Agenda and minutes

Health and Adult Social Care Scrutiny Committee
Thursday, 12th January, 2023 10.00 am

Venue: Ground Floor Committee Room - Loxley House, Station Street, Nottingham, NG2 3NG. View directions

Contact: Jane Garrard  Senior Governance Officer

No. Item


Apologies for absence


Councillor Maria Joannou - unwell


Declarations of interest




Minutes pdf icon PDF 215 KB

To confirm the minutes of the meeting held on 15 December 2022


The minutes of the meeting held on 15 December 2022 were confirmed as an accurate record and signed by the Chair.


Adult Social Care Winter Plan 2022/23 - Mid Winter Position pdf icon PDF 195 KB

Additional documents:


Councillor Linda Woodings, Portfolio Holder for Adults and Health, Sara Storey, Director for Adult Health and Care, and Richard Groves, Head of Access and Prevention, presented a report and spoke to the Committee about delivery of the 2022/23 winter plan for adult social care.  They highlighted the following information:


a)  The Service produces a winter plan every year, based on the Department for Health and Social Care template.


b)  Going into winter, in October there were 177 people waiting for social care reablement and as of 11 January there were 60 people waiting.  This shows a real improvement in waits and reflects the capacity that has been added into the service and the approach of getting people ready for reablement in advance so that timescales can as short as possible.  Temporary posts have been created with the non-recurrent funding available, but there have been challenges with recruitment. 


c)  There have been significant pressures across interim beds in residential care which are needed to support flow from hospital.  In the last few months there has been a reduction in the number of people waiting for interim beds but the position continues to be reviewed bi-weekly.  Next steps are to continue actively recruiting to all posts within the Discharge to Assess Business Case, through a block contract of 250 hours.  Once additional capacity is in place, it will be possible for assessments to take more swiftly, improving flow through the system. A key risk to this is the availability of homecare staff to fulfil care packages.


d)  The transformation programme is helping to reduce the number of outstanding reviews with over 1000 assessments being cleared in the last year.  More timely assessments support prevention, reduce the escalation of care packages helping to ensure that needs are appropriately met.


e)  The Adult Social Care Discharge Fund is being used to increase capacity in areas such as Through the Night Support, by addressing issues with recruitment and retention and creating incentives for staff.  The Council’s Procurement Team is supporting this work to ensure that the Fund is being used efficiently.


f)  One of the challenges has been that the additional funding to support hospital discharge was made available in October, to be spent by December.  It is anticipated that a further tranche of funding may be made available before the end of the financial year.  While welcome, the short timeframes from receipt to spending of money can make it difficult to use additional funding to best effect.


Caroline Nolan, System Delivery Director for Urgent Care, and Gemma Whysall, Ageing Well Programme Director, Nottingham and Nottinghamshire Integrated Care Board (ICB), spoke about the ICB’s perspective.  They highlighted the following information:


g)  It is a difficult winter period for the NHS in dealing with combinations of flu, Covid, respiratory conditions and the increased number of Strep A cases, alongside trying to work through a backlog of elective cases and the recovery of services.  These significant pressures are being felt nationally, and not just in Nottingham.


h)  There is partnership working taking place to identify creative, shared solutions to problems and joint working has been good.


i)  It is pleasing to see that citizens are not currently waiting as long for social care reablement.


j)  Despite the work taking place and good progress, things still aren’t working perfectly in every part of the pathway and there are lots of different initiatives taking place to make improvements.


k)  It is important that health and social care partners work together on discharge.  It is pleasing to see improvements but there is more to do.


