BRIEFING PAPER: SUSTAINABILITY, DELIVERABILITY & IMPLEMENTATION
PORTFOLIO: HEALTH & ADULT CARE AND PUBLIC HEALTH
How have the impact of current year (2012/13) activity levels and budget variances (under and overspends) been reflected in proposals for 2013/14 and beyond?
Demography pressures are factored into Health and Community Services’ budget proposals annually and are based on national population forecasting tools for older people and people with physical disabilities – and on a detailed list of named individuals and anticipated care costs for people with learning disabilities. All projections are compared with trends from previous years and any current projected budget variance.
Benchmarking information has shown Hertfordshire has higher numbers of care placements annually for all care groups. All care groups, therefore, have an efficiency relating to keeping younger people at home with parents or in suitable independent accommodation as their needs dictate – or keeping older people in their own home with community based services. This manifests itself in challenging targets for permanent admissions into residential care and in targets to bring people who live in expensive out of county residential care placements back to Hertfordshire into supported living accommodation tenancies.
Despite the department projecting an underspend as a whole for 2012/13, there are underlying overspends against care purchasing budgets specifically on older people’s homecare and higher numbers of older people placed by the Council in care homes. There has also been a significant increase in the numbers of older people who were former self-funders turning to the Local Authority for care funding when their savings and capital have reduced below national thresholds.
How is the budget going to be delivered? Are action plans in place and responsibilities identified?
All projects within HCS’ integrated plan proposals are already well advanced and budgets will be set at new reduced levels from April 2013 and be implemented on schedule to deliver these savings either before or in-year as profiled:
A programme within the learning disabilities service to reduce the cost of current placements, move people back into Hertfordshire from more expensive out of county placements – and reduce the average cost of new placements - is now established, has achieved planned savings for 2012/13 and will continue to be monitored by HCS Management Board and commissioners next year.
Performance targets to reduce the number of older people placed permanently in care homes every year has been in place for three years. Specialist Mental Health Teams for Older People who assessed people with dementia have now been transferred back to HCC and will deliver savings against reduced residential care placements and more enablement homecare.
All projects and programmes have identified lead officers and are monitored through a fortnightly Service Improvement Board and through the quarterly performance report and budget monitor.
Is the budget sustainable in the medium-term?
The Dilnot Commission, which reported in June 2011, acknowledged that the adult social care system and the way it is currently funded is not sustainable in the long-term. Dilnot proposed some solutions to respond to some people with capital assets having to sell their homes to fund their stay in residential care home settings. The Government is still considering its response to Dilnot but is committed to implementing it in some form.
Dilnot’s proposals do not however, propose any solution to the national demographic issue of the growing ageing population, the increases in complexity of people’s eligible social care needs - and families’ expectations for social care. This has placed tremendous pressures on council budgets; in Hertfordshire the social care demography pressures amount to between £9-10m per annum with no plateau for these costs in sight. Some additional health monies were provided to fund one year of demography in 2011/12, recurrent in 2012/13 and an additional £4.8m has been provided for 2013/14 on condition that this is used to integrate services more with health.
Nationally, the next Comprehensive Spending Review will take place in the first half of 2013 for budgets from 2015/16 onwards and will consider the pressures on adult social care.
A specific programme has been initiated to take forward a number of projects to reduce the average cost of new care packages for people with learning disabilities. This will be achieved through the commissioning of new more cost effective services and different models of supported living. A new business case on rolling out more Telecare devices in the County will also be developed and implemented in 2013/14 to prevent more people requiring health and social care services at home.
What is the reliance on one-off funding / reserves / government grants etc?
For the last three financial years, specific monies have been provided by the Department of Health via Primary Care Trusts to local authorities. Agreement was reached with the PCT to spend this money on new initiatives which benefit both health and social care – including enablement homecare, more enablement beds, weekend working for hospital social workers and provision for costs falling on social care attributable to faster hospital discharges. These are non-recurrent monies and all schemes can be either ended or a business case drawn up to continue them with existing budgets. This was approximately £2M in each year for Hertfordshire.
