Agenda Item

Health and Adult Social Care Policy & Scrutiny Committee

2 November 2021

Report of the Directors of Adult Social Care and Public Health

2021-22 Finance and Performance First Quarter Report – Health and Adult Social Care

Summary

1 This report analyses the latest performance for 2021-22 and forecasts the financial outturn position by reference to the service plans and budgets for all relevant Adult Social Care and Public Health services falling under the responsibility of the Directors of Adult Social Care and Public Health.

Financial Analysis

2 A summary of the service plan variations is shown at table 1 below.

Table 1: Health & Adult Social Care Financial Summary 2021/22 – Quarter 1

2020/21 Outturn £000		2021/22 Latest Approved Budget			2021/22 Forecast Outturn
2020/21 Outturn £000		Gross Spend £000	Income £000	Net Spend £000	£000	%
-3,189	Director of HHASC	4,663	-2,871	1,792	-103	-5.7%
+830	ASC Older People and Physical & Sensory Impairment	38,311	-19,656	18,655	+1,957	+10.5%
+1,551	ASC Learning Disabilities and Mental Health	36,572	-8,984	27,588	-282	+1.0%
+68	ASC In house services	5,971	-1,914	4,057	+181	+4.5%
-97	ASC Commissioning and Early Intervention & Prevention	8,398	-9,961	-1,563	-24	+1.5%
-837	Adult Social Care Total	93,915	-43,386	50,529	+1,729	+3.4%
0	Public Health	8,869	-9,158	-289	0	0%
-837	Health and Adult Social Care Total	102,784	-52,544	50,240	+1.729	+3.4%

+ indicates increased expenditure or reduced income / - indicates reduced expenditure or increased income

Adult Social Care

3 The projected outturn position for Adult Social Care is an overspend of £1,729k. This assumes that £1.3m of savings will be made by the year-end and that £596k of costs relating to unachievable savings and staffing working on the Hospital Discharge Programme will be covered by Covid funding. The projection is based on customer numbers in the first two months of the year and does not build in any expectations around a further surge of coronavirus, nor does it currently have any budget set aside for winter pressures.

4 The effect of Riccall Carers going into administration and the subsequent decision to bring the care staff in house is not built into these projections. Initial calculations indicate that the cost to the Council in 2021/22 (net of the payments that would otherwise have been made to Riccall) could be around £180k; further work is ongoing to refine this projection.

5 The following sections give more detail on the variations.

Director of HHASC (-£103k / -5.7% of net budget)

6 No material variances. Forecast underspend is due to the Care Act Implementation budget and mental health funding in the Director’s budget being held back to fund overspends elsewhere in the department.

ASC Older People (OP) and Physical & Sensory Impairment (P&SI) budgets (+£1,957k / +10.5% of net budget)

7 Permanent residential care is projected to underspend by £331k in total in 2021/22. OP residential care is under by £491k, largely due to having around 28 fewer customers than in the budget. This will reduce as customers come off the health funding in place to cover costs after hospital discharge (see para 11). P&SI residential care on the other hand is projected to overspend by £160k due to the current average gross placement cost per customer being £4k more than in the budget.

8 Permanent nursing care is projected to overspend by £259k. This is largely due to the average gross cost of an OP nursing placement being more than in the budget.

9 P&SI Supported Living schemes are projected to overspend by £550k in 2021/22. This is in line with previous years and is largely due to the cost per customer being around £10k p.a. higher than when the budget was last rebased. Placements are currently being reviewed to ensure that they are still at appropriate levels.

10 There is currently projected to be an overspend of £289k on the ASC Community Team. This is due to having unfunded posts, not achieving the historic vacancy factor, vacant posts in the team being covered by WWY staff and repayment of the risk reserve venture fund loan. Referrals to the Social Work teams are increasing significantly as the third wave of COVID beaches on ASC’s shores.

11 We have added £1m to the forecast to cover the additional costs which will arise in the care budgets once the customers currently being funded by Health under the Covid related Hospital Discharge Programme move to being the Council’s responsibility. This funding has reduced from six weeks to four from July 2021 and will cease all together at the end of September.

