Savings programme 2024-25 – managing new and existing demand and budget control measures integrated impact assessment

Managing new and existing demand

Budget Control Measures

To reduce costs, the EHSCP proposes to take a systematic approach to assessment and review to focus on right-sizing of packages of care. Using a person-centred, 3 Conversations approach, the Partnership will ensure that outcomes are met in the most cost-effective way, with a focus on maximising independence and consideration of digital solutions and community-based supports as an alternative to traditional care at home support.

Programme to include reviews of the following groups:

  • 4 week reviews following hospital discharge
  • Complex care reviews
  • Housing support reviews, including a review of charges levied
  • Reviews of people receiving support from a Tier 2 or 3 provider
  • Reviews of people recorded with low or moderate need
  • Reviews of people living in a residential setting that also receive other services, such as daycare, DP or 1-2-1 support
  • Reviews of people experiencing the Discharge to Assess (D2A) pathway

This is a continuation of the savings programme which commenced in 23/24 with the recruitment of a temporary team. Evidence from the One Edinburgh Review Team and the Temporary Review and Assessment Team has shown that in some cases, we are able to safely reduce the cost and size of packages of care while still delivering on individual outcomes. This proposal involves a more integrated and joined-up approach, which will apply the same methodology to assessments for new services in addition to the continuation of reviews of existing packages.

However, these measures may not be sufficient to balance our budget, and so a further proposal has been made.  To bridge this remaining gap, further restriction of expenditure in the purchasing budget and by direct implication, the services and supports that we can afford to offer to citizens of Edinburgh, may be required.

Assuming approval and delivery of all other savings proposals, it would be necessary to further restrict net growth expenditure by approximately £4750 per week across the whole of 2024/25. This would require locality teams to manage demand within set budgets and would essentially prevent approval of new or increased packages of care (across care at home, residential care, day support, transport, direct payments and ISFs) once the spend limit has been reached each week/month.

In June 2023, an Integrated Impact Assessment was carried out to identify the impact of the changes to the review and assessment processes.  In February 2024, a further Integrated Impact Assessment was carried out regarding the Housing Support changes.  Copies of these can be found here: https://www.edinburghhsc.scot/the-ijb/integrated-impact-assessments/

These proposals will be considered for approval at the Edinburgh Integration Joint Board on 18 March 2024.

6 March 2024

Name Job Title Date of IIA training
Mike Massaro Mallinson Service Director –  Operations
Deborah Mackle Locality Manager, South West
Nikki Conway Locality Manager, South East
Matt Kennedy Principal Social Worker
James Cuthbert Interim Lead Commissioner
Kirsty Dewar Cluster Manager, NE
Linda Irvine-Fitzpatrick Strategic Programme Manager, Thrive Edinburgh
Sarah Hayden Business Manager, SE
Bridie Ashrowan Chief Executive, EVOC
Siobhan Murtagh Senior HR Consultant
Jill Acheson Senior Social Worker
Elaine McGill Senior Occupational Therapist
Jessica Brown Innovation and Sustainability Senior Manager
Jennifer McLean Review Team Coordinator
Vivienne Fleming Review Team Coordinator
Lynn Freeman Discharge To Assess
Rhiannon Virgo Project Manager Feb 2020
Evidence Available – detail source Comments: what does the evidence tell you with regard to different groups who may be affected and to the environmental impacts of your proposal
Data on populations in need: Joint Strategic needs Assessment City of Edinburgh HSCP (2020)

Edinburgh HSCP

Joint Strategic Needs Assessment:

Health and Care Needs of People from Minority Ethnic Communities (April 2018)

Edinburgh Integration Joint Board Strategic Plan (2019-2022)

Cultural Curiosity Survey 26 May 23 – Edinburgh Children’s Partnership Board

Provides current and projected data on the wider population in the City of Edinburgh

(Population and demographics – Edinburgh Health & Social Care Partnership (edinburghhsc.scot)

Provides an understanding of what contributes to poor health and wellbeing and the barriers and challenges to seeking and obtaining support (many being interrelated).

