APPENDIX 5
Memorandum by Cambridgeshire County Council
(DD 8)
1. INTRODUCTION
1.1 This submission is from Cambridgeshire
County Council and is intended to give the Select Committee evidence
about the circumstances in Cambridgeshire that have a direct bearing
on the issue of delayed discharges in the local area and that
resonate with experiences in many other areas of the country.
The local experience has given clear indications of the ways in
which both central government, the NHS and local government needs
to respond in order to address the issue.
2. BACKGROUND
2.1 Residents of Cambridgeshire rely on
a number of hospitals for general health services. The main providers
are Hinchingbrooke Hospital and Addenbrookes Hospital but hospitals
in Peterborough and Kings Lynn also provide district general hospital
services for Cambridgeshire residents. The problem of delayed
discharges has been significant for Cambridgeshire residents admitted
to all of these hospitals but has been particularly significant
for residents using Addenbrookes and Hinchingbrooke. The level
of delayed discharges across the area covered by the County Council
has been well above national averages for many years and has been
subject to rigorous reduction targets for the past three years.
The area is one of the 55 "hot spots" identified for
preferential funding from the recent Building Capacity Grant introduced
in November 2001 by the Department of Health.
3. LOCAL RESPONSES
3.1 These have been in the mainstream of
recommended activity and have included:
— Agreement between the Council and
the NHS on reduction targets—set at 20 per cent in 1999
and 2000 (and achieved); set at 25 per cent in 2001 but not achieved
despite additional investment.
— Investment in intermediate care.
A strategic decision was made by the Council and local NHS partners
to invest in services that would both prevent hospital admissions
and promote the recovery of independence in non-acute settings.
The level of local investment has been well above the amounts
granted by government in ear marked funds.
— Close co-operative working between
the Council and local NHS partners. This has resulted in many
jointly provided services.
4. LOCAL CONSTRAINTS
4.1 The constraints on the Council in responding
to delayed discharges have included:
— Rapid deterioration in the ability
of home care agencies to compete in the employment market and
recruit sufficient care staff. During 2000 vacancy levels across
the sector in Cambridge City, where the problem has been most
acute, were at 40 per cent. Three major providers with whom the
Council held contracts ceased to trade, unable to cope in this
environment. On 18 January 2002 there were 104 people in the south
of the County awaiting the provision of home care. Priority is
given to those being discharged from hospital but this in turn
impacts on the capacity of the service to support those who are
at risk of admission to hospital.
— Shortage of nursing home places in
Cambridge and of residential places in Huntingdonshire. In situations
where Cambridgeshire residents can fund their own care, services
are not always available.
4.2 These constraints have arisen for a
variety of reasons. The main ones are explored below.
5. THE LOCAL
ECONOMY
5.1 The area has high levels of employment,
particularly in the south of the County.
5.2 The New Earnings Survey published in
2001 showed that between 1996 and 2000 Cambridgeshire experienced
the second highest rise (nearly 25 per cent increase) in gross
weekly earnings of any English County. (see graph in Appendix
I). Average earnings in Cambridgeshire, at £426 per week,
are above those in some other South Eastern counties that qualify
for the Area Cost Adjustment Allowance—the government grant
intended to assist high cost areas (see Appendix II). Cambridgeshire
does not qualify for this allowance. This compounds the problem
of the low Standard Spending Assessment (see Appendix III).
5.3 House prices in the area are also high
(see Appendix IV)—higher than those in some other areas
that receive Area Cost Adjustment. In Cambridge City house prices
are amongst the highest in the country.
5.4 The impact of this has been felt most
acutely in home care services and in residential and nursing homes
where there is heavy reliance on significant numbers of relatively
low paid staff. The NHS locally has experienced similar recruitment
problems. However, for the purposes of defining levels of pay
for nurses, Addenbrookes Hospital in Cambridge is defined as a
"London and the South East Hospital".
5.5 The difficulty experienced by social
care services in attracting staff at rates of pay affordable by
the public purse is a national issue but the Cambridgeshire experience
has been made worse by the local economic factors described above.
The availability of adequate home care, residential care and nursing
care is crucial to reducing the numbers of delayed discharges.
6. THE ASSESSMENT
OF SOCIAL
SERVICES SPENDING
REQUIREMENTS
6.1 Cambridgeshire experiences very similar
levels of dissonance between actual spending requirements and
the requirements assessed by government to those experienced across
the country. The pressures from higher levels of disability (particularly
learning disability) and from complex needs amongst children are
similar to those in other places.
