Report to Executive Member for Adult and Community Services Proposals for the Future of Adult Social Care Services
21st July 2010
1. Introduction
10 2. Headline proposals
3. Detail of proposals
4. Appendices
a. Summary timeline
b. Summary of risks and controls
c. Analysis of likely impact
Page 1 of 42 20 1. Introduction
This report outlines proposals for the future of adult social care provision in Bolton.
Why is this being looked at? Adult social care is the single biggest controllable budget in the Council1, and although (as the diagram below shows2) Bolton performs well in comparative spend, the fact remains that without addressing issues of cost in social care the Council will not meet its overall savings targets. This requirement comes at the same time as we are implementing “Putting People First”, the national agenda to transform adult social care. This approach has been retained by the new Coalition government3. It seeks to extend 30 choice and control particularly through the extension of personal budgets – which further undermines the sustainability of our current service models. The final reason for considering a strategic overhaul of the Council’s approach to social care provision is the underlying overspend. This is caused by levels of demand at current cost exceeding annual budgets to the tune of £1.5+ million a year.
What is the current situation? Bolton has been externally assessed4 over many years as having some of the best care and support opportunities in England. It also does so at a competitive level of spend5;
Fig. 1 Comparison of spend – nearest neighbours
BOLTON
1 Schools spend is greater, but it is ringfenced spending and therefore the Council cannot effect reductions to the same extent 2 Data from www.auditcommission.gov.uk 3 A futher White Paper, based on these principles, is planned for 2011 4 http://www.cqc.org.uk/guidanceforprofessionals/adultsocialcare/inspection.cfm 5 Audit Commission Value for Money profiles (pub. April 2010) http://vfm.audit-commission.gov.uk P a g e 2 Page 2 of 42
Fig. 2 Comparison of spend – CIPFA comparable Councils
Total spend on ASC (per Council (CIPFA6 Comparator Group) head)
Medway Council £354.64
Bolton Metropolitan Borough Council £362.25
Doncaster Metropolitan Borough Council £367.92
City of Wakefield Metropolitan District Council £371.49
Stockton-on-Tees Borough Council £372.25
Wigan Council £381.56
Dudley Metropolitan Borough Council £385.32
Kirklees Metropolitan Council £391.55
Bury Metropolitan Borough Council £423.1
Coventry City Council £423.19
Rochdale Metropolitan Borough Council £424.76
St Helens Metropolitan Borough Council £438.13
Tameside Metropolitan Borough Council £449.21
Oldham Metropolitan Borough Council £457.63
Rotherham Metropolitan Borough Council £467.27
Walsall Metropolitan Borough Council £499.25
40 During 2009-10 the Council’s adult social care services had contact with 31,6887 people, with 9,0388 receiving services from us at any one time. This represents 5% of Bolton’s population. Most aspects of adult social care provision are means tested, so that those with the resources have to pay some or all or their care costs. “Self-funders” may be in
6 Chartered Institute for Public Finance and Accountancy – this is a list of Councils across the country who most closely match the demographics etc. of Bolton
7 RAP R Form 2009/10
8 RAP P1 Form 2009/10
P a g e 3 Page 3 of 42
direct contact with care providers and are not necessarily in touch with social care (although the Council will arrange and provide care for self funders).
At present our spend is roughly 50:50 between costs of in house front line care provision, and the amount spent on services “commissioned” from 300+ external organisations. Services are commissioned from small local charities through to national organisations, and including both private and voluntary sector providers. The Council has 50 a legal duty to make sure that care needs are assessed, and to then find an appropriate way to enable those needs to be met – whilst the first function is widely considered to be something that can only be provided by Council employed staff, the second is not.
What has been the approach to reducing cost?
Having used national data to benchmark current costs it is clear that Bolton Council has a comparatively strong track record in controlling demand through careful care planning and generally competitive rates for commissioned services. The more obvious area where comparative value for money is harder to prove is in the extent to which Bolton Council retains services in house, and the extent to which the unit costs of in house services compare to rates in the independent sector. This report therefore focuses on 60 moving away from being a direct service provider, as well as identifying any opportunistic efficiencies that can be made from better commissioning and improved service design.
This report is not a “done deal”, as can be seen from the fact that many proposals are about the Council agreeing in principle to change, rather than pre-determining what exactly this will involve, when and for who. The aim, however, is to make bold proposals to reduce costs whilst maintaining as much service as possible. Because of this it is a first document, designed to be consulted on, and for most of the proposals the intention is to come back to the Executive Member for decisions in the Autumn, after a structured programme of seeking the reactions of people who use services, staff, providers and partners.
70 Some of the cost reduction approaches will work for more than one area of service, but to make it easier for people who are supported by, or work in, a particular area, the report is grouped by services. The service areas looked at are:
I. Home Care II. Supported Housing III. Residential Care IV. Preventative services V. Day Services VI. Extra Care VII. Respite 80 As can be expected from a top-performing Council, it is about more than just the money. The report is underpinned by the core values of Adult Social Care in Bolton, ie wanting people to be able to say:
P a g e 4 Page 4 of 42
Fig.3 Transforming social care – our vision statements
It’s been quick and easy to find my way through the care and support system
I’ve been the one deciding what care and 90 support works for me – it’s been my choice
I’ve been able to find the right kind of care and support to meet my needs
For further information contact:
Transformation programme office, Le Mans Crescent, Bolton
01204 337 205 [email protected]
100
P a g e 5 Page 5 of 42
2. Headline proposals
These proposals are not a one-off exercise to reduce costs for a year – rather, they reposition social care in Bolton, in terms of both what is provided, and how it is provided. The detailed timetable behind these proposals projects a three year timescale for implementing all of these proposals.