During subsequent discussion and in response to questions from the Committee, the following additional points were made:


l)  There has been recent national media coverage of proposals for the NHS to buy additional beds in care homes.  The Council does not have details of that plan but it appears to be similar to ways of working already in operation in Nottingham and elsewhere across the country.  Across the system in Nottingham there is a commitment to the principle of ‘home first as soon as possible’ by looking at how to get citizens home and what support, if any, if they need once they are at home.  However, due to challenges and risks with homecare capacity, it can sometimes be a struggle to find sufficient capacity to get people home.  In that scenario, care home beds are used as interim beds to free up beds in hospital when no homecare packages are available to enable people to go to their own home.  This is the least risky option for the system.  The focus is then on getting people from these interim beds to their home as soon as possible.  Where possible, it would be preferable for resource to be made available to support home and community care.  One of the potential risks associated the approach is that it could skew the market for beds in care homes and this is another reason for minimising use of the approach where possible in Nottingham. 


m)  The ICB representative confirmed that there is generally good flow in and out interim care beds and it is never the situation that a Nottingham patient on Pathway 1 cannot be found a bed.  There are some challenges for patients on Pathway 2, who are often older citizens who need a period of time in a community bed with wrap around care and a focus on rehabilitation with active support from physiotherapists and occupational therapists.  There are plans to use the short term funding (to be used by 31 March) to support this pathway.  As it is non-recurrent funding it cannot be used to recruit staff, but can help to relieve pressure. 


n)  The underlying issue affecting homecare availability is the low pay and status for homecare workers which, despite it being very rewarding work, results in significant recruitment and retention issues.


o)  The Service has a workforce strategy to address issues with recruitment and retention, including a significant apprenticeship programme.


p)  Agency staff are being used in key areas such as mental health, the duty team and the integrated discharge team.  Agency staff are also used to fill workforce gaps.  The Service has a good level of assurance on agencies used and providers also have their own safeguarding arrangements regarding use of agency staff.


q)  The Association of Directors of Adult Social Care has undertaken a care survey mapping delays in people receiving assessments and home care.  It is evident that there are problems nationally but data is not broken down to local authority level. Anecdotally it is known that neighbouring authorities are struggling to meet demand for homecare, compared with gains that have been made in Nottingham over the last three months.  However, it can be difficult to compare local authority performance with others because not all authorities operate in the same way.  The representative of the ICB reported that regional metrics are reviewed and show that Nottingham is doing really well in terms of keeping people in their own homes with wrap-around care.  In the acute sector, Nottingham is performing relatively well in ambulance turnaround times and delivery of same-day emergency care reducing demand for hospital beds.


r)  Forecasts of demand are carried out to help identify resource required.  The current position is that the level of resource available just about supports those in need of care, and unless demand increases significantly in the next few months improvements should continue to be seen.  This indicates that forecasts were pretty good, but it is hard to forecast really accurately due to the level of complexity. Granular data continues to be monitored and shared to ensure a good understanding of the actual position.


s)  Risks to delivery of the winter plan include the fragile market and the workforce, which is not as resilience as it needs to be.  It doesn’t take much to tip a provider (especially a small provider) into a risky situation.  In terms of the risk register, the Service could probably downgrade risks around homecare but the position is keep under review on a day to day basis to enable the Service to respond quickly to any issues.  The ICB representative added that the NHS is also really challenged in relation to workforce and this is a significant risk across all specialities.  While forecasting and demand and capacity planning takes place across the NHS, some things, such as the high number of Strep A cases, cannot be predicted and this presents different challenges.  Risks are managed daily and risks are balanced appropriately. 


t)  Given the underlying challenges, the Portfolio Holder stated that she was not very confident in the future and spoke about the need for a national long-term sustainable plan for the funding and staffing of social care.


u)  Next winter there will be a focus on more preventative work and increasing Covid and flu vaccination rates to reduce the numbers of people who are so ill that they require hospitalisation.


The Committee concluded that it is positive that the local authority and NHS are working well together and that across the health and social care system there is focus on people being in their own homes with appropriate support as much as possible.  Despite the significant challenges, the local position is relatively good.  However, the Committee had concerns that the non-current short term funding made available to local authorities won’t support a sustainable health and social care system and encouraged the Portfolio Holder for Adults and Health to lobby the Government on this matter and the need for a strategic national approach to recruitment and retention of care workers.


Resolved to review evaluation and lessons learnt from managing winter pressures 2022/23.