Actions highlighted as needed to address these include:

  • Staff training including cultural sensitivity
  • Recognition of the role of the Third Sector
  • Effective community engagement
  • Developing effective approaches to prevention including overcoming isolation.

https://www.edinburghhsc.scot/wp-content/uploads/2020/03/JSNA-Health-Needs-of-Minority-Ethnic-Communities-Edinburgh-April-2018.pdf

Details the Strategic direction of the EHSCP https://www.edinburghhsc.scot/wp-content/uploads/2020/01/Strategic-Plan-2019-2022-1.pdf

Shows activities that each organisation is undertaking to better understand and support diversity across the city.

Data on service uptake/access 1. People we support

2. System flow

3, Unmet need

4. 3 Conversations dashboard

5. Telecare use – May 2023

6. Pertemps Review Team

7. Review Project Team

8. Residential Review Team

9. One Edinburgh Team

1. We support:

  • Care at home – 5439 people
  • Residential – 957 people
  • ISF – 299 people
  • DP – 1347 people
  • Day Services (excludes block contract users) – 772 people

Some people may be supported by different services.

2. As of end Feb 24, there were 1323 people awaiting assessment.

3. The unmet need list as at the end of Feb 24, shows that 376 people were awaiting a package of care.

4. The 3 Conversations dashboard (Feb 24) sets out details of people supported through a 3C approach, including average wait times, length of conversations and numbers of people supported without the need for statutory services.

5. A snapshot of telecare data from May 2023 shows that 8672 people in the city receive a telecare service, with the dashboard splitting this by type.

6, 264 reviews recorded between 1st of October 2023 and 29th February 2024.

7. 38 Reviews recorded between 1st of January and 29th February 2024.

8. 59 Reviews recorded between 1st of January and 29th February 2024.

9. 187 Reviews recorded between 1st of January and 29th February 2024.

Reviews completed by week (January 2024 onwards)

  • 15 January – 18
  • 22 January – 32
  • 29 January – 62
  • 5 February – 74
  • 12 February – 77
  • 19 February – 58
  • 26 February – 26

A graph showing the data listed above

Data on socio-economic disadvantage e.g. low income, low wealth, material deprivation, area deprivation. Joint Strategic needs Assessment City of Edinburgh HSCP (2020)

Edinburgh Poverty Commission

Provides current and projected data on the demographics within Edinburgh

https://edinburghpovertycommission.org.uk/wp-content/uploads/2020/09/20200930_Poverty_in_Edinburgh-Data_and_evidence.pdf

Data on equality outcomes SDS Uptake Snapshot of SDS uptake as at 19 May 23 shows the client group and ethnicity of those receiving service.
Research/literature evidence Iriss – Doing social work and social care differently publication Doing social work and social care differently | Iriss

Local Government Benchmarking Framework 2021/22.

Local Government Benchmarking

Public/patient/client experience information Home care survey Satisfaction with home care services – 2022

https://www.careinspectorate.com/images/How_good_is_your_care_-_service_users.pdf

https://www.careinspectorate.com/images/How_good_is_your_care_-_relatives_and_carers.pdf

Evidence of inclusive engagement of people who use the service and involvement findings VOCAL Carer’s Survey 2021 Satisfaction with home care services – 2022

Insert presentation title here (vocal.org.uk)

Views of carers within Edinburgh and Midlothian

Evidence of unmet need Projections of budget control measures

Unmet need and community waits

Public Health Scotland Data

The Edinburgh Partnership Digital Inclusion

Assuming approval and delivery of all other savings proposals, it would be necessary to further restrict net growth expenditure by approximately £4750 per week across the whole of 2024/25. This would require locality teams to manage demand within set budgets and would essentially prevent approval of new or increased packages of care (across care at home, residential care, day support, transport, direct payments and ISFs) once the spend limit has been reached each week/month.

As an example, £4750 per week would equate to:

  • 4 people per week requiring residential care who would be unable to access it; OR
  • 11 people requiring an average sized care at home package being unable to access it.

The unmet need list as at the end of Feb 24, shows that 376 people were awaiting a package of care. 1323 people were awaiting assessment.

