appendix 1 Budget Simulator Response final
Argyll and Bute Council · 27 March 2024
Back to Argyll and Bute HSCP Integration Joint Board (IJB) — 27 March 2024 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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Appendix 1 Argyll & Bute HSCP Budget Simulator Response. Argyll & Bute ran a budget engagement exercise on behalf of the IJB as agreed by the Finance and Policy Committee between January 30, 2024 – March 10, 2024. The exercise was specifically about engaging the public with where the budget is spent and seeking a response in how they would prioritise the available budget for 2024-25 in the context of an estimated £11.4million deficit. Methodology An online budget simulator tool was used utilising the previous years agreed budget. Instruction was provided in the opening page with some context as to the purpose of the exercise. People could indicate a preference using the sliders to make a percentage budget reduction (5, 10, 50 or 100% ) or 3% increase. A rounded budget total was provided for groupings of services to support general decision making. However it should be noted that the interdependence of integrated care is challenging to demonstrate in that removal of one aspect of the service can impact on other areas of the service. Explanatory narrative on the sliders was kept to a minimum using standard statements where possible given the volume of information presented. The simulator was accessible on multiple electronic devices and an email address was provided should people wish to submit their opinion without completing the simulator. Communication A communications campaign circulated the simulator link at two points during the campaign, at the start and 7 days before closing. The second campaign elicited the greatest results. The second campaign reflected a change in language removing the word simulator, showing an image of the online site and utilising a QR code.
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Communities and stakeholders were contacted via the following utilising their wider networks: • Print media • Social media channels • Partner websites • IJB members • Elected members • Community Councils • Community Planning Partnership • Locality Planning Group/Living Well Networks • Staff Communications • Printed staff posters • School communications to target younger people and carers via Education at the discretion of the school Demographics – Who responded? Not all demographics profiles were completed or completed in full with people given then option to provide this information. Gender notes a substantial response from the female category with 261 people in total providing their gender. This trend is comparable with previous consultations. 0 20 40 60 80 100 120 140 160 180 Gender
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The demographic of response in comparison from previous engagement questionnaire is primarily among working age people with a peak at 31-50 as opposed to previous consultations where 51-65 was most popular . This is also reflected in the high number of people who express dependants under 18, 247 people provided their age. We asked if people had a disability, were cared for by others or were young carers however on 45 people responded and the corresponding demographic information did not meet the age group of young carer (3), 6 noted they were cared for by others and 36 noted a disability. We would conclude that without disclosure we did not adequately communicate with people with this identified need. 0 20 40 60 80 100 120 140 18-30 31-50 51-65 66-75 76-85 85+ Age Dependants Child or children under 18 Older relative(s) No dependents Spouse or partner Other Adult(s) No response
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There is not a significant difference between locality response with 252 responses in total. Response The simulator notes 262 responses one of which was a test response. The total number of independent respondents was 261. Email 9 people responded by email some of whom noted they had completed the simulator and three people who noted they did not wish to be contacted further for response. One respondent wished to see further support in primary mainstream education for Autism. A further response wanted more information on service detail and referenced the wider Scottish and UK detail. One response noted that the software interaction did not allow for the allocation of greater funds (beyond 3%) and on the technical aspects of the systems. This will be provided to Delib for response. One respondent noted the housing pressure and more focus on promoting fostering as a positive role and after care for children and young people. They noted an “over- reliance on public health care and community care needs to build up self-management and individual capacity.” They further noted the value of Community Link workers in their area and the positive relationship with the third sector in supporting health and social care and an holistic approach to your own health and the role of education in supporting this. 0 10 20 30 40 50 60 70 Oban, Lorn and Isles Mid-Argyll, Kintyre and Islay Helensburgh and Lomond Bute and Cowal No Response Locality
