Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Cambridgeshire County Council (DD 8)


  1.1  This submission is from Cambridgeshire County Council and is intended to give the Select Committee evidence about the circumstances in Cambridgeshire that have a direct bearing on the issue of delayed discharges in the local area and that resonate with experiences in many other areas of the country. The local experience has given clear indications of the ways in which both central government, the NHS and local government needs to respond in order to address the issue.


  2.1  Residents of Cambridgeshire rely on a number of hospitals for general health services. The main providers are Hinchingbrooke Hospital and Addenbrookes Hospital but hospitals in Peterborough and Kings Lynn also provide district general hospital services for Cambridgeshire residents. The problem of delayed discharges has been significant for Cambridgeshire residents admitted to all of these hospitals but has been particularly significant for residents using Addenbrookes and Hinchingbrooke. The level of delayed discharges across the area covered by the County Council has been well above national averages for many years and has been subject to rigorous reduction targets for the past three years. The area is one of the 55 "hot spots" identified for preferential funding from the recent Building Capacity Grant introduced in November 2001 by the Department of Health.


  3.1  These have been in the mainstream of recommended activity and have included:

    —  Agreement between the Council and the NHS on reduction targets—set at 20 per cent in 1999 and 2000 (and achieved); set at 25 per cent in 2001 but not achieved despite additional investment.

    —  Investment in intermediate care. A strategic decision was made by the Council and local NHS partners to invest in services that would both prevent hospital admissions and promote the recovery of independence in non-acute settings. The level of local investment has been well above the amounts granted by government in ear marked funds.

    —  Close co-operative working between the Council and local NHS partners. This has resulted in many jointly provided services.


  4.1  The constraints on the Council in responding to delayed discharges have included:

    —  Rapid deterioration in the ability of home care agencies to compete in the employment market and recruit sufficient care staff. During 2000 vacancy levels across the sector in Cambridge City, where the problem has been most acute, were at 40 per cent. Three major providers with whom the Council held contracts ceased to trade, unable to cope in this environment. On 18 January 2002 there were 104 people in the south of the County awaiting the provision of home care. Priority is given to those being discharged from hospital but this in turn impacts on the capacity of the service to support those who are at risk of admission to hospital.

    —  Shortage of nursing home places in Cambridge and of residential places in Huntingdonshire. In situations where Cambridgeshire residents can fund their own care, services are not always available.

  4.2  These constraints have arisen for a variety of reasons. The main ones are explored below.


  5.1  The area has high levels of employment, particularly in the south of the County.

  5.2  The New Earnings Survey published in 2001 showed that between 1996 and 2000 Cambridgeshire experienced the second highest rise (nearly 25 per cent increase) in gross weekly earnings of any English County. (see graph in Appendix I). Average earnings in Cambridgeshire, at £426 per week, are above those in some other South Eastern counties that qualify for the Area Cost Adjustment Allowance—the government grant intended to assist high cost areas (see Appendix II). Cambridgeshire does not qualify for this allowance. This compounds the problem of the low Standard Spending Assessment (see Appendix III).

  5.3  House prices in the area are also high (see Appendix IV)—higher than those in some other areas that receive Area Cost Adjustment. In Cambridge City house prices are amongst the highest in the country.

  5.4  The impact of this has been felt most acutely in home care services and in residential and nursing homes where there is heavy reliance on significant numbers of relatively low paid staff. The NHS locally has experienced similar recruitment problems. However, for the purposes of defining levels of pay for nurses, Addenbrookes Hospital in Cambridge is defined as a "London and the South East Hospital".

  5.5  The difficulty experienced by social care services in attracting staff at rates of pay affordable by the public purse is a national issue but the Cambridgeshire experience has been made worse by the local economic factors described above. The availability of adequate home care, residential care and nursing care is crucial to reducing the numbers of delayed discharges.


  6.1  Cambridgeshire experiences very similar levels of dissonance between actual spending requirements and the requirements assessed by government to those experienced across the country. The pressures from higher levels of disability (particularly learning disability) and from complex needs amongst children are similar to those in other places.