The proposals are as follows: a) Home Care 110 1. To complete research work on an enhanced model for reablement, as a development of the current in house Home Support (reablement) service, to report back to the Executive Member by December 2010 2. To commence negotiations on interim 2011/12 rates for commissioned home care with a view to reducing overall levels of spend 3. To commence work to retender existing contracts for commissioned home care provision, with a view to commencing new contracts from June 2011 4. To cease making any new placements to the in house “Home Support (Mental Health) from November 2010 5. To invest grant funding in running at least three programmes in the next twelve 120 months to support local people in becoming trained as “personal assistants”
b) Supported Housing 1. To implement a range of measures to improve efficiency and reduce costs of in house services 2. To cease making any new placements to in house services from November 2010 other than in exceptional circumstances 3. To undertake research work to develop and introduce a new alternative model to complement the existing approach, to report back to the Executive Member in Autumn 2010 4. To commence work to outsource the in house service by competitive tendering 130 (to include retendering of existing external provision), subject to meeting our duty to provide best value, with a view to transfer of the undertaking by January 2012 c) Residential Care 1. To commence negotiations on what we pay for commissioned residential care from April 2011 with a view to reducing overall levels of spend d) Day Services 1. To commence a review of Day Services, working with service users and families to identify alternative provision, with a view to closing or replacing existing provision by March 2013. P a g e 6 Page 6 of 42
140 e) Preventative services 1. To cease all current contracts for befriending, advice, drop in, handyperson and lunch club services and replace with a grants scheme, funded at £250,000 lower than current provision (plus any reductions due to government withdrawls of grant)
f) Extra Care 1. To commence work to outsource the in house service by competitive tendering 2. To commence negotiations on our 2011/12 rates for commissioned extra care g) Respite 1. To retender currently commissioned older people’s block provision, to 150 complete and start new contracts by December 2011 2. To undertake research work to develop and introduce alternative models, to report back to the Executive Member by April 2011 3. To commence work to outsource the in house service by a method to be determined by April 2011 report back to Executive Member, with a view to transfer of the undertaking in 2012
P a g e 7 Page 7 of 42
3. Detail of proposals 3.a) Home Care 160 The proposals are: 1. To complete research work on an enhanced model for reablement, as a development of the current in house Home Support (reablement) service, to report back to the Executive Member by December 2010 2. To commence negotiations on interim 2011/12 rates for commissioned home care with a view to reducing overall levels of spend 3. To commence work to retender existing contracts for commissioned home care provision, with a view to commencing new contracts from June 2011 4. To cease making any new placements to the in house “Home Support (Mental Health) from November 2010 170 5. To invest grant funding in running at least three programmes in the next twelve months to support local people in becoming trained as “personal assistants”
3.a.1 The current size and costs of the service
Home care is the provision of personal care within the home, which can be defined as including the following:
“Personal Hygiene - Bathing, showering, hair washing, shaving, oral hygiene, nail care Continence Management - Toileting, catheter/stoma care, skin care, incontinence laundry, bed changing 180 Food and Diet - Assistance with eating and assistance with special diets. Assistance to manage different types of meal services. Assistance with preparation of food. Problems of immobility - Dealing with the consequences of not being able to move Simple treatments - Assistance with medication (including eye drops), application of creams and lotions, simple dressings Personal Assistance - Assistance with dressing, surgical appliances, prostheses, mechanical and manual aids. Assistance to get up and to go to bed. Transfers including use of a hoist.”
Bolton Council commissions support for 17099 people, from 14 main providers, a mix of local 190 and national companies. The average length of time people have been receiving the service is 11 months, and the average size of care package is 9.5 hours a week, although there are wide variations.
9 As at 30th June 2010, RAP return
P a g e 8 Page 8 of 42
Home care users are spread fairly evenly across population centres within Bolton – illustrating the fact that those who are potentially vulnerable/isolated and financially eligible for social care are not necessarily concentrated in deprived neighbourhoods (which can tend to be the focus of much community regeneration and cohesion work). 200 Fig. 4 Map of Home Care users
In addition the Council has a “first stop” in house “home support (reablement)” service, which provides free care for up to six weeks to “stabilise” all new packages of care. The other in house service is “home support (mental health)” which provides long terms support to a small number of people, largely with dementia.
The vast majority of home care is for older people, and the age profile10 is as follows:
10 All domicillary care users 2009-10, RAP return
P a g e 9 Page 9 of 42
Fig. 5 Age distribution of home care users
210
Overall the demand for home care within Bolton is predicted to rise by 35% between 2009/12 and 2013/14.
The Council has a budget of £6.5m for commissioned home care during 2010/11. The standard hourly rate for commissioned care is £12.51 per hour plus 60p a visit (we assume a maximum of two visits per hour). The average actual hourly rate we assume is therefore £13.71 per hour.
220 The cost structure for the two in house services is as follows:
Fig. 6 Costs of in house Home Support
REABLEMENT MENTAL HEALTH
FTE FTE
Operational 58.64 £1,475,881 66.56 £1,528,429 Staff
Admin (shared 3.55 £78,868 service)
Mileage £138,403
Staffing Total 58.64 £1,614,284 70.11 £1,818,566
Property Costs £19,707 £19,707
Non-Property £48,444 £35,313 Costs
Internal £408,060 £408,060 Recharges
P a g e 10 Page 10 of 42
Total £2,090,495 £2,281,646
3.a.2 The Proposals Explained
Proposal 1 - To complete research work on an enhanced model for reablement, as a development of the current in house Home Support (reablement) service, to report back to the Executive Member by December 2010 From February 2010 the Council has been running a redesigned service for Home Support (reablement) which replaced the Short Term Assessment Service (STAS). Early 230 indications are that this is delivering really significant reductions (projected as 30%)11 in the amount of long term care needed because intervention by Occupational Therapists and Home Support Workers is helping people to recover fitness and independence more quickly. The intention is to assess the potential for extending the therapist input and the prediction is that this will enable the reduction of spend on commissioned homecare by £800,000 over a full year. This is in line with Department of Health projections of the benefit of this approach. The research work will allow the identification of optimum model for a future service, and also the mapping of the impact this will then have on commissioned home care, and also 240 the existing workforce in the service. This proposal will have a positive impact on service users but will mean some changes in the skills mix in the team, and a reduction in business for independent home care providers.
