Adult Social Care and Services Scrutiny Panel Minutes

Adult Social Care and Services Scrutiny Panel Minutes

Date:
Monday 7 January 2019
Time:
10:30 a.m.
Place:
Spencer Room, Town Hall, Middlesbrough
 

Attendance Details

Present:
McGee (Chair), Coupe, Dryden, McGloin, Uddin, J Walker and Walters
Officers:
C Lunn, E Scollay, C Walker and K Whitmore.
Declarations of interest:

There were no Declarations of Interest.

Item Number Item/Resolution
PUBLIC
18/38 MINUTES - ADULT SOCIAL CARE AND SERVICES SCRUTINY PANEL - 3 DECEMBER 2018

The minutes of the Adult Social Care and Services Scrutiny Panel meeting held on 3 December 2018 were submitted and approved as a correct record.

18/39 MATTERS ARISING

Members were advised that the Panel’s report regarding 'The LGB&T Community and Elderly Care’ would be considered by the Overview and Scrutiny Board on 8 January 2019.

 

NOTED

18/40 INTEGRATION OF HEALTH AND SOCIAL CARE - VERBAL UPDATE

The Director of Adult Social Care and Health Integration provided the Panel with an update regarding the integration of Health and Social Care.

 

Members were informed that officers from Middlesbrough Council and Redcar and Cleveland Borough Council had been working with the Chief Operating Officer responsible for the five combined Clinical Commissioning Groups (CCGs) locally, together with representatives of James Cook University Hospital and Tees, Esk and Wear Valley (TEWV) NHS Foundation Trust, on a proposal around integrated commissioning and data sets, and how this would be delivered in practice.

 

Consideration had been given to the provision of care on a locality model basis, which was based on service delivery to defined, registered populations of between 30,000 and 50,000.  Further exploratory work would be required as to how this would align to each geographical area and the varying needs within different communities.  Mention was made of the Aligned Incentive Contract with the hospital in relation to this work.  The proposal would be presented to the Joint Health and Wellbeing Board on 31 January 2019.

 

In response to a query regarding the Aligned Incentive Contract and commissioning of services, the Panel was informed that the CCG’s were moving towards a 'Primary Care Home’ model, which looked at bringing together small groups of GP practices to work together in specific localities.  The CCG would continue to hold finance, whilst the individual groups of GP practices would focus upon planning for their specific geography.  This would offer a new way of working for all stakeholders, therefore it was important to ensure that prevention activities, through Public Health, Social Care and Commissioning, linked in with this new model.

 

The Panel discussed the structure and functioning of the combined CCG (including the roles of the joint management team and the group of GPs that sat on it), together with the roles of each of the five local CCGs in terms of decision-making.  Consideration was given to the combined CCG’s relationship with the Joint Health and Wellbeing Board, with reference being made to accountability, openness and transparency, and to the Joint Strategic Needs Assessment (JSNA) document.

 

The JSNA identified the areas of need and the demographics within a local area, and provided details of the bodies that had been commissioned to provide services to meet those needs.  The Panel considered the role of scrutiny and how, given the new structures, an effective scrutiny function could be established to meet the changing needs and new ways of working.

 

The Chair thanked the Director of Adult Social Care and Health Integration for the update.

 

NOTED

18/41 INTRODUCTION - SOCIAL CARE SUPPORT FOR OLDER CARERS

By way of introduction to this new topic, the Director of Adult Social Care and Health Integration and the Chief Executive of Carers Together had been invited to the meeting to provide information to the Panel.

 

Reference was made to the Care Act 2014, which effectively placed carers on a par with service users and gave a greater degree of entitlement to assessment and receipt of services.  There was an eligibility criteria set nationally within the Act, which provided a way for carers to contest any decisions that were taken by Local Authorities.  Responses to the Act had been made to varying degrees by Local Authorities.

 

The term 'Older Carers’ related to a wide range of individuals, for example: an aged person caring for an older person; aged parents caring for adult children with disabilities; and elderly husbands caring for elderly wives and vice-versa.  One of the key issues was that a person may not have recognised the word 'carer’ as being applicable to them, because people often had a primary relationship with the individual that they were caring for.

 

The Chief Executive of Carer’s Together delivered a presentation entitled 'Support for Older Carers in Middlesbrough’, which covered the following topics:

  • Definition of a carer, the role and the types of activities undertaken;
  • Who might be a carer;
  • Carers: the national picture;
  • Carers: the local picture;
  • Where 'known’ older carers lived;
  • Profile of older carers in Middlesbrough;
  • Health of older carers;
  • Condition of the cared for person;
  • Older carers referred to Carers Together 2017-2018;
  • Outcomes achieved with and for carers;
  • The impact of caring;
  • The long term financial impact of caring;
  • Recommendations from Carers UK;
  • Key issues for carers;
  • Issues for older carers in Middlesbrough; and
  • Carers Together Services.