Significant additional grant money has also been provided for four years from 2011/12 – 2014/15 via PCTs to fund pressures within the social care system. This amounted to around £10M for Hertfordshire for the first two years and effectively funded one year’s worth of demographic pressures on adult social care (or reduced the savings requirement). This has increased to £14.8m for the final two years. It is expected in the White Paper that implementation costs are met for two years and progress is made on integration between health and social care. Of the £50m provided by Health over the four years, demographic pressures actual cost is estimated at £100m in Hertfordshire.
What reliance is there on partners / suppliers to deliver change?
The Director of HCS meets regularly with the Chief Executive and Chair or Hertfordshire Care Provider’s Association, which represents several hundred private, independent and voluntary sector care providers in the County. This is a frank two-way communication mechanism to relay messages from the County Council or from new national policy to care providers and pass back concerns or issues from the provider side. Issues around finance, commissioning intentions, quality, learning and development, new initiatives and care regulation are discussed. Given that approximately £350m of HCS’ gross budget is spent in the private and independent sector, care providers must provide new ways of delivering care and be aware of schemes which can make people more independent – even within care home or supported living settings.
Joint commissioning arrangements between NHS Hertfordshire and HCC for equipment and adaptations, voluntary sector services, services for family carers, learning disability services, mental health and drug and alcohol services are hosted by the County Council and include pooled budgets and contractual agreements with health trusts. HCS values joint working with heath partners and has developed early arrangements with Clinical Commissioning Groups in response to the draft Health and Social Care Bill.
The Hertfordshire Safeguarding Adults Board (HSAB) is the multi-agency strategic group which represents the Council, Health, Herts Constabulary and other key stakeholders to improve the visibility and action relating to adult safeguarding in Hertfordshire. All partners have signed up to a compact in 2012 stating how their agency will prioritise safeguarding vulnerable adults from abuse.
What impact have new contracts that started in 2012/13 - highways, property etc. – had on your IP proposals?
No major contracts were awarded during 2012/13 and none are due to be awarded in 2013/14, although we expect an improvement to recruitment processes for in-house care services with the new Carlyle Solutions contract for temporary recruitment and in-house arrangements for permanent vacancies.
All contracts with HCS are under scrutiny to ensure they deliver value for money and any mutually agreeable savings which can be made occur with the agreement of the provider and an efficiency offered up the following year.
A variation to the Shared Managed Services contract with Serco was made in April 2012 to operate the new Social Care Access Service and make the associated £3.5m efficiency savings. This has worked well and performance indicators and activity is delivering at agreed levels with increased customer satisfaction.
With the lead for customer services, HCS continues to explore all opportunities to improve efficiency through the Serco Shared Managed Services contract and strives to use the internet more for transactions, information and advice,
Has the impact of the economic situation been considered? i.e. levels of demand, inflation, charging income etc.
Hertfordshire Care Provider’s Association presented data to the Council on the inflationary pressures being faced by care homes and homecare providers including on cost of living / staffing, water and utilities and food. These have been taken into account and it is proposed that the care purchasing budgets which pay these providers are treated like internal council budgets – with no provision for a staff pay increase but with some recognition of other inflationary increases and new pension regulations. Providers who accept the Council’s standard fees (mainly older people’s care homes and homecare agencies) would receive a small inflationary increase of 1% for care homes and 0.5% for homecare with an additional 0.5% for homecare associated with performance against a quality matrix.
Although above-inflation fee uplifts were justified in 2009/10 to some of the market, a zero percent uplift was mandated in 2010/11, a minimal uplift of 0.5% provided for 2011/12 and up to 1.5% in 2012/13. We have worked closely with Hertfordshire Care Provider’s Association to measure any cost increases and ensure that the care market remains viable and costs can be contained to meet the efficiency saving. We will work with any care provider who can demonstrate that their business is no longer viable due to cost pressures.
Income budgets in 2012/13 have generally performed well – both for residential and non-residential care. People who already live in care homes who fund themselves and whose savings subsequently fall below the national threshold for assistance from the Council continues to be a significant financial pressure; an additional pressure has been lodged in HCS’ budget for 2013/14 to meet this rising cost.
What are the other risks/uncertainties associated with the budget? How are they being mitigated?
There is a risk within the budget that increased demand for care services exceeds the demography calculations within the standstill budget. This is managed through strict application of the eligibility criteria, regular budget and activity monitoring, and care reviews of existing packages to ensure value for money and appropriate care provision.
