in a care home and having left reiterated how important it was for this person to be back at home and regaining her independence. This was an important element to the transformation programme and meeting efficiencies. The Executive Director of AWHP referred to the evidence in the meeting’s agenda around the strategies being implemented. SCC contributed to a report prepared by Newton Europe on Adult Social Care funding on behalf of the County Council Network and the Executive Director of AWHP agreed to share a link to the published report.

 

14. A Member asked about the anticipated changes in the budget to social care and public health provision and what could residents expect to see. The Strategic Director of Transformation, Assurance & Integrationexplained that residents could expect to see a different ‘front door’ and approach when residents first contacted the Council, which was intended to be clearer and provide support faster. This was a key part of demand management and key lever in the transformation programme. Available options for care and support would be broader and more targeted, in addition to a more strength-based and least restrictive practice to ensure appropriate support, without overprovision.

 

15. The Chief of Staff (AWHP) brought attention to prevention and early intervention and the Director of Public Health added that prevention had been the key theme, the Public Health budget announcement was expected in February or March 2025, and a 2% increase had been budgeted for. Regarding the main Public Health commissioned services such as substance misuse, helpers and school nurses, and sexual health and residents would see that key focus on prevention, in particular substance misuse and sexual health services as early intervention led to better outcomes for residents. The CQC assessment highlighted a question around how Public Health Services could continue to be aligned to demand to ensure as much early intervention as possible.

 

Cllr Sinead Mooney left meeting at 11.27am

 

16. The Cabinet Member for Health, Wellbeing and Public Health added that the Royal Surrey County Hospital were reviewing how hospital discharge could be improved. The Hospital was trialling a process of discharging people home with a 72-hour care package in place instead of putting a person on short-term or long-term residential care, to help determine how the person could be supported at home. This reduced the costs of long-term care and allowed a patient to remain at home for longer and improve people’s health and wellbeing.

 

17. The Chairman asked which issues amongst the proposed changes in the AWHP budget, were likely to spark contention, and how was AWHP intending to meet those issues. The Cabinet Member for Health, Wellbeing and Public Health explained that the Public Health budget was ring-fenced, and a 2% increase was currently expected. Public Health would continue to look at innovation, change and grant funding. A lot of funding was brought in through external grants and central government projects. The Chairman noted the importance of Public Health in prevention and hoped for more funding as a result. The Cabinet Member for Health, Wellbeing and Public Health raised that the public would see a change in stronger messaging around prevention and living healthier lifestyles.

 

18. In terms of challenges, the Executive Director of AWHPoutlined that Surrey had several self-funders and higher rates of people going into residential care home settings than virtually anyone in the Southeast region. A question for AWHP was around why people, and families, thought residential care was the answer. There were also self-funders who would choose residential care for themselves. AWHP felt there was a time and place for residential and nursing home placements and wanted to ensure the communication around this was right. Self-funding could be impactful on people’s personal finances and if these finances depleted this meant entering Adult Social Care for funding so difficult and challenging discussions with the public would occur and would be communicated effectively. It also meant that AWHP had challenging discussions with people around whether a residential setting was the right place for individuals. Part of Adult Social Care’s value base was around enablement, empowerment, and advocacy, promoting people’s rights and which sometimes meant taking the least restrictive principles and recognising and supporting someone’s capacity to make decisions and manage those risks within the community. There could be a conflict of opinions in hospital discharge settings where, for example, a medic or nurse may suggest a care home for a person, whereas social care may feel that with the right support the person could go home. AWHP recognised these challenges and took responsibility for some changes in how they operated and communicated some of this going forward.

 

19. The Chairman raised that Districts and Boroughs (D&Bs) all had existing offers of telecare services, and asked how AWHP was going to integrate with that and manage the transition given the varied environment. The Director of Integrated Commissioning reiterated close work with Mole Valley around the digital switchover. There would be a Cabinet paper around Technology Enabled Care in January 2025. Significant work was undertaken since the Additional Transformation Resource team came into place in Summer 2024, around connecting the different approaches. AWHP’s strategy was to ensure there was a good, clear and consistent countywide offer, that allowed AWHP to remain agile and responsive as technology developed. It was important that AWHP had a core element of the offer allowing for the incorporation of new technology and partnership working with those skilled in technology development. The Vice-Chairasked if the committee could receive an advanced copy of the Cabinet paper ahead of Cabinet. The Director of Integrated Commissioning would engage with the committee as normal on this and get Member feedback.

 

20. A Member raised concerns around fibre technology and its inability to transmit electricity down a fibre cable as it does not work, to enable phone calls during a major power outage. The Member suggested the Council needed to make views around this issue known to solve the technical problem at that level, as it could restrict access to emergency services or technologies such as AI used to support people. The Director of Integrated Commissioning confirmed this was a critical point flagged for the digital switchover, which involved using SIM/mobile phone-based technology such as 4G and 5G. For kits in people’s homes, where there was a high risk of power outages that would impact the fibre broadband connection, there was planning taking place so kits could switch to SIM-based technology and was actively being thought through to find solutions to make that possible.

