Bristol’s Budget Conversation – Focus on Health and Social Care Services

As promised, we’re now publishing more detailed information about the third of our large service areas – health and social care – showing how much we spend, where the money comes from, what some of the major trends and pressures are, and how our spending compares with other comparable areas.

I hope you’ll find this useful in helping you give us your thoughts and ideas around our four big questions:

  • Which services, if any, should we consider delivering at a reduced level or even ceasing altogether?
  • Which services might be better provided by other bodies, such as the voluntary sector, or with others, such as the NHS or neighbouring councils?
  • Do you have any other ideas based on your experience for service areas where we could further explore saving money?
  • Are there any service areas from which we should aim to raise more income?

We recognise some of the graphics are a little difficult to see on this web page – so you can download a pdf copy of this article where it’s easier to read them

How much do we spend on services for Health and Social Care, and where does this money come from?

Overall each year we spend over £200.9million, on Health and Social Care, of which £47.3million is funding from income (government grants, fees and charges). The balance of £153.6million is funded by Bristol City Council.

Health and Social Care Service User Volumes

  • 14,551 service users in 2009/10 (analysed below).
  • We gave advice / information or a service to a further 3,949 carers.
  • Majority of service users are aged 75+
  • Similar age and gender profile to other core cities

What issues (challenges) and spending pressures are we facing?

The Health and Social Care department faces a number of challenges:

  • The department is well resourced but value for money needs to be improved.
  • In house services costs are higher than independent sector providers.
  • How to meet the challenge of increased numbers of service users as a result of population growth within the context but reduced public expenditure
  • Bristol has a higher rate of admissions to residential care homes for older people than most other Local Authorities. Length of stay in residential homes is also increasing indicating that older people in Bristol are going into care when, with the kind of support offered in other places they could remain at home for longer.
  • The proportion of Bristol people with Learning Disabilities who are living in residential care is higher than in most other Authorities. Are we doing enough to support people to live a normal life in the community?
  • Bristol’s proportion of residents in local authority homes is high. The Council’s programme to modernise its own residential care homes has been put on hold due to increased costs and to enable the Council to engage in discussion with the people of Bristol about how best to support older people to live in dignity and safety as they become more frail and needy.
  • The packages of care provided in Bristol tends to be higher than in most other Authorities. Is this necessary or are we providing more care to many people than they actually need. Some care arrangements are very high. The Council is spending over £10m every year on the cost of providing support to just 100 people. Can this be justified?

Demographic Change

Bristol’s population stands at 433,100 but is increasing. If recent trends continue then it is projected that the population may increase by 109,300 people by the year 2026 (+25%)

Elderly Population

The Elderly Population of Bristol is growing year-on-year and we are seeing an increase in limiting long-term illnesses and disabilities. This means increased future demand for social care services at a time of reduced public expenditure. The challenge will be to deliver improved outcomes and personalised care services, for a growing number of elderly people, whilst reducing cost and improving value for money. We will need to do more for less.

Figure 1 below shows that the 65 and over age group is projected to increase by 3,200 or 6% in the next 5 years, and by 6,300 or 11% in the next 10 years. The elderly population aged 85 and over is expected to increase by 600 or 7% in the next 5 years, and by 1,300 or 15% in the next 10 years.  Figure 2 shows the past 5 years of population estimates and projections forward to 2020. These changes are significant. People aged 85 and over are twice as expensive to care for than people between the ages of 75-85. Over the next 20 years the numbers of very elderly increases significantly, which means the cost pressures on health and social care services will rise significantly.  Planning and change has to start now.  Obviously it’s great that people are remaining healthy and living longer, but are we doing enough as a City Council, and are we doing enough to work in partnership with communities, voluntary sector organisations and health service partners?