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Simulator The simulator summary response is based on the sections provided: 1. Health and Community care 2. Acute and Complex Care 3. Children, Families and Justice 4. Primary Care 5. Public Health 6. Corporate and Supporting Services Within this section the average change for Community Hospitals and Community Integrated Services was a reduction of 1.96% and a reduction of 2.65% for Older Adult Care including Care at Home, Residential Care and Care Management which assesses and arranges the care, a total average reduction of 2.65%. Comments in this section noted a desire to maximise placements in care homes and greater efficiencies in community hospitals. Further commentary was made on under utilisation of day supports, “top heavy management” and a lack of “co-location and shared resource.” However further comment was made in sustaining community services to ensure the support of unpaid carers. Comments in favour of investment in this area would note that it would “support those historic tax payers to access a better quality of life” and “reduce ambulance £42,000,000 £42,500,000 £43,000,000 £43,500,000 £44,000,000 £44,500,000 £45,000,000 £45,500,000 £46,000,000 Health and Community Care £89.7 Original Budget Average Revised Budget
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evacuations, improve delayed discharge hold-ups and prove a longer term cost saving efficiency.” Further investment was noted in “preventative work and change the model of care we will have to continue with funding but rationalise bed numbers and improve discharge services.” Patient transport was requested to be reviewed to tighten criteria and a request for more video consultation. Further comment was made in “monitoring the use of agency staff to run nursing homes” on the islands and potential to move all care at home services to an “arm’s length not for profit company.” The average percentage reduction in each area is as follows: Lorn and Isles Rural General Hospital £19.4m -3.56% Adult Mental Health Services £16.2m -1.60% Argyll & Bute Learning Disability and Autism Services £22.8m -2.47% Argyll & Bute Physical Disability and Complex Health Care £3.5m -2.07% NHS Greater Glasgow and Clyde Services and NHS Other £78.3m -3.36% NHS Greater Glasgow and Clyde and NHS Other Mental Health and Learning Disability Services £3m -2.42% Comments in this section referenced waiting times for acute care provision. There was reference to use of agency, locum, delivery of appointments using telecommunications rather than in person, options for a reduction in costs to Glasgow or for Glasgow to £0 £10,000,000 £20,000,000 £30,000,000 £40,000,000 £50,000,000 £60,000,000 £70,000,000 £80,000,000 £90,000,000 Acute and Complex Care £143.4m Original Budget Average Revised Budget
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provide services if they can do so more effectively within their economies of scale, querying the ability of NHS Highland to provide services in area, recruitment and retention of skilled staff and provision of service at end of life. Further comment was made on the management of service level agreements and increase scrutiny. Learning disability and mental health services received numerous comments noting this was not working for people in Argyll & Bute citing capacity and travel. An early comment noted “There needs to be a review of the all the services and the organisational structure of Acute and Complex care” a further reflection was made on the number and capacity of management and clinical staff and the capacity to deliver the required services. Consideration was given to estates and equipment noting “There needs to be a more robust review of equipment, structural changes and general wear and tear . Estates and medical physics need to be more proactive in reviewing contracts , equipment maintenance and not wait until there are major issues” . Outwith this area but reflecting on wider hospital provision it was noted that “Service reviews for community hospitals - the expectation of the service needs to be re modelled and re- branded.” £0 £2,000,000 £4,000,000 £6,000,000 £8,000,000 £10,000,000 £12,000,000 £14,000,000 £16,000,000 Children, Families and Justice £23.3m Original Budget Average Revised Budget
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The average percentage reduction in each area is as follows: NHS Greater Glasgow and Clyde Children's Services and Other NHS £0.5m -1.37% Argyll & Bute Children and Families Integrated Care services £14m -2.00% Justice Services £0.22m -1.85% Children and Adolescent Mental Health Services £1.9m -0.89% Maternity Services £2.7m -0.79% Child Protection £3.8m -0.56% General commentary noted a query on the need for childsmile and supporting parents in this role, also a perception in whether the number of midwives impacted on birth choice and longer hospital stays. Commentary on number of social workers available to support justice services and help vulnerable people. A respondent noted the following “Declining population suggests need to redirect resources accordingly. Critical to retain protection & statutory provision & evidence for early intervention is clear in reducing crisis for young people. Hence mix of additional invest & redesign maximising use of digital technologies for delivery access & response.” Supporting resource and consideration of redirection of resource according to population need. Childrens mental health services, social work and maternity service were expressed as “key to communities” with a request they were not impacted by financial deficit and concern for impact on effectiveness or sustainability. There is recognition of early and preventative investment with less need later for adult services. Child and Adult protection were noted with potential to work together to achieve efficiency.