6.2 The local history differs in only one
respect in that patterns of activity and expenditure in children's
services during the late 1990s were very different to those elsewhere.
This has now been addressed and during the past two years funds
have transferred from children's services to adults services.
This has helped with the problem of delayed discharges and Cambridgeshire
has not so far encountered the national problem of funds needing
to move from adult budgets into children's budgets. However, in
line with national trends, children's services are under increasing
pressure and the strategy of protecting adult budgets may not
be sustainable.
6.3 The impact of this dissonance between
assumed requirements and actual requirements has been most significant
in the high volume services associated with the care of older
people. Inflation rates built into the SSA have been inadequate
to deal with the economic factors described above and the gulf
between pay rates, contract rates and fee rates that are affordable
for the Council and the actual costs of providing social care
services has grown.
6.4 Locally this has affected market confidence
and it has been difficult to attract new nursing and residential
care providers to the area, despite the shortage of places. There
have been no new homes opened in Cambridge City for some years.
6.5 It has been difficult to secure places
in local homes for local people who require public support. At
least 46 per cent of provision in the south of the County is occupied
by self funders and/or residents funded by other local authorities.
There is little incentive for home owners to offer places to the
Council even if the place is required for someone waiting in a
hospital bed.
6.6 A recent study commissioned by the Council
from Laing and Buisson consultancy demonstrated the size of the
gap between the actual costs of providing places and the fees
paid by the Council. In some parts of the County (see Appendix
V) the gap is £100 per place per week. It is clear that providers
are filling some of this gap through higher charges to private
clients.
7. THE LOCAL
RESPONSE TO
SPENDING REQUIREMENTS
7.1 The Council has been very committed
to resolving the issue of delayed discharges and has been well
aware of the impact of this both on older people themselves and
on the capacity of the local hospitals to meet patient need.
7.2 The Council has allocated funds to social
services well above assumed government levels in order to fill
the gap between government assumed inflation rates and actual
inflation in the local economy. For example, the Council allowed
for an assumed inflation rate of 10 per cent for home care services
in 2001-02 and is planning to allow for a rate of 7.5 per cent
in 2002-03. Similarly the average inflation rate applied to residential
and nursing home fees in 2001-02 has been 4.4 per cent. However,
the increase for nursing homes was 6.2 per cent. The Council is
planning a further average fee rate increase of 8 per cent for
2002-03. In some parts of the County increases of 17 per cent
are proposed in order to ensure that the current levels of provision
are protected and that places are available to publicly funded
users.
7.3 Some of the increases proposed for 2002-03
have been made possible by the Building Capacity Grant, a short
term grant with uncertain status after 2002-03. However, the "lions
share" of inflation costs are likely to be met by the Council
tax increases of 9.3 per cent that are being proposed by the Council's
Cabinet.
7.4 It should be further noted that during
2001-02 the problems with delayed discharges became so acute that
the Council felt obliged to take £0.5 million from reserves
in order to assist independent sector home care providers with
their recruitment problems. In effect this money was an advance
on the inflation increases planned for 2002-03.
7.5 This is all in a context where the Council's
social services department has met all the required targets from
the Department of Health for efficiency savings; and is in the
top quartile of performance nationally for providing intensive
home care services and supporting people in residential and nursing
homes.
7.6 The Council is amongst a small number
of Councils already subject to a local Public Service Agreement
with central government to deliver on "stretched" performance
targets in certain service areas in return for reward funds if
targets are met. The significant reduction of delayed discharges
is one of the Council's stretch targets and there is strong motivation
to succeed despite the constraints described above.
8. LOCAL INNOVATION
8.1 In these circumstances "doing more
of the same" has not been an option and many strategies have
been pursued as a means of closing the resource gap.
8.2 Partnership work both with the health
service and with independent providers has to be particularly
robust in these circumstances:
— Home care providers receive considerable
assistance from the Council with staff recruitment and training.
The Council has recently brokered a deal with the local Business
Links service to obtain assistance for providers in business planning.
— Promises to residential and nursing
home providers that fee rates will at least increase incrementally
have always been honoured and have helped to demonstrate "good
faith" even if the funds involved are acknowledged to be
insufficient.
— Many services have been planned and
delivered jointly with health partners and a recent best value
review of Occupational Therapy services has been carried out jointly
with health and will result in an integrated service under the
Health Act.