Figure 1 – Projections in the 65+ population in Bristol, source: ONS Sub-national Population Projections

Age Group



Variance 2010


Variance 2010


Variance 2010


Variance 2010































Total 65+










Figure 2 – Mid Year Estimated Populations and Projections for Older Population in Bristol


Dementia is increasing with our ageing population.  In the UK one in five people over 85 has dementia and one in 14 over 65 has a form of dementia.  It is estimated 13% of people with dementia live alone at home. In addition, a lot of people with mild dementia may not be diagnosed.  Bristol has an estimated 5,900 people over 60 with dementia. The number of people with dementia is forecast to increase nationally by 38% in 15 years and this will have significant cost implications for Health and Social Care.

People with learning difficulties (PWLD)

Learning difficulty (LD) includes the presence of a significantly reduced ability to understand new and complex information and to learn new skills, with a reduced ability to cope independently. LD starts before adulthood, with a lasting effect on development.

The number of people with learning difficulties is increasing, partly due to people living longer as a result of medical and technological advances. People with a learning difficulty make up approximately two percent of the total population. It is estimated that approximately 8,400 of Bristol’s population have learning difficulties and 2,100 people (a quarter of this group) have moderate to severe learning difficulties.

The table below gives figures for the current and projected PWLD population in Bristol. It is based on the most recent population projection statistics (ONS 2006).

The focus is on enabling people with LD to live as normal a life as possible, this means being able to access employment and leisure, housing and local health services, just as everyone else in the population would expect to do.

Increase in mental health problems

Nationally, one in four adults will experience an episode of mental distress in their lifetime. One in twelve of those will suffer severe and enduring mental illness, diagnosed and treated. Many cases of mild to moderate mental illness may not be diagnosed or treated.

In Bristol, the population who suffer from mental health problems is above the England average, and ranks fifth out of the core cities. Based on national proportions, Bristol is likely to have approximately 6,900 adults who have severe and enduring mental illness.

The impact of the recession has seen a sharp increase in the population who are unemployed. During unemployment, mental health problems tend to manifest themselves very quickly. Two of the highest areas of concern are fear of job loss and home repossession.

Figure 1 – Prevalence of MH in Bristol population aged 18-64









Mental Disorder








personality disorder








personality disorder
















of Above








of Service Users*








% against
estimated population








Taken from RAP P1, Number of MH clients receiving a service during 2009/10

Home Care

Home care is provided either by the in house continuing to care service or by independent sector providers.

Health and Social Care has seen a growth in the number of hours of home care provided particularly from independent sector providers.

The short term assessment and reablement service (STAR) is a short term care service which aims to assist service users to maintain current skills, regain skills they may have lost in the short term due to a health crisis, and to develop new coping strategies to replace permanently lost skills.  The focus is on ‘doing with’, rather than ‘doing for’ the service user and helping people to live as independently as possible. It aims to divert people from long term care.

Residential and Nursing care

Bristol currently makes a high number of residential and nursing placements. In the future we will need less residential care as more people are helped to live at home with personalised care services. Under self directed support, a supported self assessment, service users with eligible assessed needs will be allocated a personal budget, which will enable them to meet those assessed eligible needs in new ways.

Rate of permanent admissions to care for older people is higher than similar authorities

Length of stay for older people in care homes is increasing

Bristol’s proportion of residents in Local Authority homes is very high

Budget pressures

Health and Social Care are currently forecasting an overspend of £1.7m in 2010/11

Older people Over / (underspend)
Other (20,000)
TOTAL 754,000
Learning Difficulties / Mental Health Over / (underspend)
Learning Difficulties 447,000
Physical and Sensory
Mental Health



Care Services

Over / (underspend)
Operational Service
Long Term Services 119,000
Residential and OP
Day Services
Re-ablement (624,000)
TOTAL (186,000)
Putting People First & Standards (155,000)
Other Services 152,000

How does Bristol’s spending compare with other similar councils?


Click here for more information about this

What are we already doing to make our money stretch even further?


