Written evidence submitted by Tower Hamlets Council [ASC 066]
Submitted by Cllr Rachel Blake, Deputy Mayor for Adults, Health and Wellbeing on behalf of Tower Hamlets Council
Tower Hamlets is a richly diverse inner London borough with one of the fastest growing populations in the country. While home to iconic business districts including Canary Wharf, many residents face significant challenges of deprivation and poverty. Despite being a young borough – the average age is just 31 and 46 per cent of our population are aged between 20 and 39 - we have a growing older population and higher than average proportion of older residents with care needs.
Like many boroughs, adult social care services have been at the ‘front line’ of the Tower Hamlets pandemic response. The small number of care homes in Tower Hamlets have suffered a number of outbreaks and deaths. This has affected everyone working and living in care homes and their families, and the reverberations will be felt into the future. Demand for social care increased with hospital discharge rates as the pandemic hit, but not as steeply as expected and the system was able to cope. Going forward, we are likely to see demand fluctuate but increase overall, influenced by the impact of Covid-19 on physical and mental health. The sector has long called for a sustainable funding solution at a national level, and without this, there are likely to be significant financial pressures arising from this increased demand.
At the same time, Covid-19 has seen the profile of adult social care raised, a sector less well understood than others, and there are national commitments to boost this further and support recruitment to hard-to-fill roles. Additionally, people’s growing familiarity with technology for health and care can be capitalised upon, whilst innovative joint working between health and care will continue into recovery.
More widely the pandemic has had a profound impact on the Council's budget and its ability to deliver services and, as a consequence, on its financial planning assumptions. The Council welcomed the Government’s pledge to provide ‘whatever it takes’ to cover the cost of dealing with the crisis, however it remains unclear what the long-term impact of the pandemic will be on council finances. As a result of the pandemic new areas of expenditure were required together with fundamental changes to the Council's main sources of funding; additional emergency short term funding was made available by the government alongside other measures to support the Council's cash flow. The Council’s priorities were redefined by the crisis and the delivery of some proposed investments and savings were paused.
As of February 2021, we have 3,240 adults receiving support (urgent, short-term, or long term) from adult social care. Like other councils Tower Hamlets is experiencing a sustained rise in demand and extreme pressure on services especially in mental health, social care, homelessness, unemployment, domestic abuse as well as increased levels of financial hardship, with poverty exacerbating existing inequalities. At Tower Hamlets Council, we currently have a projected overspend of approximately £5 million in the Adult Social Care budget for 2020/21 to cover costs. Taken together, these challenges pose an enormous threat to creating a more threatening financial environment for local authorities, even before the long-term potential impacts of the pandemic are considered.
If the government fails to honour its pledge to cover the cost of dealing with the pandemic, including any ongoing long-term impacts, then as a Council we will be in an even more difficult financial position in future years and as a result will have to make tough choices about our services. Finding a sustainable long-term funding solution for adult social care is a key part of stabilising the outlook of local authority finances.
The impact of Covid-19 on the long-term funding reform of the adult social care sector is currently unclear. The ‘new’ baseline in terms of demand for our services, access levels, costs of delivery, etc is impossible to quantify at the moment, both nationally and locally in Tower Hamlets. What is certain, is that Covid-19 has magnified some of the long, deep rooted problems that have become entrenched around the issue of funding adult social care. We have seen the need for longstanding reform, investment and workforce planning in adult social care highlighted on a national level. This includes impacts on the sector’s workforce, and to its providers where the pandemic has exacerbated the decline of an already fragile adult social care market. We think that without reform, Covid-19 could result in greater financial pressures as a result of rising demand for care, new costs associated with Covid-19, and lower income as a result of the economic downturn.
We know that Covid-19 has undoubtedly both created more need and made it difficult to meet existing need. As a result of Covid-19 there will be a higher demand placed on adult social care services arising from poorer health as a result of ‘long Covid’, the impact on wider determinants of health such as social isolation, and the disruption to NHS services such as cancer screenings during the pandemic. In Tower Hamlets, we have found evidence of:
In Tower Hamlets we are working to recover from the impact on people’s health and wellbeing together with our health partners through ‘Tower Hamlets Together’, however it is unlikely to be enough to make up the gap without further support from the government to help fund these efforts.
On a practical basis, Covid-19 has led to a range of new costs for councils delivering adult social care. These include
The ‘Infection Control Fund’, ‘Adult Social Care Workforce Capacity Grant’, and the ‘Rapid Test Fund Grant’ have all been used to support Care Homes with these issues, however it has not been enough to cover all costs. These funds have all been extended short term, at least until June 21st which is welcomed, however it is unclear whether this level of funding support is going to be available longer-term, and if not, how these extra cost pressures will be met.