Proposal 2 - To commence negotiations on interim 2011/12 rates for commissioned home care with a view to reducing overall levels of spend
The Council has a budget of £6.5m for commissioned home care during 2010/11. Comparison of rates has been undertaken across the regions12 as follows. (note that the structure of supplements is different in each Council, so comparison is difficult):
11 This service has been fully operational from February 2010 – this figure is therefore an early estimate, and it is too early to assess the longer term impact including how long it is before needs recur
12 Data collated by regional contract officers – best comparative data available. National comparators are skewed by high costs in South West and in rural areas.
P a g e 11 Page 11 of 42
Fig. 7 What it costs for Home Care – North West
250 It is reasonable to expect that any reductions in public funding have an impact throughout the supply chain, hence the proposal to negotiate with a view to reducing overall levels of spend. Rates were reduced as part of cost reductions in 2010/11. Implementation of this proposal would require a consultation period with providers, followed by notice working towards a start date of April 2011. It should be noted that this coincides with a potential reduction in numbers of hours of homecare being provided, because of the impact of the review of eligibility and the extension of re-ablement (above). It will also only apply until the retendering of homecare is complete, hence this will be an interim rate. 260 Proposal 3 - To commence work to retender existing contracts for commissioned home care provision, with a view to commencing new contracts from June 2011 Current provision was last comprehensively tendered in 2003, and a refresh of current arrangements is definitely due. This offers a number of opportunities: . To review hourly rates, particularly as retendering in other Greater Manchester Councils has now driven down the regional average rate, meaning Bolton now has a rate that is at the higher end of averages; . To introduce a new quality regime and less bureaucratic processes for awarding and monitoring work; 270 . To bring new providers into the Bolton market, and lose less effective ones; and . To update current “zoning” arrangements to reflect predicted future demand growth. Providers are aware that this is due, and are already involved in regular dialogue with Council Commissioners. This proposal will not affect Council staff, and TUPE implications eg of a move from one provider to another, will be managed as part of the process. This proposal is not subject to consultation, so the Executive Member is asked to approve the formal commencement of the retendering process.
P a g e 12 Page 12 of 42
280 Proposal 4 – To cease making any new placements to the in house “Home Support (Mental Health) from November 2010 The current Home Support (Mental Health) service was established in 2009 from the Elderly Mentally Ill (EMI) service. At this time the decision was to retain this service in house. The proposal is to cease making new placements and look to closure of in house provision over time as work gradually diminishes. This proposal is made now because: a) The external market has taken well to the delivery of very similar services, supported by training from the Council’s Care Workforce Development team, and shown capacity to deliver this service at same quality but with much reduced cost b) This is an area that will continue to expand according to current demographic 290 predictions. This means that we want to strengthen local market provision as the best value way of ensuring future needs can be met, and we want to attract and retain the best providers through having a critical mass of available work c) The financial position of the Council has worsened considerably meaning that we now face change in either what is provided or how it is provided – provision via well developed external alternatives means that the Council can continue to ensure quality services are available, but at lesser cost, rather than having to make straight cuts in services Satisfaction of users of the service (formerly the EMI service) was last measured in 2009 as part of the regular survey of home care users. This table shows satisfaction levels for the top 300 ten providers of home care in Bolton, which demonstrates that independent provision is capable of more than competing in terms of perceived quality:
Fig. 8 Satisfaction level with home care – top ten
In terms of staff in the current service the intention would not be to issue “at risk of redundancy” notices at this time because of this proposal, but to review staffing levels periodically (with first formal review in January 2011) and undergo formal consultation to reduce numbers because of falling demand only as and when this became necessary. Should staff numbers drop below current need during this period, then management would enter into discussions with staff and service users about the potential to move provision to an alternative provider. The intention is to take this as a measured approach over time, to 310 allow the existing external provision to “grow” to be fully ready to meet future need – reflecting the more complex needs of individuals within the scope of this service area.
P a g e 13 Page 13 of 42
Proposal 5 - To invest grant funding in running at least three programmes in the next twelve months to support local people in becoming trained as “personal assistants” Personal Assistants (PA) are used in this sense to refer to the direct employment of a care worker by a service user, particularly where that user has chosen to take their “personal budget” and arrange care direct with the PA. The PA is employed by the service user, rather than by an agency or by the Council, and will generally be paid more than if they were working for an agency. 320 This model of provision is particularly attractive to some service users, and supply tends to be limited, so it is recommended that targeted development programmes (based on our successful “Choose Care” programmes) are delivered three times in the coming year, targeted in deprived localities and encouraging local people to gain the skills to work in this relatively new type of role. It is not anticipated that this will have a significant savings return, but it will broaden choice and control. The current provision is funded from grant monies. These have been reduced following recent budget cuts, but this proposal can be funded from diversion of remaining monies.
P a g e 14 Page 14 of 42
330 3.b) Supported Housing
The proposals are: 1. To implement a range of measures to improve efficiency and reduce costs of in house services 2. To cease making any new placements to in house services from November 2010 other than in exceptional circumstances 3. To undertake research work to develop and introduce a new alternative model to complement the existing approach, to report back to the Executive Member in Autumn 2010 340 4. To commence work to outsource the in house service by competitive tendering (to include retendering of existing external provision), subject to meeting our duty to provide best value, with a view to transfer of the undertaking by January 2012
3.b.1 The current size and costs of the service
The “Supported Housing” service (also referred to as the “networks”) consists mainly of four and five bedroomed properties, owned by a variety of landlords, where service users are tenants, and for most service users the Council’s staff provide care and support. It differs from home care in that this is more intensive support (24/7) and staff will usually be working 350 at one property only. There are approximately 200 users (dependent on how we classify need) at any one time (27.5% in receipt of care and support from 5 independent sector providers), and the age distribution (as at June 2010), was as follows13:
Fig. 9 Age distribution, Supported Housing
18-64 81%
65-74 13%
75-84 5%
85+ 2%
The cost structure of the in house service is as follows:
13 Information from quarterly RAP return
Page 15 of 42 Fig. 10 Costs of in house service - excludes additional funding from Supporting People14
MENTAL HEALTH LEARNING DISABILITY NETWORK NETWORK
FTE FTE
Operational Staff 42.25 £1,289,163 279.94 £8,859,888
Admin £14,017 1.81 £36,608
Car £32,804 £23,259 Allowances/Mileage
Staffing Total £1,335,984 £8,919,755
Property Costs £37,336 £13,363
Non-Property Costs £13,662 £93,811
Internal Recharges £138,481 £426,651
Service Redirection -£211,664
Total £1,525,463 £9,241,91615
The geographical distribution of supported houses is shown below:
Fig. 11 Geographical distribution of supported housing
14 Subject to separate review – final proposals will recognise the impact of this once future funding decisions are clearer
15 Includes a resource transfer from NHS Bolton (dowry monies) which is due to come directly to the Council from 01/04/2011
Page 16 of 42 16 360 This continues to be an area of pressure due to growth, as increasing numbers of young people with high levels of support and dependency reach adulthood. For example, current projections show £2.246m of demand growth over 2010/11 and 2011/12 for 73 young people currently in transition from children’s services, with home based support being a major cost component. The alternative of taking a personal budget (via a direct payment) is attractive to this group, again, showing the demand for more choice and control.