Social care is changing across the country and social care will look very different in Bristol in 2011 as we introduce more personalised care. We are introducing a new way of supporting people by telling them how much money there is available to support them and then giving them the choice of how that is spent to meet their needs.  This means that they can either have a direct payment for them to spend on support, or they may choose to ask us to provide a service for them, or a mixture of the two.

The main changes are likely to be:

  • giving people more choice and control over how they receive support
  • telling people how much money can be spent on their care – their personal budget
  • letting people directly control and spend their personal budget through direct payments
  • giving help earlier to reduce the need for crisis services
  • work together with the health service so we only have to assess people’s care needs once and give people the chance to assess their own care needs – self-assessment
  • social workers spending more time helping people to find the care they want and less on paper work

See a video story about people who are using their social care budgets to support them as they take control of their lives and live independently.

Bristol is introducing self directed support (SDS) and a new resource allocation system. Under self directed support, which is a supported self assessment, service users with eligible assessed needs will be allocated a personal budget, which will enable them to meet their outcomes in accordance with a validated support plan. Under SDS people can choose to spend their personal budget on anything legal that meets their outcomes.

The Resource Allocation System (RAS) is the system by which an indicative personal budget is calculated for people with eligible needs

How does the RAS operate?

The RAS consists of three main components

  • A supported self assessment questionnaire that seeks to identify a service user’s support needs
  • A points allocation system which translates these needs into points to reflect the relative scale of these needs
  • A calculation that converts the points into a sum of money known as the indicative personal budget.

It is the indicative personal budget, which allows service users to plan the support that will deliver the outcomes to best meet their identified needs. The RAS does not generate an absolute amount. Rather, it provides an indication of the resources an individual may need to meet the cost of addressing their eligible needs. It is the support planning and validation process that determines the final allocation or personal budget.

You can decide how much or how little control you want over your personal budget, some people will want us to continue to manage their budget and arrange care services for them, others will want to take complete control over their budget and have the money paid to them as direct payments so they can manage and arrange their own support. A personal budget can also be managed using a mixture of the two ways. To help with the process of commissioning the council is continually reviewing and updating its health and social care internet site and has been working along side the Care Forum and five other local authority and NHS partners to develop a comprehensive database of health, wellbeing and community resources in South Gloucestershire, Bristol and Bath & North East Somerset, called Well Aware.

New ways of commissioning and delivering services

The department is also looking at how it commissions services to improve value for money. This will include the development of new joint commissioning strategies, which will include working with other partner agencies (NHS Bristol, neighbouring local authorities) to deliver services in new and improved ways. The aim here is to avoid duplication so the same support is not provided by two institutions and joint commissioning to bring down costs. This will also include a strategic look at in house services.

Reviewing high cost placements

Bristol is seeking to work with providers to improve outcomes and reduce costs.  People’s care needs change and we need to ensure that the care we provide is delivered in the most appropriate and cost effective way, that meets peoples needs.


The council proposes to change the way in which people who receive social care services contribute to the cost of their support.  This will include asking some people who do not currently make any contribution to do so. With more people likely to need support in future and with limited public funding, we need to make best use of public money.  We have to be fair to all Bristol citizens, both as people using services and as people who pay for them through taxes.

Lots of people already contribute to the support they receive, for example for personal care, home care and community meals but some for example, who receive community support do not pay. This is inequitable and Bristol is about to start a consultation on how people contribute towards the cost of their care in the future.

Now we’ve shared lots more background information, do you have any suggestions around how we should spend money on services for health and social care in these tough financial times ahead?

If you want to leave a private comment, click here

80 thoughts on “Bristol’s Budget Conversation – Focus on Health and Social Care Services

  1. There has been much discussion on this blog of costs, cuts, and how best to support services. There has been comparatively little discussion about the actual processes the council goes through to make those decisions, and ensure an optimum compromise between value-for-money and meeting the needs of Bristol’s residents is achieved.