Budget and Medium Term Financial Plan pdf icon PDF 460 KB

Additional documents:


Councillor Linda Woodings, Portfolio Holder for Adults and Health, and Sara Storey, Director for Adult Health and Care, gave a presentation about 2023/24 new transformation project proposals.  They highlighted the following information:


a)  Existing transformation projects have been mapped against the citizen journey to identify gaps and opportunities.  From ongoing work with staff, voluntary sector partners and other stakeholders, such as the Disability Involvement Group, it has been identified that there are gaps in pre-contact with adult social care services and at the first point of contact.  As a result of this feedback a number of proposals for new projects have developed.


b)  Proposals include a mix of increasing existing projects and new projects, and are now being consulted on.


c)  There are plans to continue, and increase the focus on developing more options for independent living for those under 65 years and for older adults.  This will be an increase to the previous transformation saving.  There are still a lot of younger people who might be able to be supported to live independently and it is important to keep people in their own homes for as long as possible because this is what most people want and evidence shows that once people move into a long term care home their needs tend to increase.  Extra challenge is being put into the programme and the Service is confident that it can do more.


d)  In support of the customer first and digital by design transformation work-streams, the Service will move towards online financial assessments.  This will support citizens to claim as many benefits as possible and automatically trigger reviews.  Moving towards online assessments will bring the Council in-line with other local authorities.


e)  There are new projects relating to strength-based practice, community interventions and the use of assistive technology. 


f)  Staff leading on the strengths based work are helping to develop the project to build on work already underway to embed a strengths based approach across all teams and providers to have early strengths-based conversations and ensure assessments, documentation, systems and policies are strengths-based and focus on outcomes. 


g)  In terms of community interventions, a business case is being developed for funding from the Integrated Care Board for Local Area Co-ordination, which will double capacity for a two year period.  The Service is also collaborating with the Ageing Well Programme to change the approach to the way services are delivered enabling people to live as independently as they can and be connected to their communities.  The feedback from voluntary sector partners so far has been positive.


h)  There are proposals for a project to increase the provision and effective use of assistive technology in homes to maximise independence of citizens.  This could include assessing falls risk or prompts to change sleeping position during the night.


i)  The occupational therapy and adaptations project will aim to improve access to and speed up provision of occupational therapy, equipment and adaptations by increasing capacity within the occupational therapy team through a combination of apprenticeships and recruitment of experienced occupational therapists.  The Disabled Facility Grant policy will also be reviewed to ensure the balance of staffing is right to meet need.


j)  It is proposed to commission a support service to offer enabling/ reabling support to people with mental ill health who have recently been in hospital or may be at risk of hospital admission, offering a short-term service to get them back to independence.


k)  It is proposed to charge self-funders a one off charge for assessment and each review.  Based on the approach of other local authorities is it is proposed that the fee is £300.  Citizens could decline to this approach and arrange their own care instead.


During subsequent discussion and in response to questions from the Committee, the following additional points were made:


l)  All of the transformation projects are monitored to ensure appropriate resourcing and delivery of savings set out in the Medium Term Financial Plan.


m)  A key risk to delivery is having dedicated resource.  Resource is allocated to support transformation but sometimes has to be diverted to respond to time critical emergencies.


n)  While some transformation projects have delivered savings over target, others have under-performed financially.  The position of the overall programme against target is pretty good.


o)  In addition to financial savings and efficiency, the transformation programme will lead to better outcomes for citizens, with a greater focus across adult social care on prevention.  Approximately 1000 strengths-based reviews have been carried out in the last 12 months; good work is happening with Shared Lives carers although it has not yet been possible to increase the number of Shared Lives carers working for the Council; and increasing occupational therapy capacity will give a different perspective on need and enable reviews to be carried out more frequently.  The projects will be ramped up over the next 12 months.


p)  The challenging economic situation is affecting providers of building-based services and they are asking for increased funding to cover the increased costs of care, and while the increase in the national living wage is positive for workers it does increase the costs for providers.  This is creating an inflationary pressure for the Council.  Citizens are also feeling the impact of increases in the cost of living and may be less able to support themselves as a result.  These unanticipated inflationary pressures are a significant challenge for the Council’s budget setting process this year.  For adult social care the mitigation is prevention, reducing need as far as possible but ensuring services are able to support citizens if they are required.  Contingency is built into individual care packages.


q)  The Government’s last minute approach to funding makes setting a budget a challenge every year.


r)  There is a need for the Council to improve financial forecasting and its understanding of pressures.  There tends to be a focus on immediate internal challenges but the Service would benefit from improving its insight regarding the position of care providers in the City and the external market to improve budget forecasting.