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The average percentage reduction in each area is as follows: Community Treatment and Assessment Centres/Vaccination £1.7m -4.73% General Medical Services £20.3m -1.21% Public Dental Service £3.8m -1.57% Primary Care Prescribing £22m -2.48% Independently contracted Dentistry, Pharmacy and Optometry £10.9m -5.58% Commentary in this area to “Tighten up on prescriptions that aren't necessary e.g. paracetamol to treat Acute symptoms. Also wasted medications. Reduce support staff on gp sites by having electronic check ins! Centralise GP surgeries, increase hospital drop in clinics.” Reduction in prescription of over the counter medications and “Greater scrutiny of General Medical Services being provided.” Charging for non-repeat or life saving medicines was also put forward and a redesign of independent contracting. Pharmacy was a frequent comment noting the need to “push realistic medicine” “improve frailty support.” The GP Out of Hours model was noted as expensive and a request for a review of a model utilising nursing and paramedic practitioners and “reduction in payments” if no longer offering vaccination and treatment room. Conversely there was a request to increase Primary Care Mental Health services in a proactive and early intervention model with a means test for prescriptions. £0 £5,000,000 £10,000,000 £15,000,000 £20,000,000 £25,000,000 Primary Care £58.9m Original Budget Average Revised Budget
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Further comment was made on length of time to wait on public dental and ophthalmology waiting lists and the “huge cost of GP locum services” . Specific island comments note it is impossible even to register with a dentist privately off island and includes a full day round trip. The average budget reduction for Public Health was 4.79%. Public Health commentary indicated a lack of knowledge on the service provision, this was provided but there appears to be a lack of understanding in the role. £1,880,000 £1,900,000 £1,920,000 £1,940,000 £1,960,000 £1,980,000 £2,000,000 £2,020,000 £2,040,000 £2,060,000 Public Health Services £2m Original Budget Average Revised Budget
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The average percentage reduction in each area is as follows: Strategic Planning, Performance and Technology £3.1m -10.32% Corporate services £3.9m -11.90% Estates and Depreciation £10.7m -9.93% Central and management costs £8.8m -14.86% Final commentary in this area noted “too many planners in comparison with teams on the ground” and “too many managers in health versus council,” further commentary noted a redundancy policy. Additional commentary offers comparison to the private sector with “managers appointed who are not able to do these jobs and this often results in new posts being created to accommodate for these poor performing staff.” There was an expressed desire to “streamline” the management structure with increased expenditure on performance reporting to increase efficiency. Also a review of the role of the project managers, Estates, contracting and lease cars, “the frontline staff have better ideas about budgeting and cutting waste - let department heads have more input into service redesign and planning.” Further comment noted better investment in technology. General Comments £0 £2,000,000 £4,000,000 £6,000,000 £8,000,000 £10,000,000 £12,000,000 Corporate and Supporting Services £26.6m Original Budget Average Revised Budget
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Review of HR and recruitment service to make Argyll and Bute an attractive place to work - this would in turn reduce the need for agency staff across all the specialities. A further suggestion that “within all of these areas I would be looking at pension provision, payment by results rather than hours or salaries, bureaucracy, waste, and accountability of individuals. Without that being sorted no amount of money will be enough for decent services.” Final submission comments Twenty three respondents provided final summary comments. There was reiteration on management structure, terms and conditions, wider funding environment and peoples understanding of this. It was reflected that a respondent would like to see an “Increase focus on community care, increase focus on strategic planning and development to innovate new solutions, Reduce community hospital budgets and renegotiate GG and C contract with more call off contracting processes, use strategic planning and development to drive service redesign.” A further suggestion is that it “Very difficult to suggest where cut backs need to be made. I feel the first hit would need to be projects that can be postponed such as rebranding or upgrades unless there was a business need. I also feel where an out company supplies services they also need to look what there charges are and re- negotiate. For example temp staff vs staff. What the cost of medication is being marked up to by suppliers. Also looking at what the business model is on things purchased and negotiating better pricing with suppliers on reliable data.” Another respondent noted it was an impossible amount to save when the population is ageing. Management structure and required skills to deliver strategies were a key task. Also that “… requires radical redesign to meet the needs of our ageing population. More specialist clinics and diagnostics are required with cessation of General Surgery and review of the whole medical provision. CTAC services should be re-integrated with Primary Care as their introduction has been a very negative step.” Improvement of access to mental health services and assessment for children and adults. There was reflection from respondents generally on need “each service has an affect on the other - Primary and Community Care with Public health services directly has an impact on Acute and Complex care - there they all require reform and re- modelling because the current incarnation is definitely pass its expiry date”. However this does not change the fact that the NHS has been unfunded for years and cost has continue to rise with a population that is living longer but also getting older and sicker.” There was an appreciation of the funding landscape and requested “focus on spend to save projects and whether greater use of technology can either assist with preventative work or service redesign” noting “current system is reactive and needs to be more proactive in preventing ill health the need for expensive secondary services or onward referrals”.
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Summary In summary the simulator offered an opportunity to engage with the public on their perspective for budget priorities and acknowledgement of the wider public sector funding environment. It has managed to access a wider demographic but in future there may be a requirement for a more targeted approach for different age and care groups. This should specifically be considered where there are impacts. Commentary noted a well informed response noting wider public sector funding issues with constructive feedback on the wider staff role, role of management and related skills and a number of potential areas for follow up which are in line with already identified areas or work. Conversely the budget changes did not wholly match the commentary with marginal budgetary changes reflecting little appetite for large scale change or service reduction. There is sufficient commentary to support development in a number of different areas to be scoped and the recommendation would be to further develop use of the tool directly in consultation for policy changes with outlined impacts.