The Panel heard that Carers Together was established in 2003 and currently had 23 employees and 15 volunteers, working a mixture of full and part-time hours, to provide a full range of support to people providing unpaid care.  Since 2015, Carers Together had held the contract with Middlesbrough Council for the provision of the 'Carers Outreach and Assessment Support Service’.

 

Members were advised that the point at which a person realised that they were a carer varied from person-to-person, and it was important to remain mindful of this.  The definition of a carer, such as within the Care Act 2014 and the National Carers Strategy was generally quite broad in order to ensure that it encompassed as many different people as possible.  It was indicated that, as a general rule, if a person could not manage to undertake tasks without assistance and was receiving support, the person providing that support was a carer.  This was not limited to family and could be a friend or neighbour, and there could be a variety of reasons as to why support was required, e.g. age, frailty, physical or mental ill health, addiction or disability.  Care could be provided to adults or children (reference was made to kinship care) and must be unpaid. It was highlighted that Carer’s Allowance was not a payment.

 

Consideration was given to the term 'Carer’ and the use of it within support services.  It was felt that this was often substituted with alternative explanatory terms, such as 'you can still be a husband, but you have this other role that you may not have had before’, which tended to be better received.

 

Reference was made to the Care Act 2014 and the ability and willingness of individuals to provide care.  It was acknowledged that requirements around personal care and challenging behaviours, which may cause relationships to change, could present difficulties.

 

Consideration was given to the Care Act 2014 in relation to the impact that undertaking a caring role could have.  Every carer was different and would have varying needs, e.g. some may have had their health and wellbeing affected, whereas others may have been affected financially.  As some carers may be more resilient than others, it was important for support services to try and assess the impact of the caring role on that individual person, as opposed to assigning a set number of hours that they should be providing care, or identifying a number of times that they should be seeing a person.

With regards to assessments, it was important that these included elements of socialisation and were not based solely upon functional outcomes.  It was about quality of life and ensuring that the needs of that individual person were met, which could include, for example, offering opportunity to participate in social activities and find new friends and environments.  In response to an enquiry, it was explained that Carers Together completed the same assessments as those undertaken by the Local Authority.  However, individuals that had received an assessment by the Local Authority would not be reassessed by Carers Together.  Referrals to Carers Together were received from a variety of sources, including the Council’s Access Team and Social Workers, as well as from members of the public (e.g. via service literature and publications).

 

In terms of tasks and activities undertaken by carers, these could include, for example:

  • Cooking, cleaning and household tasks;
  • Shopping;
  • Managing medication;
  • Managing finances;
  • Personal care;
  • Accompanying to appointments;
  • Providing information;
  • Providing emotional support; and
  • Informal supervision.

It was highlighted that the extent and impact of undertaking support tasks and activities varied from person-to-person and, in some cases, carers in the 50+ age group could also be employed whilst caring for a relative or friend.  Consideration was given to the scenario of a cared-for person refusing support from professional services.  It was felt that this could put increased pressure upon an individual providing care, and therefore impact upon their health and wellbeing.

 

A discussion ensued around the funding of support services and how the changes in the Health and Social Care landscape could impact.  Members were advised that Carers Together’s contract with the Council had commenced in 2015 for an initial three-year term.  Two one-year extensions were possible, subject to annual review.  Carers Together received funding from the Big Lottery and Lloyds TSB Foundation, and also carried out an array of fund-raising activities.  Funding was difficult to obtain, with no guarantee that it could be continued after a specified period of time.  Service planning was undertaken in this regard, with potential changes in funding streams and impact upon the offers for carers being monitored.  In terms of the funding provided by the Council, there was an allocation made for carers on an annual basis, with funding also being provided through the Better Care Fund (BCF).

 

A Member queried whether carers had a Social Worker allocated to them.  In response, the Panel heard that not all carers required or wished to receive assistance from a Social Worker.  In instances where an individual was already known to Social Care, a Social Worker would carry-out the assessment.  If the individual was not already known to Social Care, Carers Together would carry-out the assessment.  It was highlighted that all cases would be dealt with on a case-by-case basis, and that the relationship between Carers Together and colleagues in Middlesbrough Council was very positive.