ASC Learning Disabilities (LD) and Mental Health (MH) budgets (-£282k / -1% of net budget)

12 Learning disability residential budgets are projected to underspend by £467k. The cost per customer in the working age budget is £1k less than in the budget (£51k), there are three more customers receiving CHC funding than originally assumed (£161k) and the average amount of CHC per customer is £4k more (£103k). In addition, there are two fewer customer in LD OP placements than in the budget (£102k) and the average cost per customer is £5k less than budgeted for (£50k).

13 There is projected to be an overspend of £116k on Direct Payments for LD customers. This is due to the average direct payment paid per customer being £5k more than when the budget was last rebased (639k). This is largely offset by having seven fewer customers than when the budget was set (£161k) and in addition, based on recoveries to date, there is likely to be an overachievement of the budget for recoveries this year (£362k).

14 The Mental Health budgets are projected to overspend by £68k in total, broken down as follows:

a. Residential Care -£109k

b. Nursing Care - £9k

c. Community Support (incl Supported Living) £152k

d. Direct Payments -£60k

e. Deprivation of Liberty Safeguarding (DoLS) -£28k

f. Other minor variations £122k

15 The main overspends are on MH Supported Living placements as there are 4 more customers than assumed in the budget (£152k) and on the Social Work staffing budget due to temporary unfunded WWY posts (£87k).

16 The MH budget pressures were more significant in 2020/21. The budget growth given in 2021/22 allowed us to rebase most of the external care budgets so the variances in MH are not as marked as last year. MH spend is, however, an area that is growing faster than the budget we have to support it so we will continue to see if there are better ways of supporting individuals, particularly regarding supported living.

ASC In house services Budgets (+£181k / +5% of net budget)

17 Be Independent is projected to overspend by £304k. There is still a budget gap of £130k relating to the financial position of the service when brought back into the Council, together with an ongoing historical overspend on recharges (£50k). In addition to this there is a projected underachievement of income on sales (£49k), a projected overspend IT systems (£48k), and other overspends across the budget. We are investigating whether some of these costs can be capitalised against existing capital budgets.

18 Yorkcraft is projected to overspend by £60k. This is due to a budget saving of £62k agreed in 2020/21, which has not been achieved. There is a project team currently looking at future directions for the Yorkcraft service who will also review how this saving can be made by the end of the year.

19 Small Day Services are projected to underspend by £138k. This is largely due to vacancies at Pine Trees, Community Base and the Community Support Assistants as some of the services are not currently open due to Covid restrictions.

ASC Commissioning and Early Intervention & Prevention (EIP) budgets (-£24k / –1.5% of net budget)

20 There are no major variances to report in this area.

Performance Analysis

Adult Social Care

21 Much of the information in the following paragraphs can also be found on CYC’s “Open Data” website, which is available at

https://data.yorkopendata.org/dataset/executive-member-portfolio-scorecards-2021-2022

and by clicking on the “Explore” then “Go to” in the “Health and Adult Social Care” section of the web page.

22 Many of the comparisons made below look at the difference between the end of the 2020-21 Q1 and 2021-22 Q1 periods, in order to avoid seasonal variations. A summary of the information discussed in paragraphs 23 to 35 can be found in the table on the next page.

Demand for, and numbers receiving, adult social care services

23 There has been an increasing number of initial contacts to adult social care (ASC) during the past year, partly caused by the COVID-19 pandemic. Our Customer Contact Workers record the number of contacts received to ASC, whether made by email, telephone or other methods. During 2021-22 Q1, they received 4,237 contacts, which is 17% higher than the number received during 2020-21 Q1 (3,684). Around 21% of the contacts during 2021-22 Q1 were resolved using Information, Advice and Guidance (IAG), which is lower than the percentage that were resolved using IAG during 2020-21 Q4 (34%); this reflects the increasing complexity of issues that are dealt with by them, and a change in recording practice to record clients who ‘only’ received IAG; most clients will receive an element of IAG during their contact, regardless of the outcome of it.