    Without a rigorous process, there’s a risk that immediate costs will be the dominant factor taken into consideration, and decisions made could turn out to be false economies because the quality of services, and hence their longer-term cost-benefit, is overlooked. Unfortunately this seems to be the case with decisions affecting the future of Bristol’s Supporting People budget announced this month.

    Conversely, by taking a holistic look at the needs of individuals, and considering the quality, i.e. long-term value for money, and not just immediate cost of services, the council could ensure the balance between needs and value for money is effectively struck.

    Understanding people’s needs

    For example, on World Aids Day (December 1st) Supporting People’s Strategic Management Board wrote to the Brigstowe Project to inform the organisation that its support service for people living with HIV/Aids will be decommissioned in March next year. This decision was made without consultation with Brigstowe, its clients or partners; without undertaking an Equalities Impact Assessment (as required by the Equalities Act 2010); and without consideration by the council’s scrutiny boards or cabinet. It not only goes against the council’s own published strategies for health and social care, but is a good example of a false economy, because the longer-term costs removing support for people with HIV far outweigh the cost of providing the sort of service Brigstowe provides.

    One rationale for decommissioning Brigstowe’s support service is that, although it’s “unique,” clients with ongoing need for support could use “broader, generic services.” Simple logic suggests, on the contrary, that it’s precisely because generic services don’t meet their needs that people use Brigstowe’s in the first place. The cost of delivering generic services is unsurprisingly less than for specialist ones, but the quality and effectiveness of those services is, equally unsurprisingly, less as well. So clients are worse off and, when they end up needing more intensive and expensive care in the long run, the council and health services are worse off too. A good example of prioritising short-term cost savings over well-informed commissioning based on a comprehensive understanding of needs.

    Ironically, in its response to ideas submitted by citizens to ‘Bristol’s Budget Conversation,’ the council identified precisely such an understanding as a priority, including the relationship between the costs and benefits of Supporting People:

    “Someone needs to be looking at the financial benefits of Supporting people funding and not just commissioning which is expensive and won’t necessarily bring improvements in.
    Response: We agree – this does need reviewing, and we have this in hand.”

    So why leave vulnerable people without adequate support for the sake of false economies?

    Storing up problems for the future

    Being HIV-positive means having a recognised disability, one which continues to be stigmatised all over the world. Many are also discriminated against due to being from minority ethnic groups or for being gay. Having often suffered prejudice and lack of understanding from non-specialist doctors and hospitals, it means that, if Brigstowe closes, many HIV-positive people won’t go to other public health services – at least until faced with an emergency. By contrast, Brigstowe provides proactive support to help people stay healthy, live independently, and avoid just such crises.

    Compared to Bristol’s ageing population, the number of people living with HIV is relatively small. However, the needs of people with HIV are particularly complex – encompassing physical health, mental health, social isolation, stigma and discrimination, the side-effects of treatment, difficulties working and appropriate housing. If these needs can be managed, people with HIV can live long, productive lives, and make a valuable contribution to the local community, just like anyone else. Some people need support before they can do this for themselves, however – precisely the support provided by the Brigstowe Project. Without it, these complex needs can spiral downwards, eventually requiring hospital admission and intensive health and social care, the cost of which is far greater than the cost of providing Brigstowe’s proactive care.

    In recognition of these needs, the Department of Health has this year increased the amount of funding it distributes to local authorities via the Aids Support Grant. However, because this grant is no longer ringfenced, councils can choose to spend it on whatever they choose, and because the people who commission council services often don’t fully understand the relationship between costs and benefits related to HIV, what initially looks like a nifty saving can end up creating more problems than it solves.