3.b.2 The Proposals Explained Proposal 1 - To implement a range of measures to improve efficiency and reduce 370 costs of in house services a) Consult with staff on changing the working arrangements
. Review skills mix in teams Over time we have replaced Residential Support Workers (currently 127 full time equivalent staff) who have left with Community Support Workers (currently 158 full time equivalent staff), achieving a net saving each time of between £5,000 and £7,000 a year. Our proposal would be to investigate the potential for changing the skills mix between the two types of worker as part of our review of in house costs, to report back to Executive Member in Autumn 2010 with any 380 further proposals requiring political approval. Formal consultation with staff on any concrete proposals would start at this point, but we would look to start early discussions now.
. Work with staff to review current working patterns and structures
Page 17 of 42 17
Staff and management have a range of views on how the current rota arrangements work, bearing in mind the 24 hour care requirement and the skills mix etc.. Learning from previous work on implementing change (particularly the 2009 Review of Home Support) it is proposed that staff and management are 390 engaged in workshops over summer 2010 to identify their ideas, with anticipated issues including rotas for staff and managers, the differences between learning disability and mental health networks, staff travel, equipment, meals and the potential for different ways of working eg peripatetic teams. The intention would be to carry out initial assessment of the ideas generated by staff and return to the Executive Member in Autumn 2010 with any further proposals requiring political approval.
b) Improve the use of equipment/technology in supporting users 400 . As part of the “Review of Eligibility16” all care packages will be reviewed, personal budget allocation will be identified, and levels of need re-assessed. As part of this process within Supported Housing it is proposed that two further elements are included, to be assessed with Occupational Therapist support and training as required from within existing staffing: a. Implementation of improved telecare and careline support within properties, providing improved monitoring and response in case of emergencies and potentially reducing the need for staff presence eg during nights b. Replacing existing hoists with new models that are much safer for both users 410 and staff, and reduce the need for “doubling up” . Both of these options will require an additional investment up front, but will lead to a net reduction in numbers of staff required. Exact numbers cannot be safely predicted until the assessments have been completed, which is expected to take up to six months.
Proposal 2 - To cease new placements to properties where the Council provides care and support from November 2010 As our current in house costs are higher than external providers, and external providers offer a comparable level of specialisms the proposal is made to immediately stop making 420 placements that maintain existing in house provision. There are a range of specialist and more generalist providers of this type of support operating across the North West and keen to develop provision in Bolton. As part of managing the implications of this, the proposal is to use the existing system of “panel” review of cases to make sure that we are able to best respond to each change in the number of people in the service and in each property, and to make sure that we optimize use of resources. It should be noted that where properties are only partially occupied the Council can be liable for the cost (“voids”) so the issue of allocations needs to be dealt with on a case by case basis. The intention would be to limit placements to in house services pending a final decision in November 2010, in order to avoid potential disruption for service users 430 should proposals be approved, although this would not stop us from re-starting in house placements after November if the proposals are not approved. There are staffing implications, as over time this will mean fewer staff are required. This service area has been deliberately retaining vacancies for some time and the intention would
16 Also being reported to the Executive Member for Adult and Community Services on 21st July 2010
Page 18 of 42 18 be to protect permanent jobs in the first instance. Our understanding is that TUPE would not automatically apply in this circumstance (but may do in some cases) as each new package would be placed in any of a range of providers’ services, and we are also planning to extend early work to support users in these services to take up a “personal budget” and work, either individually or with like minded other service users, with a broker to find something that works for them, where they have greater choice and control over managing their care 440 package monies. In terms of staff in the current service the intention would not be to issue “at risk of redundancy” notices at this time because of this proposal, but to review staffing levels periodically (with first formal review in January 2011) and undergo formal consultation to reduce numbers because of falling demand only as and when this became necessary – this sits alongside proposals in the “review of eligibility17” to review all care packages and which may also reduce demand and therefore need for staff, and proposal 1 above. Should staff numbers drop below current need during this period, then management would enter into discussions with staff and service users about the potential to move provision to an alternative provider, relocating staff to suitable alternative properties as required. 450 Proposal 3 - Report back to the Executive Member in Autumn 2010 on potential alternative models for supported living The current model was originally introduced in 1985 following the move away from long term institutional care, which has been widely perceived as being demeaning and failing to provide adequate life chances. We now have an ageing population profile within this provision, and what is clear is that although the model was appropriate when set up over twenty five years ago, it no longer automatically meets the diverse needs of our service users now and in the future and comparability of funding between different groups of users is potentially open to challenge. 460 The potential is there to examine whether or not alternative models – for example something closer to the extra care model, something more like a complex of apartments, or something involving private builders (and potentially even using some funds towards property purchase) – hold the answer for some of our current and future service users. Although not necessarily leading to initial savings of any magnitude, it is important that at times of change we keep an eye on long term opportunities, so it is proposed that further research work is undertaken and reported back to Executive Member in the Autumn.