It is possible that demand for particular forms of support may change as a result of the pandemic, but we do not know how yet. Nationally there has been a reduced demand for care home placements, (and therefore less revenue). In Tower Hamlets, we have ‘home first’ as our standard offer. During the height of the pandemic, the focus on community-based care has been reinforced with every effort being made to ease the heavy pressure placed on acute care. We will need to understand the future demand for care homes longer-term. If demand remains lower then pre-pandemic levels, care homes may not be financially sustainable, at least under their current funding arrangements. This would lead to particular pressure in Tower Hamlets as we only have five care homes for older people, therefore there will be a disproportionate impact on this group if any close.
With specific regards to day services, it should be noted that while many day centres have remained closed during the pandemic, some service users’ needs may have escalated during this period. The future costs of potential increased demand arising from the pandemic will also need to be considered. The impact of changes to how day centre must operate once they reopen is likely to impact on delivery models and potentially the financial stability of providers as they try to revitalise models of delivery within covid-secure arrangements. In Tower Hamlets we are reconfiguring our Day Centres offer, partly driven by a need to refocus spending on other areas of Adult Social Care demand, but also to provide more joined up support across the borough. This will learn from our Covid-19 experiences and focus more of our resources on quality activities for service users rather than places of provision. As part of this new offer we will create a new day centre community hub, a specialist dementia provision and covid-secure activities across the borough rather than maintaining multiple under-attended day centre buildings.
The related rise in loneliness over the course of the pandemic has exacerbated an already worrying position. For example, a Healthwatch Tower Hamlets impact of Covid-19 survey during the early phases of the pandemic reported that 32% of those surveyed reported that they were feeling socially isolated. This is likely to have grown significantly since then given the impact of multiple lockdowns, furlough and working from home rules.
The impact of the virus crisis has been both to significantly increase levels of loneliness across the whole population but also to dramatically highlight the issue and spark a society-wide effort to befriend and assist neighbours and the vulnerable which may lead to a permanent increase in social capital. The positive community responses can be built on, but the serious adverse impact of digital exclusion has been underlined. It is right that there will be an expectation on local authorities emerging from the pandemic to continue to support, including in some form financially, the befriending and loneliness initiatives which have developed over the past year.
A severe economic downturn as a result of the Covid-19 pandemic may potentially have an impact on the number of people eligible for state funded care, with the value of peoples assets and pensions affected increasing the number of people who are not eligible to pay for care via charging.
In addition, an economic downturn may reduce Local Authorities revenues, for example in adult social care there has been a reduction in client contributions, reduced occupancy in care homes, and fewer people paying for day services and transport services. At the same time national evidence suggests most Local Authorities are still paying day/community services providers despite the fact they are closed so that they remain sustainable. Subsequently, these reductions in income may lead to long term reductions in the available budget for adult social care services unless a long-term sustainable funding solution is provided to fill these gaps.
While we are now emerging from the Pandemic, the ongoing impact on social care due to long-Covid remains unclear, both in terms of the health and social care impact of the pandemic and the associated mental health impacts of continued lock-downs and societal anxiety. At a time when Covid-19 has seen the amount of income being generated by local councils and adult social care services reduced, the pandemic has led to a number of new costs. As stated above, the ongoing impact of the Covid-19 pandemic continues to affect demand for services and have a financial impact on service providers’ operating costs and their risks of financial viability. In Tower Hamlets we are seeing an increase in the complexity of cases when people are being assessed, resulting in more costly packages, more one to one support, in part due to the impact of the extended and ongoing disruptions to regular routines and not seeing loved ones in care settings. We are also unclear about the true scale of the hidden health cost of Covid-19 for those who may not have sought support or not visited hospital as usual, and expect as these people present to us that demand and costs may subsequently rise further.
In Tower Hamlets, we would want funds for the adult social care sector to be raised with an awareness of the larger health and care system. For example, any focus on community-based health support should include social care. This means it’s not simply a case of finding new funding solutions, but also involves focusing on policy. We would like more clarity around the role of ‘Integrated Care Systems’ (ICS) and ‘Integrated Care Providers’ (ICP). In Tower Hamlets, we have Tower Hamlets Together, which is a partnership of local health and social care organisations working together and looking at whole system solutions to health and wellbeing needs. We would like to see long term funding proposals that give a consideration and guidance as to how ICS should prioritise spending within their area of responsibility while also retaining the flexibility for local decision making, in some cases at a borough rather than a system level. Also, with regards to the funding arrangements around the two systems at the moment it can often appear arbitrary from the perspective of service users and patients who use them, for example if a person is ill with cancer then their care services are provided free of charge, however if they are ill with dementia they are charged for their care. We would like long term funding arrangements that places social care on an equal footing with the NHS.
Any funding solutions should enable preventative, local, and tailored responses to need. People should be supported and empowered to stay well and healthy through a clear service offer that links all relevant local services and agencies together in a way that is intuitive, easily navigable and focused wherever possible on prevention and maintaining independence. In Tower Hamlets, our Tower Hamlets Together Strategy is focused on building strong, resilient communities to achieve this.