Public Health Scotland – demand for care at home services across Scotland

Social care – Demand for Care at Home Services 25 April 2023 – Social care – Demand for Care at Home Services – Publications – Public Health Scotland

Good practice guidelines Self-Directed Support Statutory Guidance Social Care (Self-directed Support) (Scotland) Act 2013: statutory guidance – gov.scot (www.gov.scot)
Carbon emissions generated/reduced data N/A
Environmental data N/A
Risk from cumulative impacts The cumulative impact of this and other savings proposals for 2024/25 was assessed on 4th March 2024 and can be found here: https://www.edinburghhsc.scot/the-ijb/integrated-impact-assessments/
Other (please specify) The Independent Review of Adult Social Care

https://www.gov.scot/groups/independent-review-of-adult-social-care/

A National Care Service for Scotland: Consultation

A National Care Service for Scotland: consultation – gov.scot (www.gov.scot)

Inspection of adult social work and social care services: the City of Edinburgh  Inspection of adult social work and social care services March 2023

Integrated Impact Assessments for Review and Assessment, 2023-24, and Housing Support, February 2024.  https://www.edinburghhsc.scot/the-ijb/integrated-impact-assessments/

Additional evidence required

If you would like to see any of the documents noted in this table, email Mike.Massaro-Mallinson@nhslothian.scot.nhs.uk

Equality, Health and Wellbeing and Human Rights Affected populations
Positive

  • If we undertake reviews and assessments appropriately and right size then this ensures that care meets people’s needs. We should not see any additional escalation in, for example, hospital admission from reviews and assessments as we will still be meeting eligible need.
  • The aim is to deliver support within finite resources while ensuring that a balance of fairness and equity to meet the need of future service users is maintained. This approach will help us to support as many people as possible.
  • Some people will have support increased as a result of the review. This means they will be safer and will have their needs met more quickly.
  • Right-sizing support will enable people, especially young people, to maximise independence
  • D2A reviews are often for people with physical disability.  This represents an opportunity for a positive impact where rehab makes a real difference to their condition and helps increase independence.
  • Changes to practice and processes will have an impact on staff, however, this can be positive if it aligns with best practice values and ensures that staff are working consistently across different teams
  •  All
  • All, including people in or at risk of poverty, and carers and families
  • All, especially young people, young carers and people with disabilities
  • People with disabilities and mobility issues
  • Staff
Negative