  6.2  The local history differs in only one respect in that patterns of activity and expenditure in children's services during the late 1990s were very different to those elsewhere. This has now been addressed and during the past two years funds have transferred from children's services to adults services. This has helped with the problem of delayed discharges and Cambridgeshire has not so far encountered the national problem of funds needing to move from adult budgets into children's budgets. However, in line with national trends, children's services are under increasing pressure and the strategy of protecting adult budgets may not be sustainable.

  6.3  The impact of this dissonance between assumed requirements and actual requirements has been most significant in the high volume services associated with the care of older people. Inflation rates built into the SSA have been inadequate to deal with the economic factors described above and the gulf between pay rates, contract rates and fee rates that are affordable for the Council and the actual costs of providing social care services has grown.

  6.4  Locally this has affected market confidence and it has been difficult to attract new nursing and residential care providers to the area, despite the shortage of places. There have been no new homes opened in Cambridge City for some years.

  6.5  It has been difficult to secure places in local homes for local people who require public support. At least 46 per cent of provision in the south of the County is occupied by self funders and/or residents funded by other local authorities. There is little incentive for home owners to offer places to the Council even if the place is required for someone waiting in a hospital bed.

  6.6  A recent study commissioned by the Council from Laing and Buisson consultancy demonstrated the size of the gap between the actual costs of providing places and the fees paid by the Council. In some parts of the County (see Appendix V) the gap is £100 per place per week. It is clear that providers are filling some of this gap through higher charges to private clients.


  7.1  The Council has been very committed to resolving the issue of delayed discharges and has been well aware of the impact of this both on older people themselves and on the capacity of the local hospitals to meet patient need.

  7.2  The Council has allocated funds to social services well above assumed government levels in order to fill the gap between government assumed inflation rates and actual inflation in the local economy. For example, the Council allowed for an assumed inflation rate of 10 per cent for home care services in 2001-02 and is planning to allow for a rate of 7.5 per cent in 2002-03. Similarly the average inflation rate applied to residential and nursing home fees in 2001-02 has been 4.4 per cent. However, the increase for nursing homes was 6.2 per cent. The Council is planning a further average fee rate increase of 8 per cent for 2002-03. In some parts of the County increases of 17 per cent are proposed in order to ensure that the current levels of provision are protected and that places are available to publicly funded users.

  7.3  Some of the increases proposed for 2002-03 have been made possible by the Building Capacity Grant, a short term grant with uncertain status after 2002-03. However, the "lions share" of inflation costs are likely to be met by the Council tax increases of 9.3 per cent that are being proposed by the Council's Cabinet.

  7.4  It should be further noted that during 2001-02 the problems with delayed discharges became so acute that the Council felt obliged to take £0.5 million from reserves in order to assist independent sector home care providers with their recruitment problems. In effect this money was an advance on the inflation increases planned for 2002-03.

  7.5  This is all in a context where the Council's social services department has met all the required targets from the Department of Health for efficiency savings; and is in the top quartile of performance nationally for providing intensive home care services and supporting people in residential and nursing homes.

  7.6  The Council is amongst a small number of Councils already subject to a local Public Service Agreement with central government to deliver on "stretched" performance targets in certain service areas in return for reward funds if targets are met. The significant reduction of delayed discharges is one of the Council's stretch targets and there is strong motivation to succeed despite the constraints described above.


  8.1  In these circumstances "doing more of the same" has not been an option and many strategies have been pursued as a means of closing the resource gap.

  8.2  Partnership work both with the health service and with independent providers has to be particularly robust in these circumstances:

    —  Home care providers receive considerable assistance from the Council with staff recruitment and training. The Council has recently brokered a deal with the local Business Links service to obtain assistance for providers in business planning.

    —  Promises to residential and nursing home providers that fee rates will at least increase incrementally have always been honoured and have helped to demonstrate "good faith" even if the funds involved are acknowledged to be insufficient.

    —  Many services have been planned and delivered jointly with health partners and a recent best value review of Occupational Therapy services has been carried out jointly with health and will result in an integrated service under the Health Act.

    —  There are plans to do everything possible to integrate social care with primary care, although the Care Trust option is considered to be a distraction from service delivery. The option is complex in the Cambridgeshire environment as so many of the PCTs cover patients who are not Cambridgeshire residents.