    Difficult choices, but positive ones

    There is of course a bigger debate to have about political priorities for the country as a whole, and the acceleration of health and social inequalities. For example, UK Uncut’s actions against billion pound corporate tax dodging highlight the fact that if the government could ensure UK Inc. paid its taxes as well as its shareholders, they would cover proposed budget cuts several times over. In the meantime, however, we must try to ensure that good decisions are made in the local context, and the process by which those decisions are made is well-informed, transparent and stands up to rigorous scrutiny – especially when, as with health and social care, they affect the most vulnerable members of society.

    To judge from debates to date, the primary justification for the current round of spending cuts is “the financial mess left to us by the last government” – another example of making negative choices rather than positive ones. Rather than blame their predecessors for making difficult decisions now, are we not entitled to governments and councils making positive decisions based on a full understanding of people’s needs and how different types of services meet them? Unless this happens, we’re likely to sleepwalk into making false economies, rather than effective decisions, and be faced with further messes to sort out in the future.

  2. Cllr Dr Jon Rogers

    Thank you for the reply
    SUSTRANS has to much sway with the council for my liking. !!!!
    You say “we are even looking at bringing the old Brunel swing bridge in the Cumberland Basin back into operation” In these economic times I say that is not essential and should be shelved (whatever the cost) including upsetting the vested interests.


  3. I hope E Tranter is wrong regarding a spend of £2.3m on a cycle track. In today’s economic climate, such expenditure is both unacceptable and irresponsible.

  4. Councillor Rogers
    I see in the Evening Post tonight (27 Oct) that the council have a reported short fall in the care home plan of £2M and yet they are backing a £2.3 M cycle route to the city along with this obscene plan to sell off green spaces (The Area Green spaces Strategy) in this city of ours coupled with an under the counter proposal for the Gypsy / Travellers sites (up until very recently a lot of my neighbours new nothing of these proposals) I respectfully suggest to you that whilst the city and the country are so strapped for cash it would be better to look after the care homes (and thereby the elderly residents in them) These people do not appear to have vested interests fighting for them at the moment in the council, therefore I implore you to take up the baton and fight their corner, (reading some of your comments to date I suspect that you are already of a mind to do just that).

    The Councillor’s who are pushing for all the totally irrelevant work, (in my personal view), need to step back and reconsider what they are trying to do. The great majority of strongly negative objections reported in the local media etc. must have an impact on the strategy, if not! Then democracy in this city is fast becoming a thing of the past. It leaves me with disgust and despair for what is probably going to be, whether reasonable people / residents disagree via the sham of a consultation.

    Please note the last paragraph has been moderated at the request of the web site administrator, I have removed personal references and remarks that were considered over the top (presumably), even though these comments can be seen in other media.

    E Tranter

    • Mr Tranter raises a number of issues.

      (1) The shortfall in the capital budget for refurbishing our care homes is obviously a cause of concern. Property and development values have dropped, making (Labour’s) original plan unaffordable. We are now listening to the views of Bristol residents, including elderly, carers, staff, providers, unions, councillors, etc, etc on what we should do about the shape of the service.

      (2) The SUSTRANS Connect 2 walking and cycling route that will link the centre of Bristol with Nailsea and beyond was part of a bid to improve cycling and walking friendly routes across the country. Cycling City has contributed, and we are even looking at bringing the old Brunel swing bridge in the Cumberland Basin back into operation to improve the link further. Cycling and walking are both healthy ways of getting about, and these can help with pollution, climate change and obesity! The money is not available to use for other purposes.

      (3) Rest assured, the council will continue to provide the best possible care for our elderly and vulnerable. We will also listen to all comments and suggestions about where our priorities should lie.

  5. Dear Cllr Dr Rogers,
    I was opposite the Hippodrome Theater and was surprised to see water fountains about 8inches high, possibly 20 in each of the 4 shallow pools still pumping out water. Though this may be pleasing to watch surely in times of cuts that’s the sort of thing people wont complain about being stopped. They could be restarted when times get better.
    I did note that College Green fountains were still running too. Though this may be a tourist attraction, no one will die if they stop them for at least a few days of the week.

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