24 After an initial fall in the early months in the number of individuals in residential/nursing care placements during 2020-21, mainly due to the Covid crisis, this number has remained relatively low. Our policy that the majority of people should no longer be placed in residential/nursing care directly following hospital discharge has proved to be successful. At the end of 2021-22 Q1, this number was 558, compared to 566 at the end of 2020-21 Q1. During 2021-22 Q1 the number of new admissions of older people to residential/nursing care was 44, an increase of 63% on the 2020-21 Q1 figure of 27. This has been because hospitals having been discharging people earlier than previously, with those people having more complex health issues. Some of these people would, in normal circumstances, be given home care provision, but we are unable to expand this service due to workforce issues.

25 There has been a fall in recent months in the number using home care services. At the end of 2021-22 Q1 there were 693 people in receipt of a home care service; this is 6% lower than the corresponding figure at the end of 2020-21 Q1 (736).

26 In the first three months of 2021-22, there were 142 clients that received a paid ASC service for the first time (“new starters”). This is a significant reduction from the number in the corresponding three months of 2020-21 (201). This suggests that although we are doing well in keeping the number of first-time entrants low, but there are still challenges ahead with regards to ensuring that people do not require adult social care for prolonged periods.

Mental Health

27 The percentage of adults in contact with secondary mental health services living independently, with or without support, has fallen over the last year. Provisional results for 2021-22 Q1, 67% of them were doing so, compared with 72% a year earlier. The 2019-20 ASCOF results showed that York is the 18th best performing LA in the country with a performance of 80% in this measure, compared with 58% in England and 63% in its statistical neighbour group.

28 During 2021-22 Q1, 19% of all clients in contact with secondary mental health services were in employment – a figure that has consistently been above the regional and national averages, and the same as a year earlier. Based on the 2019-20 ASCOF results, York is the 4th best performing LAs on this measure, with 22% of all those in contact with secondary mental health services in employment, compared with 9% in England and 9% in its statistical neighbour group.

Delayed Transfers of Care (DToC)

29 Reporting on DToC has been suspended since February 2020, as the COVID-19 pandemic began in the United Kingdom. The Department of Health and Social Care has not re-introduced this as a target or a key performance indicator. The Hospital Discharge Service Requirements published by DHSC in March 2020, and updated in August 2020, focus on delivering Home First as the accepted pathway. Information on the number of people who return directly home from hospital is not published at LA level.

Overall satisfaction of people who use services with their care and support

30 The 2020-21 Adult Social Care User Survey was a national survey of adult social care users that sought their opinions on aspects of their life and the care provided to them, whether from LAs, the voluntary sector or other providers. Only 19 LA areas, including York, participated, as doing so was voluntary due to the Covid-19 pandemic.

31 Provisional results for 2020-21 showed that a higher percentage of ASC users in York were “extremely or very satisfied” with the care and support services they received. It is an increase from the 2019-20 level (68% gave this response).

Safety of ASC service users and residents

32 The safety of residents, whether known or not to Adult Social Care, is a key priority for CYC. The ability of CYC to ensure that their service users remain safe is monitored in the annual Adult Social Care User Survey, and for all residents with care and support needs by the number of safeguarding concerns and enquiries that are reported to the Safeguarding Adults Board.

33 Provisional results from the 2020-21 ASC Survey reported an increase in York’s ASC users “feeling as safe as they want”, and is an increase from the 2019-20 level (71%).

34 During 2021-22 Q1 there were 360 completed safeguarding pieces of work, which is a 18% increase on the number completed during the 2020-21 Q1 period (304) – this is a partial reflection in the increase in the number of safeguarding concerns reported during this time (444 in 2021-22 Q1 compared with 297 in 2020-21 Q1). The percentage of completed enquiries where people reported that they felt safe as a result of the enquiry continues to be high - 99% during both 2020-21 Q1 and 2021-22 Q1 - and remains consistent with what has been reported historically in York.

Sickness rates of Adult Social Care staff

35 In the People directorate, which includes Adult Social Care, the number of sickness days taken per full-time employee fell from 15.1 in the year to June 2020 to 12.1 in the year to June 2021. Work continues to reduce this further.

