Agenda item

To consider and comment on the Council’s draft 5 year (2018/19 to 2022/23) Medium Term Financial Strategy proposals relating to the Scrutiny Panel’s remit (Priority 2).

Cllr Bernice Vanier, Cabinet Member for Adult Social Care and Culture, introduced the report as set out and Marc Kidson, Transformation Strategy Manager, provided further information via presentation.

 

Mr Kidson commenced his presentation by providing an overview of the budget strategy for the services within Priority 2 (P2). It was noted this included all services managed by the Director of Adult Social Services and those adults-focused services managed by the Director of Public Health and the Assistant Director for Commissioning.

 

In terms of delivering the budget strategy, the Panel was informed that the actions below set out the primary levers for managing the main sources of financial pressures across P2:

 

-       Demand Management (preventing, reducing and delaying demand for social care), including:

o   Strengthening preventative support across the community

o   Diversion at the Community Front Door

o   Managing demand from acute hospitals

o   Managing transitions from Children and Young People’s Services

o   Expanding the use of assistive technology

o   Promoting independence through care planning and reviews

 

-       Market Management (commissioning packages of care that meet needs in the most cost-effective way), including: 

o   Improved information and access to community alternatives

o   Increasing the sufficiency and value for money of community-based provisions including Day Opportunities

o   Increasing the local availability and utilisation of a range of Supported Living Options

o   Strengthening the Homecare market, improving quality and outcomes

o   Containing the cost of residential and nursing placements by working across North Central London to develop capacity

o   Developing capital assets to deliver commissioning intentions

 

-       Operational Management (reducing the cost base for delivering Adult Social Services), including: 

o   Improving the resilience and permanence of the workforce

o   Strengthening management oversight and decision-making on performance and finance

o   Implementing operational integration with health and other local authorities

o   Establishing fairer contributions – income and subsidies

o   Revising contracts for services (non-care packages)

 

In response to questions, Mr Kidson provided information on the context for future savings. The Panel was informed that service improvements, invested in over the past 18 months, meant the Council was in a much stronger position to deliver savings through maximising independence of residents and service users during the next MTFS period. The improvements that had taken place across the following areas were considered by the Panel:

 

-       Service Redesign, including multi-disciplinary First Response

 

-       Established Brokerage Service, including issues in relation to income maximisation

 

-       Improved Reablement, including double the number of clients

 

-       The work of the Care Authorisation Panel to ensure asset-based support planning

 

-       The work that had taken place to build relationships with other North Central London boroughs

 

-       Issues in relation to health and care integration, including hospital discharge

 

In terms of the Council’s approach to savings, the Panel was informed that aside from £1m of unplanned expenditure on Osborne Grove, the pressure on the P2 budget during 2017/18 had predominately been from care purchasing across three main client groups. In part this was because of undelivered savings where proposals had tended to overstate what could be achieved, due to double-counting of effects across different interventions such as the use of Assistive Technology and Reviews.

 

In response to questions, the Panel was informed that there was no single action or transformation project that would take the required £2.4m out of the Adult Social Care spending in 2018/19. Instead, officers explained budget management plans had been developed to identify how the service and commissioning could deliver savings across each of the care purchasing budgets, informed by the over P2 budget strategy. 

 

Mr Kidson also provided the Panel with further information on strategic risks, demand growth trends, the estimated number of clients and care budget requirements for 2017/18 – 2022/23, and the estimated care budget requirements 2017/18 – 2022/23 by service area.

 

Before considering the savings proposals for P2, outlined on pages 51- 57 of the agenda, the Panel raised concerns about the limited financial information provided in the report. The Panel asked whether it was realistic to make additional savings when the demand for services was rising and asked for further information, for consideration by the Overview and Scrutiny Committee on 29 January 2018, on how savings would be made.

    

Maximising independence for Adults with Learning Disabilities

 

The Panel was informed that over five years, the Haringey Learning Disability Partnership, working jointly with Children's Services and with key partners such as the Clinical Commissioning Group and the London Borough of Islington, would implement a coherent strategy with the aim of bringing Haringey's demand and spending on adults with learning disabilities in line with Haringey’s statistical neighbours and limit growth in spending in line with population growth. It was highlighted that this would require the following actions:

 

-       Demand management

o   Improved Transitions from CYPS to ASC

o   Application of indicative needs bandings

o   Assistive Technology to reduce the need for live-in or double-handed care

o   Strengths-based assessment and support planning, with annual review

 

-       Market management

o   The need to develop larger supported living units for adults with learning disabilities

o   Deregistration of current residential providers

o   The need to avoid residential and facilitate step-downs from residential where VfM

o   Developing the market for Day Opportunities and Personal Assistants

o   Specialist brokerage capacity for Learning Disabilities care packages

o   Outcomes based commissioning from providers on Positive Behaviour Support

o   Joint commissioning of LD services with London Borough of Islington and across the NCL five boroughs 

 

-       Operational management

o   The need for workforce development on strengths-based assessment and support planning for workers and brokers

o   The need for operational alignment across CCG and Adult Social Care as part of implementing a pooled budget from 2018/19

o   Applying a 'top up' policy to enable choice of provision while containing cost to the council

 

During the discussion, the Panel was informed of the work that was taking place via the Care Authorisation Panel in Haringey. The Panel was informed that this model had been used effectively in Oxfordshire. In response to questions, officers advised there had been inconsistencies across service areas with different practitioners offering different services. As a result, all practitioners now had to work with the Council’s Brokerage Team to see whether value for money options had been explored, including community alternatives and assisted technology.