— There are plans to do everything
possible to integrate social care with primary care, although
the Care Trust option is considered to be a distraction from service
delivery. The option is complex in the Cambridgeshire environment
as so many of the PCTs cover patients who are not Cambridgeshire
residents.
— There has been work with housing
colleagues to accommodate staff recruited from the Philippines
and also to develop new sheltered schemes, including schemes that
specifically offer intermediate care.
8.3 Workforce planning has resulted in a
number of initiatives designed to attract to social care different
population groups:
— The Home Care Apprentice scheme has
been very successful in attracting younger people and has also
secured funding from the Learning Skills Council.
— The "Silver Service" has
attracted older people who are prepared to undertake some of the
less physically demanding care tasks.
— The "Night Cap" service
has attracted people who specifically want to work during unsocial
hours. This service has dedicated drivers who transport home carers
enabling the service to recruit non-drivers and reducing the fear
of night time work.
8.4 Vacancy rates in Cambridge City have
reduced from 40 per cent to 20 per cent, which is also the current
rate across the rest of the County.
9. RECOMMENDATIONS
TO THE
COMMITTEE
9.1 Cambridgeshire's experiences highlight
a number of issues for the Select Committee to consider:
— The resourcing of social care has
clearly lagged well behind the expectations of what can be delivered.
This must be acknowledged as a significant threat to the delivery
of the NHS Plan. It cannot be resolved solely through improved
partnership work with the NHS. The problems have been greatly
exacerbated by the failure to recognise the full impact of economic
and other changes on the costs of social care.
— Although there has not been sufficient
evaluation of intermediate care schemes and their impact on delayed
discharges, the policy of promoting independence and decreasing
reliance on residential and nursing home care is soundly based
but cannot work in the absence of a stable and properly funded
market of care for the most dependent people. There needs to be
a continuum of care and whilst funds that are targeted at new
service developments are welcome, they are also wasteful when
there are inadequate funds for existing services. A vicious circle
develops whereby time and energy is devoted to propping up services
that are failing through lack of resources. This diverts energy
from making sure that new services work well and genuinely contribute
to the total continuum. In Cambridgeshire intermediate care beds
get blocked because home care cannot take on the return home package.
— The strategic intent to change the
way in which a system functions requires a more strategic approach
to funding. This creates an environment of confidence for providers
and enables Councils to plan ahead. The problem of delayed discharges
has been made worse by short term fixes involving short term funds.
Councils often receive very short notice that funds will be made
available. The funds are accompanied by targets that can only
be met by quick responses that are simple to achieve but not necessarily
sensible in the longer term. For example, it may be considered
that greater investment in a service that prevents admissions
would have the best long term impact. However, services like this
cannot be expanded instantly. There is therefore a strong temptation
to simply purchase more beds (if they can be obtained) as this
moves people from hospital very quickly. This often ties up funds
in this service for some considerable time (the remaining lifetime
of the user). This problem is compounded when the funds are short
term—the service or the user are still in place, along with
the financial commitment. Other funds have to be diverted to fill
the gap. This then impacts on delayed discharges so further short
term funds appear—and the vicious circle is perpetuated.
— There is an urgent need to address
workforce issues across the health and social care spectrum and
not solely as issues that occur separately within Councils and
the NHS. A recent profile of the current workforce in Cambridgeshire
across the health, social care and independent sectors, showed
low proportions of younger people in the workforce and high proportions
of older people. Given the current retirement age, the public
sector in Cambridgeshire will see significant numbers of people
leaving the workforce in the next five to ten years with little
prospect of replacement, given current trends. In this scenario,
applying different levels of funding increases to health and social
care; treating Addenbrookes as a London hospital for pay purposes
whilst excluding Cambridgeshire from the South East Area Cost
Adjustment club, compound the lack of coherent national strategies.
The NHS and its partner councils will need shared workforce strategies
and not ones that pull in different directions with different
funding contexts. The apprentices attracted by the Council to
home care may well be the nurses of the future. Similarly nursing
auxiliaries in hospitals might move to work in the community to
gain a different experience. They may be the home carers of the
future.
— The persistent tendency of the NHS
to focus on structural change as the means to secure improved
delivery needs to be resisted. There is significant potential
for the Council to forge successful partnerships with the new
Primary Care Trusts and there is much local optimism about the
potential to secure improvements in service delivery, including
the issue of delayed discharges. However, this optimism derives
from the hope that 2002 will bring greater organisational stability
to the NHS and allow more energy to be focused on changes for
users derived from service and front line practice improvements
rather than from different structures.
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