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The Bristol Cable

Further cuts and restructures to adult social care services in Bristol are on the table this week. Here we recap what’s happened so far, what changes are afoot and what impact people are seeing.

Photo: Obencem

Bristol councillors are due to set next year’s budget on 20 February, with proposals for £34.5 million in savings.

Just over £4.5 million comes from the council increasing its income, for example by looking for new commercial opportunities or charging for things it currently offers for free.

But the remaining £30 million-odd sits in the ‘cuts’ column: efficiency drives, changing how services are provided, or shrinking or stopping them altogether.

And more than a fifth of that – £6,221,000, with a similar amount to follow by 2021 – is coming from changes to adult social care services, which support people with disabilities and long-term illnesses, and their carers.

The council has big plans to reshape these services – which, as they are elsewhere in the country, are in crisis. But there are already fears about the impact of the changes on the people who receive them, and on some of the organisations paid to deliver them.

The national squeeze

The last few years have not been kind to the adult social care sector. Councils’ budgets have been steadily squeezed at the same time as the UK is grappling with the challenges of people living longer with increasingly complex care and support needs.

This means local authorities are trying to do more with less. The Care Quality Commission, which regulates the sector, has repeatedly warned of it being at a “tipping point”.

Last year, stories of care providers handing back ‘unviable’ contracts – which they said they could not fulfil at the rates councils were offering – hit the headlines. With jobs in supermarkets often paying more than highly demanding care roles, it’s no surprise these employers often struggle to hire and keep hold of staff.

Perhaps predictably, 2017 also saw delayed discharges from hospital attributable to social care services hit record levels (though there has since been some improvement). These delays, often referred to as ‘bed-blocking’, occur when someone is ready to leave hospital but can’t because a care package or placement has not been sorted out.

Last March, the government announced an extra £2 billion of ‘improved Better Care Fund’ money for councils, spread over three years, to prop the system up.

But this is a sticking-plaster at best. The forthcoming publication of a government Green Paper on the future of older people’s social care, due this summer, has been described as a “once-in-a-lifetime opportunity” to sort things out.

Bristol’s situation

In Bristol, the council overspent significantly on its adult social care budgets in 2015-16 and 2016-17, by around £7 million and £9 million respectively.

Last year’s Bundred report into financial mismanagement at our local authority actually cut it some slack in terms of the pressures it faced around adult social care – though it concluded “Bristol did not address [its] problems early enough or with sufficient rigour”.

In the wake of Bundred, Bristol council approved £33 million in cuts for 2017/18, including about £6 million relating to adult social care.

Almost £5 million related to the council reconfiguring its whole service model to a ‘three-tier’ system – intended to promote people living as independently as possible, in line with the Care Act 2014 – and recommissioning community support services alongside this.

Other associated 2017-18 cuts included reducing respite care at a saving of £454,000 and restructuring the ‘care and support, adults’ social work team, trimming £196,000 from the budget.

‘Intrusive’ scrutiny

It’s early days for the service redesign, known as the Better Lives Programme, which basically aims to ensure people have access to advice or more hands-on help if they need it, while keeping as many of them as possible away from expensive long-term packages of care.

The process, under which the next three years’ savings also sit, has so far included reviewing support packages, and promoting the use of electronic prepayment cards for people who receive a direct budget to manage their social care needs.

The reviews are not proceeding at anything like the pace envisaged by the council. But there are are already concerns about thier impact.

“We are hearing some people are getting their support package reduced, but we can’t yet determine whether this is a general trend or just a few isolated cases,” Laura Welti, the manager of Bristol Disability Equality Forum (BDEF), tells the Cable.

Speaking on condition of anonymity, several people receiving direct social care payments say that while they have managed to maintain their existing packages, reviews carried out by the council have featured excessive levels of scrutiny.

One, whose personal assistants (PAs) were asked to complete detailed diaries of exactly what tasks they carried out, and when, says they felt they had been left with “no private life” by the process.