Proposal 4 - To commence work to outsource the in house service by competitive tendering (to include retendering of existing external provision) to transfer by January 470 2012 The proposals above will improve the comparative costs of in house services, maintain or improve customer service, and will also lead to a reduction in the staffing establishment. However, to remain as Council operated provision will leave Bolton as one of a minority in the North West who have predominantly in house provision for this type of service, which reflects the fact that there are well developed markets for providing this type of service, from organizations for whom it is their sole, specialist business, and who are able to deliver comparable or improved quality eg by being able to work more closely with private sector
17 Separate report to be considered by Executive Member for Adult and Community Services 21st July 2010
Page 19 of 42 19 building companies, working with innovative charities, or by involving specialist therapy staff who become commercially viable because of the bigger size and scope of the business etc.. 480 The growing impact of Personal Budgets also exposes the Council to additional risk, because individuals can at any point choose to withdraw from Council provision – unlike independent providers, the Council is not able to respond quickly to this loss of finance, and this in part accounts for the department’s £1.5+ million underlying overspend. It is anticipated that many staff working in the service at the time are likely to be eligible to transfer to the new provider(s), under TUPE18 regulations. The intention would be to engage and inform staff throughout the process of tendering and implementation. Because of this it is proposed that we consult on the intention to tender existing provision in 2011, following implementation of the proposals above, with a decision to proceed or not to be brought back to the Executive Member by December 2010. 490
18 Transfer of Undertakings (Protection of Employment). More information can be found at http://www.acas.org.uk/index.aspx?articleid=1655
Page 20 of 42 20
3.c) Residential Care
The proposals are: 1. To commence negotiations on what we pay for commissioned residential care from April 2011 with a view to reducing overall levels of spend
3.c.1 The current size and costs of the service
During 2009/2010 the Council spent just over £15 million commissioning residential care in 500 the independent sector. The projection is that we will purchase 839 residential care places for older people during the year 2010/11. The majority of provision is in Bolton, although there are out of borough placements. It is up to the individual to choose their preferred residential care home.
All residential care establishments in Bolton are assessed as being either “good” or “excellent”19.
The Council’s in house care homes are both rated as “good”. These provide specialist dementia care, an area of provision and skill which we have been consciously developing in recent years across the whole care sector, providing training and advice to providers who recognise the future growth in demand for this kind of support. The cost structure of 510 these in house services is as follows: Fig. 12 Cost of in house services
TOTAL
Operational Staff £1,659,876 (70.34 full time equivalent)
Car Allowances £635
Staffing Total £1,660,511
Property Costs £174,647
Non-Property Costs £101,774
Internal Recharges £206,569
19 www.cqc.org.uk
Page 21 of 42 21 Total £2,143,501
3.c.2 The Proposals Explained
Proposal 1 - To commence negotiations on what we pay for commissioned residential care from april 2011, with a view to reducing overall levels of spend
At £15m spend each year Residential Care is one of the biggest single elements of Council spend. It is reasonable to expect that any reductions in public funding have an 520 impact throughout the supply chain, hence the proposal to negotiate with a review to reducing overall levels of spend. Rates were reduced/restricted as part of cost reductions in 2010/11. Implementation of this proposal would require a consultation period with providers, followed by notice working towards a start date of April 2011.
Page 22 of 42 22
3.d) Day Services The proposals are: 1. To commence a review of Day Services, working with service users and 530 families to identify alternative provision, with a view to closing or replacing existing provision by March 2013.
3.d.1 The current size and costs of the service
“Day Services” is a term used to refer to both day services for people with disabilities, mental health issues and also day care for older people. The scope of the review is all of this provision.
A snapshot of numbers receiving services in June 2010 shows the following levels of users in each service20:
Fig. 14 - Day Service Provision
Service Number of users
Age Concern (commissioned – older adults) 15 users
Alderbank (older adults) 48 users (Intermediate Care Service with 365 days available per year)
Blackburn Road (disability) 17 places per day
Direct Payments 9
Falcon View (learning disability) 22 (23 places per day)
Harrowbys (disability) 13 (17 places per day)
Brazley (Horwich Day Care) (older people) 60 users
Brazley (Horwich Day Care) (disability) 82 users
20 It should be noted that there are significant variations in levels of attendance
Page 23 of 42 23 Jubilee (Physical Disability) 38 places per day Jubilee View (Learning Disability) 26 places per day
Market Street (learning disability) 15 (18 places per day)
Newport Street (learning disability) 30 (21 places per day)
Nugent Care (learning disability) 19
Hilton Suite (learning disability) 16 places per day
Thicketford (older adults) 74
Winnifred Kettle (older adults) 57 (Intermediate Care Service with 365 days available per year)
540
The geographical spread of current provision is shown below:
Fig. 15 Geographical spread of day services
As at June 2010 the age spread of service users was as follows:
Page 24 of 42 24
550 Fig. 16 Age distribution of day service users
The cost structure of the in house provision breaks down as follows:
Fig. 17 Cost structure – in house day services
LEARNING MENTAL OLDER ADULTS PHYSICAL DISABILITIES HEALTH DISABILITY
FTE FT FTE FT E E
Operational Staff 70.4 £1,703,28 6.2 £179,20 47.7 £1,041,31 21 £486,55 8 7 7 8 0 1 0
Admin 2.21 £46,282 0.3 £2,284 2.95 £69,052 2
Car £14,563 £1,183 £917 Allowances/Milea
Page 25 of 42 25 ge
Staffing Total £1,764,13 £182,67 £1,111,28 £486,55 2 5 0 0
Property Costs £187,791 £8,85721 £168,491 £57,782 22
Non-Property £61,248 £8,004 £123,082 £55,984 Costs
Transport £473,832 £342,448 £166,66 Recharges 7
Internal £143,879 £29,545 £211,781 £57,440 Recharges
Total £2,630,88 £229,08 £1,957,08 £824,42 2 1 2 3
3.d.2 The Proposals Explained
Proposal 1 - To commence a review of Day Services, working with service users and families to identify alternative provision, with a view to closing or replacing existing provision by March 2013 560 There are a number of reasons behind this proposal, as follows:
. There is a national and local trend away from this style of provision
. We are bearing increasing costs as users choose to take a Personal Budget rather than access this service – Personal Budgets it is the single biggest area of overspend in the department
. Creative use of Personal Budgets provides the opportunity to design bespoke packages of care and support that work for individual needs
. This will also release poor quality and costly buildings for more suitable alternative use
There is no simple alternative, as care and support needs will remain, but in order to meet 570 them effectively research is needed into the aspirations of service users and their families.