Public Health

36 Public Health is expected to underspend by £224k but this can be transferred the earmarked Public Health reserves to fund future budget commitments.

37 The pandemic has had a significant impact on the Public Health Team with resources diverted into supporting the response to the pandemic. The Healthy Child Service, Healthchecks and Sexual Health services have all had impact on demand for services that is leading to savings in year however these are assumed to return to more usual activity later in the year which will lead to spend closer to budget.

38 The table below provides a more detailed breakdown for the services within Public Health

Service Area	Net Budget £’000’s	Outturn Variance £’000’s	Comments
Public Health General	1,428	-115	Delayed recruitment to the new staff structure & use of COMF funding to cover additional staff costs
Sexual Health	1,778	-7	Anticipated £7k reduction in GUM recharges
Substance Misuse	1,772	+0
Wellness Service	346	-7	Underspend arising from staff vacancies
Healthy Child Service	2,530	-63	Underspend arising from staff vacancies
Public Health grant	-8,143	0
Total Public Health	-289	-224
Transfer to Reserves		+224	Total reserves (£1m)
Reported Position		0

39 A new staff structure has been approved but recruitment to some of the new posts is not expected until later in the summer. In addition, some staff dealing with Covid issues are being funded by Control the Outbreak Management Grant (COMF) grant.

40 Despite lower activity due to Covid in 2020/21 it is anticipated that LARC contraception costs will return to normal. However, Genitourinary Medicine (GUM) recharges from out of area treatment are expected to be lower due to reduced tariffs and activity resulting in £7k underspend.

41 Due to a number of vacancies the Health Trainer Service is expected to underspend by £7k.

42 Healthy Child Service is currently being restructured and following a number of vacancies it is expected to underspend by £63k.

43 There is £2.4m unspent 2020/21 Control Outbreak Management Funding with a further £1.1m awarded for 2021/22. This is being used to manage the additional resources and cost pressures resulting from the pandemic across the council and is expected to be spent by the end of the year. In addition, DHSC are providing separate funding so the council can operate a number of Covid testing sites around the city, including LFT test kit collection points and delivery of kits.

44 There was £776k in the Public Health Reserve at 31^st March 2021. Based on current estimates total reserves will increase to £224k to £1m. This is not unexpected and the planned additional growth and restructuring in Public Health services over the next 3 to 4 years will ensure these savings are re-invested.

Directly Commissioned Public Health services

Health Trainer Service (NHS Health Checks and Smoking Cessation)

45 The Health Check programme aims to help prevent heart disease, stroke, diabetes and kidney disease. Everyone between the ages of 40 and 74, who has not already been diagnosed with one of these conditions, will be invited (once every five years) to have a check to assess, raise awareness and support them to manage their risk of cardiovascular disease. A high take up of NHS Health Check is important to identify early signs of poor health, and lead to opportunities for early interventions.

46 The Health Check programme had to be halted for safety reasons during the COVID-19 pandemic period. Nimbuscare will start to deliver health checks during quarter 3 of 2021-22 and data will be available from January 2022 onwards.

47 Closer work with Primary Care Networks is being undertaken, which will see health checks being delivered in a primary care setting leading to a more joined up service for the patient. Health Checks are delivered from various locations across the City. We aim to target this service to those most at risk. Our approach is more than just identifying risk, and that is why we now deliver a Health Trainer Service, which aims to provide individuals with advice and support to tackle the things that increase their risk, such as excess weight, high blood pressure, lack of exercise and poor diet. The Health Trainers put the individual at the centre and work with them to help achieve the health goals that matter to them.

48 The Health Trainer service is currently mainly dedicated as a support service for people that want to stop smoking. This includes one-to-one advice as well as access to medications that make the journey to being smoke free easier. We have recently formed a Tobacco Alliance in York so that we can ensure that we tackle some of the wider issues that lead to people taking up smoking, such as ease of access to cheap illicit tobacco products.