 

Maximising independence for Adults with Mental Health

 

The Panel was informed that over five years, Adult Social Care would work closely with Barnet, Enfield and Haringey Mental Health Trust, the Clinical Commissioning Group and communities in order to strengthen the prevention and 'enablement' pathways for mental health and to ensure the support provided minimises the long-run dependency of adults with mental health issues. For those whose needs required a social care intervention the Panel was advised that the Council would develop the market and look at new commissioning arrangements to improve value for money as well as promoting choice and control for the service user. It was highlighted that this would require the following actions:

 

-       Demand management

o   An 'Enablement' pathway, including Primary Care Mental Health Locality Hubs

o   The application of indicative needs banding

o   Increased take-up of Direct Payments by Mental Health clients

o   The use of strengths-based assessment and support planning, with annual reviews

 

-       Market management

o   The need to expand Supported Living units for adults with mental health needs

o   Deregistration of residential mental health providers to become Supported Living

o   The need to avoid residential and facilitate step-downs from residential where VfM

o   The need for specialist brokerage capacity for mental health care packages

o   Development of the Clarendon Recovery College provision

o   Joint commissioning of Mental Health services across the NCL five boroughs

 

-       Operational management

o   The need to address recruitment and retention challenges for Mental Health social workers

o   The need for workforce development on strengths-based assessment and support planning for workers and brokers

o   The need for operational alignment across BEH Mental Health Trust and Adult Social Care

o   Applying a 'top up' policy to enable choice of provision while containing cost to the council

 

During the discussion, a number of issues were raised in relation to the importance of transformation funding to ensure work in this area was a success. In response to questions about whether it was realistic to ask the BEH Mental Health Trust to deliver savings, the Panel was informed joint meetings were taking place, with the Trust, to look at ways to provide more community based support. It was noted that this was challenging due to the Trust delivering bed based support.   

 

Maximising independence for Adults needing Physical Support

 

The Panel was informed that over the next five years, Adult Social Care, working with the CCG, acute providers and primary care would seek to extend independence, choice and control for those with physical support needs and further strengthen the pathways that prevent, reduce and delay the need for social care. In response to questions, the Panel was advised that this would offset projected growth, particularly from the 76-85 cohort of older people with physical support needs. It was highlighted that this would require the following actions:

 

-       Demand management

o   The use of preventative equipment, adaptations and technology

o   Working with the CCG on admission avoidance, including falls

o   Targeted expansion of reablement, including for cases from community

o   The need to expand the Assistive Technology offer within reablement and long-term care

o   The use of Discharge to Assess, Out of Hospital services and intermediate care

 

In response to questions about the use of Discharge to Assess, the Panel was informed evidence from other boroughs had highlighted both the success and potential of the model.    

 

-       Market management

o   The need to develop a more outcomes-focused Homecare offer

o   The need to develop the market for Day Opportunities for older people

o   The need to target intermediate care provision and manage voids

o   The need to expand the provision of ExtraCare supported housing for older people

 

-       Operational management

o   Continued evaluation and review of BCF-funded services

o   Applying a 'top up' policy to enable choice of provision while containing cost to the council

o   Developing an integrated Occupational Health offer across acute, social and primary care

 

During the meeting both Mike Wilson, Director, and Sharon Grant, Chair, from Healthwatch Haringey contributed to the discussion, especially in relation to the proposal for Learning Disabilities. A number of issues were considered including the importance of advocacy provision to ensure service users and carers received the support and information they needed. A number of Members raised concerns that some families they had spoken to had not been aware of this support. In addition, issues relating to the impact of the Care Act on service provision, the importance of communication, sign posting and the use / appropriateness of new technology were discussed with Healthwatch.   

 

In addition to the areas above, a number of issues were considered in relation  to the London Living Wage and carer progression for care workers under the new model of home support being developed. In terms of day opportunities, the Panel suggested there could be a dementia hub is the east of the borough as feedback from clients highlighted some residents spent nearly 4 hours a day travelling to and from activities.     

 

The Chair concluded the discussion by thanking everyone for their contributions.

 

AGREED:

 

1.    That further financial and strategic information concerning the evidence base for the Learning Disability budget proposal, especially savings for 2018/19, be made available for consideration by OSC on 29 January before final budget scrutiny recommendations are made. Where possible, this information should be provided for the “mid-way” point.

 

2.    That further financial and strategic information concerning the evidence base for the Mental Health budget proposal, especially savings for 2018/19, be made available for consideration by OSC on 29 January before final budget scrutiny recommendations are made. Where possible, this information should be provided for the “mid-way” point.

 

3.    That further financial and strategic information concerning the evidence base for the Physical Support budget proposal, especially savings for 2018/19, be made available for consideration by OSC on 29 January before final budget scrutiny recommendations are made. Where possible, this information should be provided for the “mid-way” point.

 

4.    That further information on the risks associated with each of the budget proposals be made available for consideration by OSC on 29 January.

 

5.    That further information on the overspend on care packages be made available for consideration by OSC on 29 January.