Some also describe attempts to micromanage down the amount of time spent with PAs, whether in the name of saving money or promoting independence, as incompatible with real life – and in one instance potentially dangerous.

A click of a button and anyone with access can see exactly [how, when and] where we have spent our direct payment – as you can imagine, this feels very intrusive

The new prepayment cards – which were criticised last year in a national study carried out by the Independent Living Strategy Group (ILSG) – have been another sore point, again because of their potential for restrictive monitoring.

One person tells us they were offered the choice between a cut in their personal budget and accepting one of the cards. But others also say Bristol has behaved far less aggressively than neighbouring councils in trying to switch people onto them.

“The concern of most of our activists who are on direct payments is the inroads into their privacy that prepaid cards bring,” says Welti. “A click of a button and anyone with access can see exactly [how, when and] where we have spent our direct payment – as you can imagine, this feels very intrusive.”

She adds that the cards could leave people who lack confidence using computers at a disadvantage – or even at risk of financial abuse if they ended up over-reliant on PAs to administer their finances.

Supported living and transport cuts

Two other specific cuts announced last year but only due to come into full force this April relate to the council’s Supporting People services and its Community Links day centres.

Supporting People was a pot of money for housing support brought in under the second Blair government and originally ringfenced. Once the ringfence was removed in 2009, services in many areas dwindled or disappeared – as has been the case with some ‘floating’ tenancy support services, for instance around substance abuse, in Bristol.

But Bristol council appears to have taken an unusually broad approach to the services funded by its Supporting People cash. As a result, some – which support older people, and people with learning disabilities, sensory impairments and mental health issues – have remained. These are overseen by adult social care (rather than housing) but delivered by third parties, who in some cases keep people away from needing statutory social work interventions.

Budgets for these services will now be cut by 15% as the main part of a £1.8 million saving over three years. A risk is that if their capacity to support also reduces, some people with higher needs will end up having to be assessed by social workers, meaning money taken by one hand could simply be paid out by another. Alternatively, they might end up needing costly NHS treatment.

“These people need support, whether it comes from Supporting People or the main adult social care budget,” says Linda Phelps, head of supported living at the Milestones Trust, a supported housing provider affected by the cuts. “Some are in 24-hour provision – you can’t really cut that and call it a saving.”

Meanwhile, changes to Community Links services, amounting to £1.3 million over three years, will see automatic entitlement to transport to and from three daytime ‘community hubs’ removed. They are primarily used by people with physical and learning disabilities, or with dementia.

“Many service users that access the Bristol Community Links service are vulnerable adults who may experience difficulty in adapting to any changes within the service,” the council’s assessment said. “Similarly, a small change to routine could adversely impact on carers or family members.”

BDEF’s Laura Welti adds that the plans pose a “real risk” of increasing people’s isolation.

‘Hard conversations’

Interviewed by the Cable last week, Bristol council’s cabinet member for adult social care, Helen Holland admits the consultations around the Supporting People and Community Links cuts had involved “hard conversations”.

But in each case, she argues, the alternative choices – of deeper and more selective cuts – were less popular and would have done more harm.

According to Holland, the bulk of savings this year and over the next few will be achieved by addressing Bristol’s “huge over-reliance” on residential and nursing care. The council plans to invest more than £9 million of its Better Care Fund money into the local home care sector – a cheaper option than residential – with a view to making it a more viable career choice for people.

It goes without saying that most people receiving social care support would prefer to remain in their own homes if possible. With this in mind, it’s potentially positive that the council also says it will be putting £3 million into assistive technology – which helps people stay in their homes and reduces their reliance on human carers. This area has come on in leaps and bounds in recent years thanks to internet-connected devices – though critics warn that great care must be taken not to simply phase support workers out of the equation as a means of councils saving money.

Holland, who says she wants to hear directly from anyone who feels they are getting a raw deal as the system changes, claims that “if we get things right and can change the balance of how we approach care, this can end up as a good news story”.

Time – and developments at a national as well as local level – will tell whether that proves to be an over-optimistic view.

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