49 In the most recent quarter the Health Trainer Service’s stop smoking team had received 88 referrals from those wishing to quit smoking. Of these, 68 (77%) went on to engage with an advisor. Subsequently, 45 went on to set a quit date and 33 had quit by the end of that quarter (73%). There were 20 pregnant smokers who were in the group of 88 referrals. Of these, 10 (50%) went on to engage with an advisor, and subsequent to that, six went on to set a quit date and five (83% of these) had quit by the end of the quarter.

Substance Misuse

50 Individuals successfully completing drug / alcohol treatment programmes demonstrate a significant improvement in health and well-being in terms of increased longevity, reduced alcohol related illnesses and hospital admissions, reduced blood-borne virus transmission, improved parenting skills and improved physical and psychological health.

51 In the latest 18 month monitoring period, 259 alcohol users were in treatment in York and 78 (30%) left treatment successfully and did not represent within six months. The equivalent figures for opiate and non-opiate users were 4% (19 out of 466) and 26% (41 out of 157) respectively. The York rates are currently lower than the national averages (35% for alcohol users, 5% for opiate users and 33% for non-opiate users.

Healthy Child Service

52 Although the NCMP programme for 2019-20 was discontinued in March 2020 due to the COVID-19 pandemic, the data submitted for children measured prior to lockdown has been published with appropriate local data quality flags. The coverage rates for York for 2019-20 were 38% for year 6 pupils and 57% for reception (coverage rates are usually in excess of 95%). As a result of this, the York values have been flagged as ‘fit for publication but interpret with caution’. The 2019-20 NCMP found that 7.6% of reception children in York were obese, which is significantly lower than the England average (9.9%). The York figure has fallen from the 2018-19 level (9.5%). Of Year 6 children in York, 22.1% were found to be obese in 2019-20, which is not significantly different from the England average (21.0%). The York figure has increased from the 2018-19 level (15.1%). There is a wide variation in obesity rates at ward level, and there is a strong correlation between obesity and deprivation at ward level. For the 2020-21 measurement year, a minimum 10% representative NCMP sample will be screened, which, in York, equates to five schools.

Sexual and Reproductive health

53 Being sexually healthy enables people to avoid sexually transmitted infections and illnesses, and means that they are taking responsibility for ensuring that they protect themselves and others, emotionally and physically. It also ensures that unwanted pregnancies are less likely to occur.

54 In the period July 2019 to June 2020, the rate of conceptions per 1,000 females aged 15-17 in York (15.1) was lower than the regional (17.6) but higher than the national (14.0) averages. There has been a gradual fall in this rate in York over the last year.

Other Public Health Issues

Adult Obesity / Physical Activity

55 Obesity amongst the adult population is a major issue as it puts pressure on statutory health and social care services, and leads to increased risk of disease, with obese people being more likely to develop certain cancers, over twice as likely to develop high blood pressure and five times more likely to develop type 2 diabetes. It is estimated that obesity costs wider society £27 billion, and is responsible for over 30,000 deaths each year in England.

56 The latest data from the Adult Active Lives Survey for the period from November 2019 to November 2020 was published in April 2021. In York, 477 people aged 16 and over took part in the survey, and they reported higher levels of physical activity, and lower levels of physical inactivity, compared with the national average. 67% of people in York did more than 150 minutes of physical activity per week compared with 61% nationally and 60% regionally. There has been no significant change in the York value from that 12 months earlier. 22% of people in York did fewer than 30 minutes per week compared with 27% nationally and 29% regionally. There has been no significant change in the York value from that 12 months earlier.

Smoking: pregnant mothers

57 Smoking in pregnancy has well known detrimental effects for the growth and development of the baby and health of the mother. The Tobacco Control Plan contains a national ambition to reduce the rate of smoking throughout pregnancy to 6%, or less, by the end of 2022.

58 For the latest 12 month period, 9% of mothers that gave birth in York were recorded as being smokers at the time of delivery. This represents an improvement on the figure for the previous 12 month period. However, there is considerable variation within the wards in York on this figure, ranging from 2% to 20% of mothers being recorded as smoking at the time of delivery in the latest 12 month period.