  • Third and independent sector organisations may be less able to respond to people’s needs if their funding is reduced and therefore be less available to support people who have care packages reduced following review.  This can be mitigated by an asset-based approach to review and assessment to identify alternative options and ways of providing support.
  • Budget control measures could result in needs not being met, which carries an inherent risk of people deteriorating without support.  Although every attempt will be made to triage people appropriately to ensure that those most in need receive care, this risk cannot be entirely mitigated.
  • It is likely that people will be asked to live with a level of support that they are not used to. They may feel that this is a negative impact, even where their care is rightsized and still meeting their need.  This can be mitigated by appropriate conversations regarding right-sizing support.
  • If people are asked to make a contribution towards the cost of Housing Support, this may impact on their disposable income. This would only happen where they have been financially assessed but people may still feel the effects. This can be mitigated by staff training to ensure that alternative funding is considered eg veterans can access a range of activities and support – need to promote this more and make sure review teams are aware of what is available.
  • People may not always be aware of income maximisation support, and even when signposted, there can be difficulty in ensuring people will actually follow through with applying for attendance allowance. There is a lack of practical support to help people with this process and sometimes review teams end up leaving higher levels of housing support in place because they are not satisfied that people will be able to manage this on their own. Mitigation – session for teams with Strategic Programme Manager for Thrive Edinburgh and EVOC to outline some of the practical supports/services to support with this.
  • People may choose to go without their Housing Support service if they are asked to pay towards it. This raises a further set of risks if people are going without services which they have been assessed as needing. However, where people have capacity they are free to make these choices.  This risk can be addressed through the “Money counts” training programme to upskill staff.  VOCAL and other carers organisations also have expertise in this area and can help advise staff.
  • If young people in transition see packages reduced this may cause difficulty or stress.  This can be mitigated through the Working Age Adults transitions workstream which is looking at a more holistic, best practice approach to care planning for young people approaching adulthood.
  • There may be greater impacts on women who tend to have more caring responsibilities and tend to be paid less.  This can be mitigated by Carer Support assessments being carried out where appropriate.
  • Some services we deliver to people with disabilities can be less about core personal care and more about emotional and social support, companionship etc. If we focus more on critical and substantial criteria then these types of supports may reduce. Much of the housing support provided is early intervention and preventative in nature. This can be mitigated by a person-centred assessment or review to ensure that outcomes are met appropriately.
  • A great deal of housing support is for people with mental health problems, usually a low level support package, however, this can be what sustains people in the community and prevents chronic deterioration. Risk that this group is more significantly disadvantaged than others if we reduce this kind of support. This can be mitigated by a person-centred assessment or review to ensure that outcomes are met appropriately.
  • There is an alternative risk that we fail to make the savings that we need because we realise on review that it is not possible to reduce this kind of support, which would increase the necessity to implement budget control measures. This can also be mitigated by focusing on person-centred, asset-based reviews and assessments to ensure that only appropriate levels of support are provided
  • There may be increased communication issues for those who do not speak English. This group is more vulnerable in terms of access to support in the first place, and may be less likely to seek early support and therefore may be in crisis before they present. May be less able to access community/universal services. Mitigation – work with EVOC and wider third sector to use local and thematic networks.
  • Some of these supports are keeping people safe – adult support and protection, financial exploitation. There is a risk that if support is reduced people may be less safe.  This can be mitigated by a person-centred assessment or review to ensure that outcomes are met appropriately
  • Unpaid carers may be at risk of feeling constrained to reduce hours of employment or even give up altogether. This risk will fall more onto women. Young carers could be at risk as they may be less likely to attend school regularly – may not secure better paid employment in future. This risk can be mitigated via income maximisation supports, both internal and external.
  • Cumulative impacts on people with disability – PIP will not always stretch far enough. We encourage people to maximise that but need to be aware that charging for services may put further strain on their ability to manage financially. They may also be asked to make a contribution to the Independent Living Fund. Financial assessment processes are not always detailed enough to take account of all outgoings. This can be mitigated through amending financial assessment processes and through ensuring that people are well-supported to maximise their income
  • There may be less availability of alternative community supports for people living in rural areas if their formal support is reduced.
  • Changes to review and assessment practices will impact on how staff are used to working. This can be mitigated through a robust learning and development programme and leadership support, increasing senior coverage so that staff feel that they are supported in their decision making. Need to ensure that there are really clear escalation processes so that this risk is not left with individual staff.
  • Risks of increased stress etc through having difficult conversations with families or feeling that they are carrying increased risk to service users. This can be mitigated through a robust learning and development programme and leadership support.  Team stress risk assessments have identified the need for clear public communications which set out what is happening and why to support staff.
  • Risk of escalating complaints and staff having to deal with this. This can be mitigated by clear public communications which set out what is happening and why to support staff.
  • If we cannot offer support to people because we have reached our maximum limits then this carries a much greater level of risk and has a very significant level of stress for staff. While training and development and leadership offer some mitigations, it is not possible to completely mitigate against this risk.
  • Budget control measures may represent risks to safety, deteriorating condition and ultimately risk of shortened life span. We need to acknowledge the severity of the risk to people if we have assessed them and are unable to put a service in place.  Effective and robust triage processes will mitigate against this risk, however, they may not be sufficient to completely alleviate the impact.
  • If some providers go out of business as spend in the private sector is reduced through these measures, then there are risks that people they support are more likely to fall into poverty as they may need to seek their support elsewhere and pay for it. This could result in growing inequity between those who can afford to do so and those who cannot. This can be partially mitigated by maximising access to appropriate benefits and other forms of funding.
 

  • All
  • All, including carers and families
  • All, including people in or at risk of poverty, and carers and families
  • All, including people in or at risk of poverty, and carers and families
  • All, especially people in or at risk of poverty and their families and carers.
  • People and carers in or at risk of poverty
  • Young adults or children approaching adulthood and their families and carers
  • Women
  • People with disabilities
  • People with mental health issues
  • People of minority ethnic backgrounds and people who do not speak English
  • Vulnerable adults
  • Carers, especially female carers and young carers
  • People with disabilities who are in poverty or at risk of falling into poverty
  • People living in rural areas
  • Staff
Environment and Sustainability including climate change emissions and impacts Affected populations
Positive

There were no specific positive impacts identified as a result of these proposals.