 

The Panel discussed the financial implications for a person providing care.  Members were advised that none of the services provided to carers by Carers Together were financially assessed.  In some areas of the country some services were means tested, but the majority were not.  In consideration of the 50+ age group, Members recognised the economic impact that could be felt if a carer was employed and circumstances changed.  Reference was made to work that Carers Together had undertaken with Middlesbrough Council in respect of working carers within the Authority.  It was felt that support such as the provision of carers leave and group activity had made an immeasurable difference to working carers.

 

Regarding the profile of a carer, the Panel was informed that carers were of all ages and backgrounds.  In terms of the remit of this investigation, older carers included adults with parental responsibility providing care for a disabled child (parent carers/kinship carers); 'Sandwich’ carers - individuals who cared for growing family members, but also elderly parents; and people caring for more than one person - e.g. caring for both parents because they now had a greater life expectancy and were living longer with longer-term conditions.

 

Most carers nationally were between the ages of 45-59, but there had been an increase both locally and nationally in carers aged 65+; some carers now had children with physical and/or learning disabilities who were now adults.  It was explained that a lot of work with carers in the 45-59 age group concerned planning for the future.  In terms of gender, the national statistics identified that there were more female carers than male, which was reflected locally within the Carers Together service: there were twice as many female carers as male.  A potential reason for this was that males may have approached caring in a different manner, perhaps being more unwilling to discuss it or seek support.  Nationally, 42% of carers were male.

 

A Member made reference to the BAME community and individuals perhaps feeling less inclined to seek help because they felt it was their responsibility to provide care.  The Panel heard that circa. 10% of referrals to Carers Together originated from the BAME community.  A Member made reference to a BBC documentary that had been shown on 6 January 2019 in relation to an individual providing care for his elderly parents.  It was agreed that the Democratic Services Officer would locate the documentary online and forward a link to the Panel Members.

 

Members were informed that, nationally, there were currently 6.6m carers in the UK; three in every five people would become carers during their lifetime.  Carers provided £132bn of support per year, which was based on information obtained during the 2011 census, i.e. the number of hours cared for in relation to the (then) National Minimum Wage payment.

 

Locally, in Middlesbrough in 2015/2016, the same calculation for those individuals who completed the 'carer’s box’ on the census form (14,000 people) was £346m.  If there were more individuals not completing this element of the form, which was highly likely, that figure could have been greater.  This was deemed a considerable factor in terms of sustaining care.  It was envisaged that the number of people completing this element of the form during the next census in 2021 would be higher.

The Panel heard that, locally, over 50% of carers provided 50+ hours of care per week.  From the services operated by Carers Together, 1643 carers from Middlesbrough were known to the organisation.  A large number (1036) were aged 50+ and the gender balance was currently 716 female and 320 male.  Carers Together had completed 477 Carers’ Assessments and support plans.  The total number of carers known to the organisation was over 8000 (8847), essentially because the service had existed in Redcar since 2003, and was the reason why there were more individuals known to Carers Together from Redcar (7204) than from Middlesbrough (1643).  The Director of Adult Social Care and Health Integration indicated that there would be other people identifying as carers within the Council’s Social Care system, who would not necessarily have been referred to Carers Together.

 

The Panel was provided with information regarding 'known’ carers and where in Middlesbrough they resided.  The highest numbers related to Coulby Newham, Hemlington and Linthorpe.  In terms of the postal code areas where fewer carers were seen, consideration was given as to whether specific targeting of these areas was required.  It was felt that GP practices would act as an excellent source for identifying older carers, however at present, Carers Together received few referrals from these.

 

Members were informed of a project that was currently being undertaken as part of the contract with Middlesbrough Council, to support carers in James Cook University Hospital.  This was part of an approach to consider the various scenarios where a change in circumstances would cause an individual to identify sudden change, e.g. in cases of stroke.  Members discussed the statistics presented and a query was raised as to whether any demographic information was available that would provide reasoning around this.  Reference was made to Public Health and consideration given towards the possibility of available demographics that may assist with mapping, e.g. areas of increased ill health and therefore potentially more carers.  Conversely, it was felt that this could potentially assist in identifying areas with 'hidden carers’, and therefore result in increased resources being targeted in those directions.