21 Halliwell drop in “57% of cost based on floor space calculation”
22 All cost “57% of cost based on floor space calculation”
Page 26 of 42 26 It is therefore proposed that a review team, to include a reference group of users and families, is set up to report back to the Executive Member by January 2011 with a programme for alternative provision and exit from existing service model by March 2013.
If, as is anticipated, there are significant changes to the current model then this will affect the number and types of staff required. Without having consulted meaningfully with service users it is not possible to assess how many staff will be affected – because the future model has not yet been designed. Staff will be involved throughout the process.
Page 27 of 42 27
580 3.e) Preventative services
The proposal is: To cease all current contracts for befriending, advice, drop in, handyperson and lunch club services and replace with a grants scheme, funded at £250,000 lower than current provision (plus any reductions due to government withdrawls of grant)
3.e.1 The current size and costs of the service
The table below summarises the current provision.
590 Fig. 18 Current preventative services
Service type Providers Total Value
Drop in, day centres, Afro Caribbean £10,2594 lunch clubs for older Elders adults Age Concern
Polish Day Centre
Active Ageing Age Concern £12,000
Befriending & visiting Age Concern £13,5713
Halliwell Befriending
Horwich Visiting
Westhoughton Visiting
Practical Support Age Concern £28,671
Resource Centre, Asian Elders £466,641 support services, advocacy general BAND (Mental Health)
Bolton Carers’ Support
Page 28 of 42 Bolton Social Centre for the Blind
GM West (Mental Health)
MHist
TOTAL £745,619
3.e.2 The Proposals Explained
There are a number of reasons behind this proposal:
. In order to meet the savings targets the department is required to look firstly at areas of non statutory spend, because of the amount of money committed to meeting statutory need – preventative services are non statutory
. Preventative work is seen as “a good thing”, but it can be harder to prove cause and effect – there is no guarantee that the Council is investing in services that have 600 the broadest appeal and with the greatest impact, albeit that they are undeniably highly prized by those involved with them
. Prevention is an area of potential double, triple etc funding as other organisations fund similar work. A detailed mapping and audit of preventative activity in Bolton is currently underway (to complete Summer 2010), jointly funded by the Council and NHS Bolton, and this will report during the consultation period
. At present we subject providers of preventative work – all of who are voluntary sector organisations – to formal Council contract tendering and management procedures. This potentially exceeds their capacity and skills
. We also define the services required within the Council – rather than working with 610 communities so that they can generate ideas that represent local energy (and therefore the potential volunteer capacity on which these projects depend). This can stifle innovation, and also tends to lead to repeat contracting for existing service types
Bolton has been assessed as “excellent” in our preventative work – something only a handful of Councils have achieved, and reflective of the comparatively high level of investment. In times of financial challenge this is inevitably an area for review.
Some preventative services are grant funded, and may also be affected by separate cuts to grants and removal of ringfencing – it makes sense to include these services in this exercise in order to maintain the opportunity for affected services to apply for alternative grant 620 funding.
The proposal, however, is not simply to cut funding, instead it is to:
Page 29 of 42 29 . Give notice to cease existing contracts from March 31st 2011 or as soon as is legally possible;
. Consult on and develop a grant scheme targeted specifically at social support and inclusion for vulnerable people, with funding reduced by £250k (plus any other impact of reductions in grant funding), to report back to Executive Member in October 2010
. Commence submissions in Autumn 2010, to be awarded by December 2010 with start date of 1st April 2011
630 It is proposed that the consultation covers the following issues:
. Processes for identifying need for preventative support
. Criteria for grant selection
. Frequency of awards
. Format for submissions including support available to potential bidders
. How decisions are made
. Proportionate monitoring / reporting / relationship management once the grant is given
. How this should link in to the wider funding for voluntary and community groups by the Council and its local strategic partner organisations
640 It is further proposed that the consultation includes the following activities:
. Policy Development Group, including the opportunity for expert witnesses as the Group sees fit
. Workshop event to include voluntary sector, Bolton Council, NHS Bolton, Greater Manchester West Mental Health Trust, Royal Bolton Hospital
. Desktop review of existing data on unmet need, and secondary research on the most effective preventative interventions from elsewhere
. Opportunity for members of the public to complete the questions on preventative services as part of the wider consultation on proposals for the future of social care provision.
650
Page 30 of 42 30
3.f) Extra Care
The proposals are: 1. To commence work to outsource the in house service by competitive tendering 2. To commence negotiations on our 2011/12 rates for commissioned extra care
3.f.1 The current size and costs of the service
660 “Extra Care” refers to housing schemes where a number of flats are within a building (owned by the Council or a housing association) where residents typically have a mix of care needs from lower level to higher levels of support being provided, with back up “telecare” to cover any emergency needs.
Fig. 19 Current Extra Care provision
Name of Scheme name Date scheme No of units provider started as extra care
Anchor Eden Lodge 2008 28
Anchor Kenyon Rise 2008 37
Anchor Rushey Fold 2007 29 Court
Anchor Thurstons 2007 28
Anchor Whitecroft 2007 37
Adult Services Merton 32
Adult Services Eldon St 31
Adult Services Campbell House 24
Adult Services Maxton House 39
Places for Manor Gardens 2009 36 People
Total 322
The total budget for 2010/11 for in house provision is £1,199,246 for 127 places ie average of £9,518 per place (although there is a broad range of actual levels of care Page 31 of 42 provided). The total budget for 2010/11 commissioned provision is £645,031 for 195 places ie £3,308 per place. This is slightly skewed because the in house provision is is 670 older, meaning the age profile of residents is also older and therefore on average more care is needed, though not sufficient to account for the difference in costs.