 

21. A Member asked how AWHP would ensure that the framework for monitoring the Technology Enabled Care and Homes (TECH) strategy was robust and that its’ Key Performance Indicators (KPIs) were kept on target. The Director of Integrated Commissioning noted the importance of monitoring service transformation. AWHP worked closely with corporate and departmental colleagues to ensure the rights KPIs were identified. This was focussed on the ability to capture and evidence technology’s benefits. There was a strong link in AWHP’s operation practice workflow within the Social Care records System (LAS) so that there was understanding around a person’s situation prior to having a technology package, the situation after, and the outcomes and improvement delivered as a result. In summary they were ensuring that KPIs were designed up-front, as part of the overall delivery model and technology solutions.

 

22. The Executive Director of AWHP added that some elements of AWHP’s transformation plan would align more to the corporate transformation activity. There was a council transformation board, where KPIs and some savings and efficiencies’ scrutiny would occur, with an element of scrutiny from the Section 151 officer and the Finance team around savings’ delivery, to ensure that efficiencies have been made and that AWHP was held to account.

 

23. The Vice-Chair noted AWHP’s work with Oxford University and RAND Europe to monitor the effectiveness and cost-saving impact of the motion sensor offer, how the communication and tracking was being managed, and how often AWHP expected to be informed of updates concerning the cost-savings. The Vice-Chair also asked what AWHP’s plan was to monitor how they were reducing the amount of money they could be spending through the proposed changes in the future. The Director of Integrated Commissioning explained that work done with Oxford University would bring a robustness to the way tracking was designed through good research and evidence-based approaches. Some savings would be longer term which meant AWHP would need to calibrate the points where changes were measured. Technology put in place as an alternative, to for example motion sensors, based on social care assessment and working with the individuals, created a clear and quantifiable change in cost. Cases were often individual specific and was therefore about layering in measurements to convey the state of the situation, what was provided, and what savings and benefits had been delivered for the person. AWHP could make reporting to the committee part of future monitoring to provide assurance that AWHP’s strategies and savings were delivering what was expected.

 

24. A Member asked how AWHP would interface with General Practice (GP) system, Epic, at Frimley Health NHS and Oracle Health at Royal Surrey Hospital, to ensure there was accurate monitoring and to move away from a demand that was difficult to predict to a demand that could be predicted, and one that could measure the output from those systems and the population health to ensure there was accurate monitoring of trigger factors and to ensure there could be intervention to prevent deterioration, and to work with for example, the Estimated Date of Discharge (EDD) within those hospitals that were digitally mature, and to interface that with the provision of care at home. The Executive Director of AWHP highlighted the challenge of interface between health and social care systems, which was being addressed through work with Integrated Care Partnerships (ICPs) and Integrated Care Boards (ICBs). AWHP had access to some systems such as through AWHP’s Social Workers and Approved Mental Health Practitioner’s work in the mental health space. This required collaboration between AWHP and its health partners. Information sharing agreements existed between SCC and NHS providers, but more work was needed in this area. Excellent joint strategic analysis work occurred in Public Health which allowed AWHP to review Surrey’s population health data. In terms of predicting demand, challenges around this were not completely solvable, so AWHP did their best and would continue to improve on this. AWHP had good data-rich internal information sharing that could be looked at in terms of people who accessed benefits and use that data to inform whether AWHP needed to provide different types of services moving forward. This had been used for crisis intervention funding arrangements and fuel poverty. The AWHP team were members of the Association of Directors of Adult Social Services (ADASS) which included various partners that worked alongside regional colleagues around the available data, which also helped with benchmarking. As a result, a lot of work was already done to help AWHP understand the budget and pressures. Similar work occurred around the care technology efficiencies and would be monitored through the savings and efficiencies programmes with partners.

 

25. The Chairman asked about how confident AWHP was that the transformation work was aligned with the Council’s guiding mission of ‘No One Left Behind’, and that SCC’s four equality objectives were being met. The Executive Director of AWHP explained that AWHP worked hard to ensure the transformation programme aligned with the corporate objectives and the vision of the Council. AWHP welcome check and challenge. AWHP was transforming and changing their model, how they delivered the care offer across Surrey, how they worked with colleagues such as in Public Health and those community-based to ensure the offer was not leaving people behind, outlining enablement and empowering people to live the best life as possible and that what this looks like will be modernised with a new approach.

 

RESOLVED:

1. It is recommended that strong and effective Risk Management is treated as a key requirement to ensure that Surrey's Adult Social Care Services remain sustainable while delivering the services needed by Surrey's residents.

 

2. It is recommended that Needs Assessment is appropriately resourced and robust as it is central to the reduction of costs and at the same time it is essential the weaknesses identified by the CQC are rectified.

 

3. A plan will be required within the next six months for review, to support the provision of Technology Enabled Care in areas where the provision of appropriate telecommunications services is weak or lacking.

 

4. It is recommended that there is investment in the tracking of spending.

 

Actions/requests for further information:

• More information to be provided for Cllr John Furey on how the cost of care packages could be reduced with an increasing population.

 

• AWHP to share the link to the Newton Europe report with reference to the work about working age adults and the national picture – and how SCC are implementing some of the best practice that was drawn out of this.

 

• A request was made for the committee to have sight of the paper in relation to telecare offers amongst District and Boroughs before it goes to Cabinet in January 2025, for review and comments.

 

The meeting adjourned at 11.51am

The meeting resumed at 12.06pm