 

In response to an enquiry regarding assessments and how often these were reviewed, the Panel was advised that there was an annual review undertaken automatically.  However, if the individual concerned experienced a change in circumstances, that review could be undertaken at any time.  This could be triggered either by Carers Together or Social Care.  Statutorily, there was no real distinction between the carer and the person being cared for. Members heard that, although not necessarily in direct correlation, the individual whose needs were changing was often because the needs of the person that they were caring for were changing.  A carer could have their needs met through support plans or a Carer’s Assessment, or some of those needs themselves could be dealt with as part of a support plan for the person being cared for.  It varied depending upon the specifics of the situation, though carers often conveyed that when the support for the cared-for person was increased, that automatically helped them.

 

Regarding carers and their employment status, Members heard that, where Carers Together had been advised (85% of carers had informed whether or not they were working), 20% of those were employed, and employers varied enormously in their attitudes towards carers.  It was highlighted that Middlesbrough Council was exemplary in this regard, offering such initiatives as flexible carers leave and group support.  Other businesses, smaller businesses for example, could find it difficult to provide such support.  Carers who had left paid employment often approached Carers Together for advice and support.  The representative explained that Carers Together offered an advocacy service and could provide support to carers prior to leaving their employment.  A Member commented that self-employment also needed to be borne in mind.

 

In terms of the individuals being cared for, carers aged 50+ in Middlesbrough cared predominantly for partners (38%), but also their parents (27%), sons and daughters (17%), siblings (4%) and grandchild(ren) (5%).  The point was made that the profile of a carer was not as traditional as one may have thought, with more carers providing support to elderly parents and other family members.

 

The Panel was informed that, in relation to carers’ individual health needs, of the 1643 carers in Middlesbrough known to Carers Together, 32% had their own health needs.  Some of the conditions that affected carers were physical, such as osteoporosis and fibromyalgia, and others revolved around mental health and wellbeing, such as stress, depression and anxiety.  It was important to recognise this in order to ensure that appropriate support could be provided to carers.  In terms of mental health and wellbeing, it was indicated that attendance at group and other support activities could reduce feelings of isolation, stress, depression and anxiety.  In relation to future-planning, it was highlighted that the more that was known about the state of health in Middlesbrough, the more could be predicted about what the caring population could look like, and resources targeted as such.

 

Reference was made to the Care Act 2014 and outcomes that had been achieved by Carers Together, with and for carers.  When first accessing support services, carers completed an assessment in respect of ten outcome areas:

  • Accommodation;
  • Emotional and Mental Health;
  • Employment and Education;
  • Family Relationships;
  • Feeling Informed and Supported;
  • Looking After Myself;
  • Maximising Income;
  • Physical Health;
  • Recognition and Involvement; and
  • Social Networks.

It was explained that the individual allocated themselves a score of 1-5 on each outcome prior to intervention, and then again following intervention.  In Middlesbrough, the largest improvements were in the areas of Feeling Informed and Supported (improvement outcome: 1.46) and Recognition and Involvement (improvement outcome: 1.50).  It was recognised that there were limitations as to what a service such as Carers Together could achieve, for example: Employment and Education were currently quite low (improvement score: 0.02), although it was reiterated that this could potentially be improved if individuals liaised with the organisation prior to withdrawing from employment or education.  It was explained to Members that the figures presented were far more significant than they may first suggest, i.e. a relatively modest movement actually generated a large increase in the sub-total health and wellbeing, which reflected positively for the people accessing the service.  Further, if the scores across the different outcomes were added, this could result in great significance for the individual concerned.

A discussion ensued in respect of referrals from GP practices.  A Member commented that they would have expected more referrals to arise from GP practices, whether from support staff or GPs themselves.  Consideration was given to staff training and placement of other professionals (such as Social Workers) in GP practices in order to increase the number of referrals made.  In response to a Member’s comment that even a short appointment with a Doctor could multiply into several hours (after taking such matters as travel time and preparing the person for the appointment into account), the Panel was informed that Carer’s Together had asked GPs to offer flexible appointments for carers to assist with this, and had also spoken to GPs about having one of their staff members available in practices.  It was explained that by offering an immediate time slot to carers with that Carer's Together staff member, the individual would know that the referral came from the GP, would be immediate and convenient, and would avoid the need to send people home with a leaflet (which may result in no further action).

 

Regarding training initiatives, the Panel was advised that Carers Together had undertaken Carers Awareness training with newly qualified GPs and TEWV NHS Foundation Trust.  In response to an enquiry, Members heard that aside from one payment, this training had been offered free of charge.  The Panel felt that, as a charity with limited funding, payments for training should be sought as standard practice.