The Committee welcomed the continued approach of co-production of transformation and was generally supportive of the expansion of existing projects and development of new projects in increasing the independence of citizens, enabling them to live in their own homes with appropriate support, and consequently improving outcomes for them alongside being more financially efficient.


Resolved to submit a comment to the consultation on the budget 2023/24 outlining that, having seen the benefits of the transformation projects already underway, the Committee is supportive of the budget proposals relating to adult social care as both benefitting and improving outcomes for citizens and achieving financial savings.


Councillor Linda Woodings, Portfolio Holder for Adults and Health, David Johns, Consultant in Public Health, and Nancy Cordy, Senior Public Health Strategy and Service Improvement Manager, spoke to the Committee about use of the Public Health Grant and recent work to ensure that the Council has completed its duties with regard to the use of the Grant.  They highlighted the following information:


s)  In 2022/23 the Public Health Grant was £35.5m.  The value of the Grant for 2023/24 will be announced in February/ March.  Plans for use of the Grant have to include a degree of flex because the final value is announced so late.


t)  Over the last 18 months there has been a review of how the Council uses the Public Health Grant to ensure that it is eligible, that the Council is achieving best value and that it is being used in a way that is effective in improving health outcomes.


u)  There are certain prescribed functions that the Council must deliver through the Public Health Grant, for example sexual health services; and there are locally identified priorities for its use, for example delivery of the Joint Health and Wellbeing Strategy.


v)  It can sometimes be hard to distinguish whether the main and primary purpose of a way that the Grant is being used is to support public health and therefore a thorough line-by-line review was carried out to look at the purpose and outcomes from its use.


w)  Based on the findings of the review, a Transition Plan was developed and put in place for the lifetime of the Medium Term Financial Plan allowing the Council to think differently about how public health works with other parts of the Council.  The Transition Plan was shared with the Office for Health Inequalities and Disparities (OHID) and it confirmed that it was satisfied with the Plan. Engagement continues with OHID regarding its implementation.


x)  Feedback from the review has put the Council in a stronger position in terms of the services commissioned by Public Health and how the Council, as a whole, makes appropriate and effective use of the Grant.


y)  Every year the Council has to report on how it has spent the Grant and meetings are held with OHID to check on that spend.  This gives assurance that the Grant is being appropriately used.


z)  Once the Grant for 2023/24 has been announced, the Commissioning and Procurement Executive Committee will decide how it will be invested.


During subsequent discussion and in response to questions asked by the Committee the following additional points were made:


aa)Although public health responsibilities have been devolved to local authorities, the Grant is still ring-fenced and there are lots of statutory duties that need to be met.  Some Committee members suggested that there should be more flexibility in how health needs of the local population are met.


bb)While there are prescribed functions, the Council can determine how these functions are delivered, for example which service model is best for its population.  Decisions about the best approach are evidence-based and informed by best practice.


cc)  The Council is an outlier in terms of the proportion of the Grant spent on wider Council services, but the extent to which it is different to other local authorities can be difficult to fully know because comparative data on usage is only published by certain categories.  The Council is comfortable with the current proportion spent on commissioning of other Council services.


The Committee concluded that it was comfortable that there are assurance mechanisms in place to ensure that the Public Health Grant is being spent in a way that is eligible and appropriate, but wanted to explore in more detail what Nottingham is doing differently to other local authorities that means it is meeting the distinct needs of Nottingham citizens.


Resolved to review how Nottingham is spending its Public Health Grant in a way that is distinct to meeting the need of Nottingham citizens.


Work Programme pdf icon PDF 224 KB

Additional documents:


The Committee noted its work programme for the remainder of municipal year 2022/23.