A further uncertainty has been flagged around new welfare reforms which could both negatively impact the amount of income the Council collects from people receiving care services – but also increase the number of people presenting with eligible care needs because they or their families can no longer afford to support them at home.
Have any impacts on public health (positive or negative) been considered (e.g. cutting budgets on footpaths or cycle routes)?
Many of HCS’ efficiency savings are based on improving people’s independence through better rehabilitation or enablement services, thus reducing their reliance on care and support. Public Health colleagues are committed to working with commissioners to ensure the benefits of these projects are monitored, analysed and demonstrated to cost less whilst improving people’s health and wellbeing.
PORTFOLIO: HERTFORDSHIRE LOCAL & LIBRARIES
How has the impact of current year (2012/13) activity levels and budget variances (pressures) been reflected in proposals for 2013/14 and beyond?
Hertfordshire libraries have not been affected by budget pressures or significant changes in activity levels during 2012/13 which warrant action to be taken in respect of the 2013/14 budget. Income levels have actually increased through more innovative marketing and sales of stock and so the financial pressure around reduced library income has been removed (thus improving the Council’s financial position).
How is the budget going to be delivered? Are action plans in place and responsibilities identified?
The fundamental review of library staffing is advanced and changes will be put in place to reduce overall levels of staffing and associated budgets to achieve the £400k saving.
Is the budget sustainable in the medium-term?
A view will need to be taken in due course about the future of the public library service as it is currently configured. This will be needed when the full impact of the next Comprehensive Spending Review is known and the reduction in the County Council’s budget and ability to perform its statutory duties is assessed. The library budget, policy and communications budgets are sustainable at current activity and performance levels otherwise.
What is the reliance on one-off funding/reserves/government grants?
No grants or one-off funding are used for the revenue budgets of the library service or policy functions.
The Hertfordshire Family and Adult Learning Service is fully funded by a government grant to deliver learning to adults. The service operates and commissions courses within the budget allocated by the Government and targets these to provide maximum impact for Hertfordshire citizens, including those from minority or disadvantaged groups.
How do proposals contribute to CO2 reduction / increased recycling?
Hertfordshire libraries plays their part in reducing the County Council’s carbon footprint through repairs and maintenance to its estate, best practice in any new buildings provided with partners, in maximising the efficiency of its logistical routes and through responsible disposal of its stock when it has reached the end of its useful life.
What reliance is there on partners/suppliers to deliver change?
Localism continues to be a priority in the new Corporate Plan through continued working with partners for example, police, health, and town and parish councils. There will be a new intake of Members post election in May, with a Member induction programme which will place Localism at the heart. There will also be ongoing training and development for our elected Members.
As previously mentioned, due to the shortage of capital any new library schemes will have to be developed in collaboration with partners and evaluations of current projects will be important to learn lessons and maximise opportunities for the public library service as new schemes appear.
What impact have new contracts started in 2012 – highways, property etc had on your IP proposals?
Not applicable to libraries, HAFLS or localism.
Has the impact of the economic situation been considered? Ie levels of demand, inflation, charging income etc
Demand, library membership, library book issues and subscriptions to events and voluntary schemes are reviewed annually to ensure that the public library service is delivering optimally for the budget it receives. The review of library staffing will make further savings whilst not negatively affecting customer service in libraries.
Library charges are reviewed annually and compared with other local authorities and with stakeholder groups to ensure they are affordable and reasonable in the current climate.
What are the other risks/uncertainties associated with the budget? How are they being mitigated?
An uncertainty around library income is stated in the budget – relating to whether income from the hire of DVDs and talking books can be sustained at current levels given citizen’s access to new technology through iTunes, on-demand films at home and cheap deals from the internet. The trend of decreasing income was bucked last year and every effort will be made to continue this.
Have any impacts on public health (positive or negative) been considered (eg. Cutting budgets on footpaths or cycle routes)?
Public Health colleagues have already made contact with Library and Heritage Services and Hertfordshire Adult and Family Learning Service to find areas of mutual interest and exploit national evidence for improving people’s wellbeing through better sign-posting, information and advice, and healthy living schemes run through public facing services.
PORTFOLIO: ENVIRONMENT & COMMUNITY SAFETY
ENVIRONMENT