 

Further consideration was given to the financial future of Carers Together and other charitable organisations.  The BCF would be in existence for a further (circa.) two years, but the future of the scheme was unknown beyond that.  It was acknowledged that financial planning for charitable organisations was especially difficult, with forward plan terms being reduced from five years to three years, and potentially annually.  The awarding of contracts for prolonged periods was difficult for public sector organisations due to funding matters.  Contracts tended to be awarded on a two-to-three year basis with the option to extend, which enabled financial situations to be monitored/reviewed.

 

In response to an enquiry regarding provision of similar support from other organisations, the Panel was advised that other organisations did support carers, but often other organisations had a different remit to Carers Together.  For example: the remit of a substance misuse support charity would generally be to support the person with substance abuse and their family, but mainly the person with the addiction.  Carers Together did have contact with other organisations, but ultimately remits did differ.

 

Regarding the impact of caring, Members heard that:

  • 61% of carers stated that caring had had a negative impact on their physical health and 66% of older carers expected their health to get worse;
  • 72% of carers said their mental health had been affected by caring;
  • 20% of carers identified a lack of practical support;
  • 37% of carers described their financial situation as 'struggling to make ends meet’ and 47% of them cut back on essentials such as food and heating; and
  • 2.3 million people had given up work at some point to care for a loved one.

Regarding the long term financial impact of caring, Members heard that:

  • Nationally, 25% of those caring for more than 15 years had been in debt as a result of caring and 50% of long-term carers had cut back on essentials like food or heating; and
  • 368 older carers in Middlesbrough had accessed support from Carers Together’s Welfare Benefits Officers.

The Panel was provided with details of recommendations proposed by Carers UK. These were as follows:

  • Improve access to information and advice for carers about rights at work and benefit entitlements;
  • Raise Carer’s Allowance;
  • Consider the impact of Universal Credit on carers;
  • Right to paid time off work to care;
  • Support carers returning to work and employers;
  • Better care services; and
  • Greater public awareness and recognition of carers and their contribution.

The Panel discussed key issues for carers, which included:

  • Timely access to information and advice;
  • Quality services for the cared for person;
  • Recognition and respect;
  • Support to maintain their health and wellbeing;
  • Taking a break from caring; and
  • Support to continue in work.

Reference was made to issues with public transportation and the potential high costs associated with private hire taxis.  Consideration was given to breaks and respite, which could include, for example, an hour each day to go cycling, or time to pursue social activities - it did not necessarily need to refer to holidays or time away.

 

Information leaflets detailing the support provided by Carers Together, alongside contact details, were tabled for Members’ perusal. Services included, but were not limited to:

  • Individual information and practical and emotional support;
  • Carer’s Assessment and support planning;
  • Counselling Service;
  • Legal Clinic; and
  • Training for carers, families and professionals.

Regarding the latter, the Panel heard that Carers Together worked very closely with colleagues in Adult Social Care, which had included the joint preparation and delivery of training to Social Workers and other staff.  The representative was unaware of such an arrangement taking place in other areas and felt this to be extremely positive.

 

Members considered the assessment criteria, the input of all stakeholders in assessment criteria reviews, and the clear distinction between respite care being based on a clinical need for a person and funded by public health, and the care needs of the carer.  It was recognised that assessment processes needed to be kept separate.  Reference was made to the Care Act 2014 and the role of health professionals in supporting carers.  It was indicated to the Panel that carers were often afraid to discuss their own care needs for fear of being viewed in a negative light.

 

The Panel considered the terms of reference for the investigation.  It was felt that the following matters needed to be recognised as part of these:

  • Service provision and support providers;
  • Advocacy work (as some people did not have the skills to advocate themselves); and
  • Financial sustainability for voluntary sector organisations and this area of work.

In preparation for the next meeting, it was agreed that the Democratic Services Officer would formulate a potential aim and terms of reference for the investigation.

 

The Chair thanked the representatives for their attendance and contributions; the invited representatives left the meeting at this point.

 

AGREED that:

  1. The Democratic Services Officer would forward a link to the recent BBC documentary, which focused upon an individual caring for elderly relatives, to the Panel Members.
  2. The Democratic Services Officer would formulate a potential aim and terms of reference for the investigation in preparation for the next meeting.
  3. The information, as presented, be noted.
18/42 OVERVIEW AND SCRUTINY BOARD UPDATE

The Chair provided a verbal update on the matters that were considered at the Overview and Scrutiny Board meeting on 4 December 2018.

 

NOTED

18/43 DATE OF NEXT MEETING - 11 FEBRUARY 2019

The next meeting of the Adult Social Care and Services Scrutiny Panel had been scheduled for Monday, 11 February 2019.

 

NOTED

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