Smoking: general population

59 Smoking, amongst the general population, has a number of well-known detrimental effects, such as increased likelihood of certain cancers, increased likelihood of heart disease, diabetes and weaker muscles and bones. It is estimated that smoking-related illnesses contribute towards 79,000 premature deaths each year in England, and that the cost to the NHS is approximately £2.5bn each year, with almost 500,000 NHS hospital admissions attributable to smoking.

60 The latest figures on smoking prevalence amongst the general population in York show that 11.9% of adults in the city were reported as smokers, which is a lower percentage when compared with adults in the Yorkshire and Humber region (15.7%) and in England as a whole (13.9%). Amongst those who work in “routine and manual occupations”, 26.9% of adults in York were reported as smokers, which is higher than the national average (23.2%) and slightly lower than the Yorkshire and Humber average (27.6%).

Alcohol-related issues

61 The effects of alcohol misuse are that it leads to poor physical and mental health, increased pressure on statutory health and social care services, lost productivity through unemployment and sickness, and can lead to public disorder and serious crime against others. It is estimated that harmful consumption of alcohol costs society £21 billion, with 10.8 million adults, in England, drinking at levels that pose some risk to their health.

62 In 2019, there were 66 deaths from alcohol-related conditions in York (47 males and 19 females); a rate of 34 per 100,000 population. This rate is lower than regional and national averages (40 and 36 per 100,000 population respectively).

63 The Public Health team in York are continuing to deliver Alcohol IBA (Identification and Brief Advice) training to health professionals and frontline staff across the city. The training is aimed at staff who have regular contact with residents, to equip them with the skills to measure drinking levels and offer simple advice on how to reduce alcohol consumption.

Mental health and Learning Disabilities.

64 It is crucial to the overall well-being of a population that mental health is taken as seriously as (more visible) physical health. Common mental health problems include depression, panic attacks, anxiety and stress. In more serious cases, this can lead to thoughts of suicide and self-harm, particularly amongst older men and younger women. Dementia, particularly amongst the elderly population, is another major mental health issue.

65 The latest available information (2019/20 Q2) data on improving access to psychological therapies (IAPT) in the Vale of York CCG area shows the following: referrals to IAPT (504 per 100,000) are lower than the England average (953 per 100,000). The percentage of the estimated population with anxiety and depression who enter IAPT (18%) is comparable with the England average (18.3%), and the percentage leaving treatment who have achieved reliable improvement (70.4%) is similar to the England average (71.8%).

Life Expectancy and Mortality

66 Average Life Expectancy and Healthy Life Expectancy for males in York (80.2 years and 65.8 years) is above the England average (79.8 years and 63.2 years). Average Life Expectancy and Healthy Life Expectancy for females in York (83.7 years and 66.4 years) is also above the England average (83.4 years and 63.5 years). The inequality in life expectancy for men in York for the measurement period 2017-19 is 8.3 years. This means there is around an eight-year difference in life expectancy between men living in the most and least deprived areas of the City. This inequality for men has improved (fallen) for two successive periods. The inequality in life expectancy for women in York for the measurement period 2017-19 is 6.2 years. This means there is around an six-year difference in life expectancy between women living in the most and least deprived areas of the City. This figure is the same as in the previous period (2017-19). The inequality in York is below the national average for men (9.4 years) and for women (7.6 years).

Recommendations

67 As this report is for information only there are no specific recommendations.

Reason: To update the committee on the latest financial and performance position for 2020-21.

Contact Details

Authors:	Chief Officers Responsible for the report:
Steve Tait Head of Finance: Adult Social Care Phone: 01904 554225 Steve.Tait@york.gov.uk Terry Rudden Strategic Support Manager (Adults and Public Health) Phone: 01904 551655 terry.rudden@york.gov.uk Mike Wimmer Senior Business Intelligence Officer, Public Health Phone: 01904 554646 Michael.wimmer@york.gov.uk	Michael Melvin Director, Adult Social Care Sharon Stoltz Director of Public Health
	Report Approved	X	Date	2 November 2021

Specialist Implications Officer(s) None
Wards Affected: List wards or tick box to indicate all					All	Y

For further information please contact the author of the report.