Agenda item
Mental Health and Adult Social Care performance
At the last meeting of the One Council Overview and Scrutiny Committee on 21 March 2013, members requested that a special meeting of the committee be arranged to consider and question lead officers on the following issues:-
· Further information on Mental Health Services and in particular an explanation as to why performance remained red in this area and what was being done to address this.
· Further details concerning Adult Social Services, specifically in relation to details of the strategy on re-assessment of clients and the number of clients moving to direct payments.
A briefing note and the report that went to the Executive on 22 April 2013 on authority for procurement of community based mental health support are attached for information.
Minutes:
Phil Porter (Interim Director of Adult Social Services) introduced the briefing note and referred to the various performance indicators. Starting with performance indicator NI 130 – social care clients receiving self-directed support, Phil Porter explained that this was part of the ‘putting people first’ agenda. Initially, self-directed support had operated as a separate process using a specific set of documents, however in April 2011 it became amalgamated with Adult Social Care. Phil Porter advised that the definition of the NI 130 indicator had not previously been interpreted correctly as the percentage figures applied to those who received direct payments only. Clarification had since been sought that the indicator includes any who receive self-directed support to fund services, whether through making their own arrangements or who choose to have council managed services. In view of this, the target would be duly set at 100% as of quarter one in 2013/14, as everyone who is eligible receives self-directed support. Phil Porter stressed that the council was focusing on helping with the individual needs of each client.
Mary Stein (Head of Transformation Service, Adult Social Services) added that new legislation would be coming in over the next two years and it was anticipated that some NIs would be added, removed or changed as the emphasis focused on reablement. Elizabeth Jones (Assistant Director of Finance, Adult Social Services) advised that future performance data would also include a breakdown of those receiving direct payments only and the total number receiving self-directed support.
Members then discussed issues relating to NI 130. In respect of the misinterpretation of NI 130, it was queried how long inaccurate data had been provided and did this also mean that performance was below the required standards. It was commented that as direct payments had been in place for some time, the relevant performance indicators should have been interpreted correctly and confirmation of the numbers of those presently receiving direct payments, those not claiming and those receiving council managed services was requested. It was queried whether training was given to clients who were on direct payments and was it clearly explained to them about the need to keep records such as receipts. Information was sought on what clients were asked to record. In addition, it was asked what the charges were to help those on direct payments manage their accounts. Officers were asked if direct payments were monitored and the need for transparency and to account for funds was emphasised. Details were sought as to what actions were being taken to identify suitable alternative providers for those on direct payments and a list of these was requested. It was asked what steps would be taken to take performance forward and when was it likely to change to green RAG status.
In reply to the issues raised in respect of NI 130, Phil Porter clarified that previous performance data that had been provided was not inaccurate as such, but reflected a different interpretation. He advised that around 400 clients presently received direct payments, whilst a total of around 1,000 received traditional health care services. The committee heard that clients received training as part of their support plans following their assessments and it was clearly set out what they could and could not do in these plans. In addition, assistance is given in setting up direct payments when clients employ someone to provide services. Phil Porter added that the contract framework would help identify suitable providers and establish the care contract process. He anticipated that NI 130 would achieve a green performance status the next time that it was reported to the committee. Phil Porter confirmed that details of the numbers on self-directed support, those on direct payments only and those receiving council managed services would be provided.
Elizabeth Jones advised that some clients may be receiving both direct payments and receiving traditional services. Elizabeth Jones explained that the direct payments contract also set out what clients and their carers needed to do. A pre-paid card had also been introduced which allowed clients to either telephone or use the internet to purchase services and this made it easier to maintain an audit trail and provide the added advantage of real time monitoring. Around 85% of direct payments clients were now on a pre-paid card arrangement and this had made monitoring much easier. Clients could also upload receipts and receive support by telephone. Elizabeth Jones explained that when direct payments had initially been introduced, the Government had promoted a ‘light touch’ to monitoring, however now much more transparency was desired. Members heard that the council would pick up costs associated with support given to clients to manage their accounts. Elizabeth Jones stated that a demonstration of how the pre-paid card worked could be provided to Members.
Elizabeth Jones explained that following a one-to-one dialogue with the assessor and the client, the client’s needs would be identified to help put together the support plan and how its’ objectives could be achieved. A number of organisations could be used by clients and Age Concern also provided advice on this. Mary Stein added that the market of providers would be assessed as part of the commissioning strategy.
Members requested that information include raw data and a breakdown of these figures and also to include the numbers of clients involved, as well as percentages. It was felt that statistics in the form of a set of tables would be more useful and a member suggested that a template similar to that used to report information to the Budget and Finance Overview and Scrutiny Committee could be used. The Chair added that a presentation demonstrating how the direct payments pre-paid card worked could be provided at a future meeting.
Phil Porter then drew Members’ attention to NI 132, timeliness of social care assessments (mental health only), whose performance status was red, and NI 133, timeliness of social care packages following assessment (mental health only), whose performance status was green. He explained that last year, the number of referrals had been 50 per month, whilst the average for this year was 150 and so this partly attributed to the reasons why NI 132 indicator was red. The Central and North West London Hospital Trust (CNWL) was investigating the reasons for the increase in GP referrals. However, once the assessments were completed, performance in putting together social care packages was good and this is why NI 133 was green. Although CNWL had redesigned the service, this had not led to the improvements desired. Phil Porter advised that a recent comprehensive review of Brent Mental Health Services had recommended that a process of competitive dialogue commence with any willing provider to redesign the service to make it more efficient and effective. It was anticipated that the competitive dialogue process would take between 12 to 18 months.