The Council has a mix of in house and commissioned service, with a big difference in unit cost (ie cost per hour of commissioned care). The cost differential is made worse because the Council is liable for costs where a unit remains empty over a certain period of time (“voids”).
The cost structure of the in house services is as follows:
Fig.20 Costs of in house Extra Care
EXTRA CARE HOUSING
FTE
Operational Staff 38.06 £986,262
Car Allowances/Mileage £3,222
Staffing Total £989,484
Property Costs £56,360
Non-Property Costs £12,682
Internal Recharges £140,720
Total £1,199,246
3.f.2 The Proposals Explained
680 Proposal 1 - To commence work to outsource the in house service by competitive tendering
Extra Care is an example of very marked differentials in unit cost between Council provided and commissioned services, without any demonstrable differences in quality. Because of the contractual arrangements with the providers of the housing element for in house schemes the Council becomes liable for the payment of any “void” costs where properties become empty, which makes the option of gradually reducing service size through not taking on new entrants is not financially tenable. Whilst there may be potential efficiencies achievable, the high cost of in house services limits the amount of likely potential interest. The detailed project plan includes an element of 690 “soft market testing” and it may be necessary to return to members with alternative Page 32 of 42 32 proposals if it becomes clear that this proposal is not financially viable due to lack of market interest. It is anticipated that staff working in the service at the time are likely to be eligible to transfer to the new provider(s), under TUPE23 regulations. The intention would be to engage and inform staff throughout the process of tendering and implementation. Because of this it is proposed that we consult on the intention to tender existing provision in 2011, following implementation of the proposals above, with a decision to proceed or not to be brought back to the Executive Member by December 2010.
700
Proposal 2 - To commence negotiations on our 2011/12 rates for commissioned extra care
At present the Council pays a total of £1,844,277 per year for Extra Care. It is reasonable to expect that any reductions in public funding have an impact throughout the supply chain, hence the proposal to negotiate with a review to reducing overall levels of spend. This would be the second year in a row that the Council has restricted rates paid to providers of extra care. Implementation of this proposal would require a consultation period with providers, followed 710 by notice working towards a start date of April 2011.
23 Transfer of Undertakings (Protection of Employment). More information can be found at http://www.acas.org.uk/index.aspx?articleid=1655
Page 33 of 42 33 3.g) Respite The proposals are: 1. To retender currently older people’s block commissioned provision, to complete and start new contracts by December 2011 2. To undertake research work to develop and introduce alternative models, to report back to the Executive Member by April 2011 3. To commence work to outsource the in house service by a method to be determined by April 2011 report back to Executive Member, with a view to 720 transfer of the undertaking in 2012
3.g.1 The current size and costs of the service
Respite or short breaks24 are very important in supporting carers, and many carers report that they enable them to keep going, and providing the vital support that means that there is less overall pressure on social care budgets. It is therefore a cost effective form of expenditure.
Costs and volumes of respite are not always clear, as what is recorded is, for example, a stay in residential care which may be for any number of reasons. Budgeted expenditure specifically for respite in 2010/11 is £252,000, although it is likely that actual spend exceeds 730 this. Respite is also provided within the Council run residential care properties.
3.g.2 The Proposals Explained
Proposal 1 - To retender currently commissioned provision for Older People, to complete and start new contracts by December 2011
At present there is a mix of in house, spot purchased and block contract provision for Respite. With the potential variation in demand because of eligibility review and take up of Personal Budgets, and the need to ensure similar contracts are reviewed together (as most efficient approach to procurement) it is recommended that existing provision is retendered, commencing late 2010 to complete by end of 2011. This will affect current 740 providers.
Proposal 2 - To undertake research work to develop and introduce alternative models, to report back to the Executive Member by April 2011 Respite is a vital part of the picture of social care because it enables carers and users to carry on, but its form is less set than for other areas of care. Because of this it is suggested that the period of consultation on the wider proposals is also used as an opportunity to gather ideas for future design, to then be researched and reported back to
24 Note that this tends to be described differently dependent on the service area
Page 34 of 42 34 Members in December 2010. Although not a savings option, it is a necessary dependent piece of work for other services to be redesigned. 750 Proposal 3 - To commence work to outsource the in house service by a method to be determined by April 2011 report back to Executive Member, with a view to transfer of the undertaking in 2012
Although not a large area of service, it is one that is likely to continue to decline in its current format, and the in house provision struggles to demonstrate best value compared to independent sector provision. It is therefore proposed that this be included as a project in the later stages of transforming social care provision, with a report containing options to return to Executive Member in April 2011. Overtime this will affect staff, with those in the service at the time potentially subject to a TUPE25 transfer to a new provider.
760
Caveat on data
This report has been informed by analysis of existing data, which was not necessarily collected for this purpose. A separate project is happening in the department which is drawing together information on performance and spend in order to harmonise how data is collected and recorded. Any requests for data during consultation period will be accompanied by this caveat, as there are minor variances in categorisation eg where users access multiple services, in apportioning costs etc., and these will be explained as needed. These may cause minor discrepancies, but do not affect the fundamentals of the proposals which are to change the amount and nature of adult social care provided in 770 Bolton.
APPENDICES
a. Timeline
b. Risks and Controls
c. Impact
25 Transfer of Undertaking (Protection of Employment)
Page 35 of 42 35
Appendix A – Timeline
MAY JUNE JULY AUGUST SEPTEMBER OCTOBER Reports prepared on options
Options reports briefings:
- Executive Membership
- Opposition Leaders
- Senior Management
- Joint Consultation Committee
- Press Briefing
Options Review and Approval –
Executive Membership Consultation on options with Staff
Consultation on options with Partners
Consultation on options with Providers
Executive Membership – Final Decision
Commence retendering of home care
Page 36 of 42
Appendix B – Risks and Controls
780
This table summarises the headline risks. More detailed risk and control registers are part of each project listed in Appendix C. More detailed Equality Impact Assessments are available from the programme office, telephone 01204 337 205 or email [email protected]
Risk Control
Inability of independent sector to deliver Quality workstream in all projects. Quality provision of high enough quality at low requirements built into contracts. Training enough cost – compromising quality of care provision continues for independent sector. Contract inspection continues to improve. Complaints system actively promoted so we have “early warning” of any issues
Negative impact to staff has a detrimental Consistency of messages, involvement of effect of the workplace – compromising trade unions and staff, easily accessible quality of care information on proposals, genuinely listening to staff concerns
Service failures due to level of change / Working at a reasonable pace, so providers reduced base eg homecare, meaning can plan ahead. Well written contingency providers cannot continue plans, tested and publicised.