    —  There has been work with housing colleagues to accommodate staff recruited from the Philippines and also to develop new sheltered schemes, including schemes that specifically offer intermediate care.

  8.3  Workforce planning has resulted in a number of initiatives designed to attract to social care different population groups:

    —  The Home Care Apprentice scheme has been very successful in attracting younger people and has also secured funding from the Learning Skills Council.

    —  The "Silver Service" has attracted older people who are prepared to undertake some of the less physically demanding care tasks.

    —  The "Night Cap" service has attracted people who specifically want to work during unsocial hours. This service has dedicated drivers who transport home carers enabling the service to recruit non-drivers and reducing the fear of night time work.

  8.4  Vacancy rates in Cambridge City have reduced from 40 per cent to 20 per cent, which is also the current rate across the rest of the County.


  9.1  Cambridgeshire's experiences highlight a number of issues for the Select Committee to consider:

    —  The resourcing of social care has clearly lagged well behind the expectations of what can be delivered. This must be acknowledged as a significant threat to the delivery of the NHS Plan. It cannot be resolved solely through improved partnership work with the NHS. The problems have been greatly exacerbated by the failure to recognise the full impact of economic and other changes on the costs of social care.

    —  Although there has not been sufficient evaluation of intermediate care schemes and their impact on delayed discharges, the policy of promoting independence and decreasing reliance on residential and nursing home care is soundly based but cannot work in the absence of a stable and properly funded market of care for the most dependent people. There needs to be a continuum of care and whilst funds that are targeted at new service developments are welcome, they are also wasteful when there are inadequate funds for existing services. A vicious circle develops whereby time and energy is devoted to propping up services that are failing through lack of resources. This diverts energy from making sure that new services work well and genuinely contribute to the total continuum. In Cambridgeshire intermediate care beds get blocked because home care cannot take on the return home package.

    —  The strategic intent to change the way in which a system functions requires a more strategic approach to funding. This creates an environment of confidence for providers and enables Councils to plan ahead. The problem of delayed discharges has been made worse by short term fixes involving short term funds. Councils often receive very short notice that funds will be made available. The funds are accompanied by targets that can only be met by quick responses that are simple to achieve but not necessarily sensible in the longer term. For example, it may be considered that greater investment in a service that prevents admissions would have the best long term impact. However, services like this cannot be expanded instantly. There is therefore a strong temptation to simply purchase more beds (if they can be obtained) as this moves people from hospital very quickly. This often ties up funds in this service for some considerable time (the remaining lifetime of the user). This problem is compounded when the funds are short term—the service or the user are still in place, along with the financial commitment. Other funds have to be diverted to fill the gap. This then impacts on delayed discharges so further short term funds appear—and the vicious circle is perpetuated.

    —  There is an urgent need to address workforce issues across the health and social care spectrum and not solely as issues that occur separately within Councils and the NHS. A recent profile of the current workforce in Cambridgeshire across the health, social care and independent sectors, showed low proportions of younger people in the workforce and high proportions of older people. Given the current retirement age, the public sector in Cambridgeshire will see significant numbers of people leaving the workforce in the next five to ten years with little prospect of replacement, given current trends. In this scenario, applying different levels of funding increases to health and social care; treating Addenbrookes as a London hospital for pay purposes whilst excluding Cambridgeshire from the South East Area Cost Adjustment club, compound the lack of coherent national strategies. The NHS and its partner councils will need shared workforce strategies and not ones that pull in different directions with different funding contexts. The apprentices attracted by the Council to home care may well be the nurses of the future. Similarly nursing auxiliaries in hospitals might move to work in the community to gain a different experience. They may be the home carers of the future.

    —  The persistent tendency of the NHS to focus on structural change as the means to secure improved delivery needs to be resisted. There is significant potential for the Council to forge successful partnerships with the new Primary Care Trusts and there is much local optimism about the potential to secure improvements in service delivery, including the issue of delayed discharges. However, this optimism derives from the hope that 2002 will bring greater organisational stability to the NHS and allow more energy to be focused on changes for users derived from service and front line practice improvements rather than from different structures.

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