During Members’ discussion, one member suggested that specific dates be included in reports, rather than references to events being recent or historical. With regard to the reference in the briefing note to the high volume of cases where clients did not attend their appointments, it was suggested that a friendly telephone reminder would be helpful, especially as some clients may be less trusting of authority and a more informal approach could be beneficial. It was queried in what other areas had a competitive dialogue process been undertaken and how did this differ from other tendering processes. Another member queried why a competitive dialogue process had not been considered previously. Views were sought as why the number of referrals had increased so significantly and what was being undertaken to address this. It was queried whether the increase was partly attributable to the closure of day centres. Members asked whether the Director of Public Health would be involved in addressing this issue.
In reply, Phil Porter stated that an incentives based system could partly explain the reasons for the increase in referrals by GPs and in addition, the move towards more safeguarding could also be a reason. He stated that in around 50% of the referrals, clients did not attend assessments and it was possible that a number of these were clients who had been re-referred. To address these issues, monthly meetings with the Brent Clinical Commissioning Group (CCG) were taking place to see if the service set up was the most appropriate, whilst efforts were also being made to improve communications with GPs. The Director of Public Health would also play a role in looking at mental health needs and would be involved in the competitive dialogue. Phil Porter stated that a competitive dialogue process had been used previously in social services, however the perceived risk element had prevented such a process from being used more frequently.
Elizabeth Jones explained that during competitive dialogue, the council would ask potential providers for their ideas in helping achieve its’ objectives and this would allow flexibility in that the council could ‘cherry pick’ the best ideas emanating from the process, rather than having to set a service specification from the outset.
Councillor Hirani (Lead Member for Adults and Health) added that provider hostility to competitive dialogue was also a factor as they would not want to see their best ideas taken by a competitor. However, there were a number of other examples of competitive dialogue exercises across the council, one of the most recent being the procurement of the Public Realm contract.
In respect of the rising number of referrals, Mary Stein added that the comprehensive review of Mental Health Services had suggested that appropriate training, particularly in respect of GPs, would be needed to address this issue.
Phil Porter then provided an update on NI 135, percentage of carers receiving needs assessment or review and a carer’s service. The performance indicator was red and there had been difficulty in recording carers because of:
· Social workers traditionally focusing more on the needs of the service user
· The process of recording carers on Frameworki in a systematic way not being as robust as it could be
· Some carers not identifying themselves in this role and refusing assessment on the basis that they do not see it as being relevant
· The indicator assumes that 100% of carers require annual reviews of their assessments
Phil Porter advised that there would be more focus on carers in 2013/14 to address this and a number of initiatives have been put in place to improve performance. This included setting up a Carer’s Hub ‘one stop’ service and improving workflow processes to help identify and record carers more easily and ensure 100% of identified carers are offered assessments.
Members enquired how collecting data issues through Frameworki were being resolved and sought further information on how the Carer’s Hub would operate. It was acknowledged that carers would appreciate being able to relate to other people in similar situations. One member suggested that the number of carers in Brent was likely to be higher than estimated and asked how this number had been arrived at and commented that a lot of carers would not be visible. This was partly attributable to a cultural mind set where it was seen as the norm for some members of the family, particularly women, to take on a carer’s role and not wishing to mention it publically or to authorities and this was an issue that should be tackled. It was enquired whether there was information on the profiles of the carers who were being assessed and those who were not. Information was sought on how many carers there were in Brent and the number who were receiving financial support and also to compare this with figures for 2010/11.
In reply, Councillor Hirani explained that the Carer’s Hub would act as a single point of access for all carers across Brent and that it was estimated that there were around 23,000 carers in the Borough, a comparatively high number. He felt that the Carer’s Hub needed to be publicised more to encourage carers to participate.
Phil Porter added that the Carer’s Hub would also work with GPs and a private care liaison nurse to extend help to carers. With regard to Frameworki, he explained that processes to record carers were being simplified and improvements in performance should be evident by quarter two in 2013/14. He stated that there was a moral duty to be supportive to carers and at an early stage, as this would lead to better outcomes for both service users and carers, as well as resulting in less costs in the longer term. He agreed to provide information in relation to the number of current carers in Brent and how the figure of 23,000 had been determined, those receiving some kind of financial support and a comparison of these figures with 2010/11.
Turning to the performance indicator relating to local quarterly number of delayed hospital charges, Phil Porter advised that the indicator was red, however a very ambitious target had been set for 2012/13. Performance was still a significant improvement from 2011/12 and the target would be revised accordingly for 2013/14.
Elizabeth Jones then referred to transitions overspend forecast for 2012/13, which was associated to the cumulative shortfall in funding for the Transitions Service over the previous two financial years. The costs for running the service had not been properly calculated upon transferral from Children and Families and as a result a legacy overspend had been inherited. However, the shortfall had been addressed within the medium term financial strategy for 2013/14 and a balanced budget was on track for the department for 2012/13. Elizabeth Jones confirmed that children were transferred to the responsibility of Adult Social Services when they reached 18 years of age.
Whilst acknowledging the success in managing to balance the accounts, a member asked what steps were being taken to ensure that inheriting such an overspend would not occur in the future.
In reply, Elizabeth Jones explained that the inherited overspend was due to Frameworki not being fully utilised in Children and Families, however a One Council project had been looking at ways to improve the way it was used and Frameworki was to be re-launched in that department in October 2013.
Supporting documents:
- 2013-05-02-adsocialcare[1], item 2. PDF 88 KB
- 2013-05-02-mental-health[1], item 2. PDF 104 KB
- 2013-05-02-adsocialcaresupp[1], item 2. PDF 59 KB