Demand growth is so great that the Close monitoring of performance and spend department cannot achieve cost reduction – if necessary revisiting savings projections targets – in effect cancelling out savings being made
Lack of earlier intervention and preventative Grants scheme to require evidence of “return services accumulates into reduced on investment” ie making sure money spent quality/quantity of life delivers a positive impact
Page 37 of 42
Appendix C – Impact
PROPOSAL HOW IT WILL BE LIKELY IMPACT MANAGED26
Home Care K. Enhance Re-Ablement To complete research work on Users – improved independence and confidence Service an enhanced model for reablement, as a development of Staff – some changes to roles and skills mix the current in house Home Providers – reductions in the volume of commissioned Support (reablement) service, to homecare report back to the Executive Member by December 2010
To commence negotiations on O. 2011-2012 Contract Users – none specific interim 2011/12 rates for Negotiations commissioned home care with a Staff – none specific view to reducing overall levels of Providers – affects cost model spend G. Re-Tender External To commence work to retender Users – potential change of provider Homecare existing contracts for Staff – none specific commissioned home care provision, with a view to Providers – potential loss or gain of work depending on commencing new contracts from success in tendering. Work required to put in tender. June 2011 L. Set-Up Interim Demand To cease making any new Users – in house option no longer available Management Systems
26 Refers to the departmental project which will work on this proposal. Each project has a detailed project plan, project team and supporting work
Page 38 of 42 placements to the in house Staff – reduction over time of numbers of staff
“Home Support (Mental Health) from November 2010, and to Providers – opportunity for business growth if providers meet discuss the best options for the the standards for specialist dementia care future with each resident (and families where appropriate), with a view to the eventual closure of this service B. Personal Assistant To invest grant funding in Users – greater choice Development Programme running at least three programmes in the next twelve Staff – may wish to become Personal Assistant months to support local people Providers – competition from an alternative model in becoming trained as “personal assistants”
Supported Housing A. Reduce Costs of In-House To implement a range of Users – greater independence where use of equipment is A1. Re-design in-house measures to improve efficiency A2. Use of assistive extended. May mean change in care arrangements. and reduce costs of in house technology Staff – likely to lead to a reduction in staff numbers services Providers – potential to reduce service cost in commissioned provision via use of technology L. Set-Up Interim Demand To cease making any new Users – in house option no longer available Management Systems placements to in house services Staff – reduction over time of numbers of staff from November 2010 other than in exceptional circumstances Providers – opportunity for business growth H. Develop Alternative Models To undertake research work to Users – greater choice and control for Supported Housing and develop and introduce a new Extra Care alternative model to complement Staff – depends on models to be piloted the existing approach, to report Page 39 of 42 39 back to the Executive Member in Providers – potential to develop new lines of business
Autumn 2010 D. Outsource / Re-Tender To commence work to outsource Users – change in care provider Supported Housing the in house service by Staff – potential transfer or (if service design changes) loss of competitive tendering (to include jobs retendering of existing Providers – business opportunity. Time taken to submit bid. provision), subject to meeting our duty to provide best value, with a view to transfer of the undertaking by January 2012
Residential Care
To commence negotiations on O. 2011-2012 Contract Users – none specific what we pay for commissioned Negotiations Staff – none specific residential care from April 2011 with a view to reducing overall Providers – affects the cost model levels of spend
Day Services
To commence a review of Day N. Review of Day-Care and Users – change of service type – potentially greater choice and Services, working with service Day Services control users and families to identify alternative provision, with a view Staff – potential for reduction in numbers of jobs, different to closing or replacing existing types of jobs, may include TUPE transfer depending on nature provision by March 2013. of services redesigned Providers – potential business opportunities NOTE – this also has an impact on Vulnerable People’s
Page 40 of 42 40 Transport (Council’s Environmental Services Department)
Preventative services To cease all current contracts for F. Replace Preventative Users – less spend may mean less service, although the befriending, advice, drop in, Contracts with Grant Scheme opportunity to apply for grants should lead to imaginative ideas handyperson and lunch club making best use of local energies services and replace with a Staff – none specific grants scheme, funded at £250,000 lower than current Providers – opportunity for community and voluntary sector provision (plus any reductions due to government withdrawls of grant)
Extra Care A. Reduce Costs of In-House To commence work to outsource Users – change in care provider A1. Re-design in-house the in house service by A2. Use of assistive Staff – potential transfer or (if service design changes) loss of competitive tendering technology jobs
C. Outsource / Re-Tender Providers – business opportunity. Time taken to submit bid. Extra Care
H. Develop Alternative Models for Supported Housing and Extra Care
To commence negotiations on O. 2011-2012 Contract Users – none specific 2011/12 rates for commissioned Negotiations Staff – none specific
Page 41 of 42 41 extra care Providers – affects the cost model
Respite J. Re-Tender & Block Bed To retender currently Users – potential change of provider Respite commissioned provision, to Staff – none specific complete and start new contracts by December 2011 Providers – Business opportunity. Time taken to submit bid.
I. Develop Alternative Models To undertake research work to Users – greater choice and control for Respite / Short Term develop and introduce Breaks Staff – depends on models to be piloted alternative models, to report back to the Executive Member by Providers – potential to develop new lines of business April 2011 J. Re-Tender & Block Bed To commence work to outsource Users – change in care provider Respite the in house service by a method Staff – potential transfer or (if service design changes) loss of to be determined by April 2011 jobs report back to Executive Providers – business opportunity. Time taken to submit bid. Member, with a view to transfer of the undertaking in 2012
Page 42 of 42 42