 

 

 

Negative

There were no specific negative impacts identified as a result of these proposals.

 
Economic Affected populations
Positive

  • The private care market in Edinburgh is fragmented – there is potential for this approach to consolidate the market and make it more resilient in the longer term. However, it will be crucial to monitor and track and ensure early warning of issues. EHSCP will need to grow and nurture those providers that give quality care and that we want to work with in the future.
  • There are opportunities within the EHSCP – vacancies – for some staff displaced from the independent sector, they may be able to be supported into some of these roles
Businesses
Negative

  • Risk that providers increase the number of packages which they hand back. While this can be mitigated by working closely with and monitoring our providers and assessing their viability, there still may be an impact on businesses and people who are currently supported.  In mitigation, we will make every effort to manage this carefully, keep communicating and monitor impacts. The Older People’s Pathways programme and the One Edinburgh commissioning work will help to mitigate against the impact by developing a supportive framework and working closely with our providers.
  • Risk of redundancies and a risk of people on zero hours contracts having their hours reduced.  This can be mitigated through the One Edinburgh and OPP programmes through the development of a supportive framework for commissioning.
  • Potential for a decrease in consistency and continuity of carers for people through provider instability.  This can be partially mitigated through the One Edinburgh framework.
  • Viability of businesses (especially smaller ones) may be impacted.  This will be mitigated as far as possible by working closely with and monitoring our providers and assessing their viability
  • Care at Home organisations are increasingly recruiting through the Home Office and they need to guarantee a certain number of hours. This may lead to less local recruitment if the organisations are to fulfil this requirement with less hours being commissioned
  • The quality of care provided may decrease if providers are disrupted.  This will be mitigated by routine monitoring processes eg by the Care Inspectorate and EHSCP Contracts Team.
  • Services supporting people are not all directly funded by the EHSCP and may be funded by other area of the Council. This means that organisations may have multiple funding sources which are also being reduced, with a risk of double impact.  This can be mitigated by monitoring organisations closely and working with them to establish potential impacts.
  • Third sector redundancies may result in loss of volunteers as well as the third sector staff who coordinate that. This will reduce the alternative options to formal support packages.  This can be mitigated by careful distribution of the remaining third sector grants programme.
  • Businesses and all people supported by private providers
  • Businesses and people in lower-income roles, especially people on zero-hours contracts
  • Smaller and local businesses
  • Third and independent sector organisations

The Edinburgh Health and Social Care Partnership commissions services from both the third and independent sector.  Robust contract management arrangements ensure that this will be addressed.

A full communications plan is in place, to ensure communication with service users, the general public, partners, provider organisations and staff. Where individual savings proposals impact on these groups, appropriate communication methods will be used.

If yes, it is likely that a Strategic Environmental Assessment (SEA) will be required and the impacts identified in the IIA should be included in this.

No

If further evidence is required, please note how it will be gathered. If appropriate, mark this report as interim and submit updated final report once further evidence has been gathered.

None identified.

Specific actions (as a result of the IIA which may include financial implications, mitigating actions and risks of cumulative impacts) Who will take them forward (name and job title Deadline for progressing Review date
Review and update the IIA once implementation is complete to ensure any additional impacts are identified Mike Massaro-Mallinson June 2024 July 2024
Continue, and strengthen, the approach already being taken by the EHSCP contracts team to monitor impacts across providers and allow for early warning where a specific provider may be at risk through reductions. Emma Gunter, Contracts Manager Ongoing
Ensure that training in income maximisation eg Money Counts is delivered to review and assessment staff.  This should include advice on using third sector support eg VOCAL. Linda Irvine-Fitzpatrick, Strategic Programme Manager, Thrive Edinburgh June 2024 July 2024

Although mitigating actions have been identified as far as possible, it is recognised that the Budget Control measures in particular are likely to have a significant impact on people requesting support, staff and businesses.  This proposal carries high levels of risk which can only be partially mitigated.

This proposal will continue to be reviewed with ongoing consideration to any impacts that arise.

Mike Massaro-Mallinson's signature

Name: Mike Massaro-Mallinson

Date: 08/03/24