Our response to Covid has shown that having a local approach is much more effective, we know our local communities and can adapt our approach accordingly and are most able to meet the diverse needs of different communities. We are building prevention into our new Information, Advice, and Advocacy service as we recognise the importance of a person-centred and preventative model of social care that is rooted in supporting people’s wellbeing in line with the Care Act and building resilience in our local public services and communities. A top down national, or system-wide, approach would not be nimble enough to achieve this.
There is little doubt that the growing increase in demand for adult (and children’s) social care are placing an unsustainable strain on local authority budgets. Rolling one-year settlements, as well as a lack of certainty over the future levels, or existence, of the various adult social care related grants exacerbates this and hinders councils’ ability to plan ahead effectively. Whilst the option to levy an additional Adult Social Care precept increase via council tax has helped financially, it is not in our view a sustainable alternative to a long-term and nationally agreed funding settlement for adult social care.
In terms of the shape of any long-term funding model for adult social care, there have been numerous studies, commissions, and reports on options. As set out in the Dilnot Report, “the possibility of needing long-term care is the one risk that everyone faces, but that no-one can insure against.” This supports our, and the Local Government Association’s, view that while local government should play a leading role, any funding solution needs to be met nationally. This is particularly the case given the regressive nature of local taxation and the imperative to avoid excessive variations in approach and cost dependent on post-code area.
We believe one of the key mechanisms to stabilising the adult social care market is for the government to set out, and more importantly move to implement, plans for the long-term funding reform of the sector. Short term funding solutions to ‘plug the gap’ and ease cost pressures are welcomed, and have helped saved lives during the pandemic, however definite long-term solutions are needed to enable Local Authorities and providers to better plan for the future.
It is absolutely key that, in order to stabilise the adult social care market, investment and policy solutions are put towards solving the current crises in the adult social care workforce. We know that pay for care workers is appallingly low, especially in comparison with the NHS. A nurse working in the NHS earns 7% more than those working in adult social care and this gap is growing. This has a direct impact on a providers ability to recruit and retain care staff who rightly expect to receive better pay terms and conditions, and career progression than social care can afford. If the pandemic has shown us anything it is that we need to place more value on these frontline caring roles. More must be done to support social care – for instance, matching pay increases in the NHS. In Tower Hamlets we have adopted the Ethical Care Charter for homecare, and are committed to paying the London Living Wage. We have also recently developed our own workforce strategy through Tower Hamlets Together, allowing us to develop our workforce in partnership with health partners. Lastly, with regards to workforce one of the ways we have tried to stabilise the adult social care market in Tower Hamlets, especially during Covid, is to adopt a flexible approach to Direct Payments. This includes allowing service users to employ close family members as Personal Assistants.
Market shaping is another key mechanism to stabilise the adult social care market, predicting and preparing for future need. This works well locally, and its something that we work closely with our providers to do. Recent examples of this working well in Tower Hamlets include our commitment to developing more ‘Extra Care Sheltered Housing’, and we are about to reprocure our homecare services, working with providers to remodel this in order for it to be more nursing-led. This will enable us to design a service that more accurately reflects need, focuses on prevention, and reduces the number of ‘hand offs’. We believe that this approach should be emulated at a national level. The challenge here can be that when working with privately run organisations, the focus can sometimes be on financial sustainability. However, we believe it is crucial to work with providers at a national level to shape the direction of travel through a more cohesive approach.
More regional and cross boundary cooperation would also help to stabilise the market, for example by enabling and encouraging local authorities to work across boroughs to collaboratively commission care home placements rather than leaving the market fragmented with authorities competing against one another.
While providers should take the lead on this, local authorities have a role in showcasing high standards of work that others can look to emulate. There has been a lot of learning through the Covid-19 pandemic, where a traditionally siloed, somewhat closed off provider market have come together to share best practice and collaboratively problem solve. For example, Beaumont Court, one of our care homes that achieved 100% staff and service user vaccination rates shared how they were able to achieve this with others. There have also been other key areas of joint working with providers during the pandemic that can be looked at as a model to developed further. For example, a range of multi-agency support has been given to providers over the pandemic, such as our care homes which received enhanced primary care, public health, and infection control support to ensure wraparound, easily accessible expertise was on hand to improved outcomes and quality. Elsewhere, the digital roll out during the pandemic showed that IT can not only quickly enable care home residents to stay in contact with loved ones, but also provide digital records which are more easily and securely shared between partner agencies. These are all key developments that should be built on moving forward.
We believe that the Care Quality Commission can play a crucial role in driving quality and innovation, and suggest that their role can be further strengthened in doing this.
It is also possible for Local Authorities to drive this change through procurement. An ongoing focus for us at Tower Hamlets is to develop real outcomes-based contracts, with payment mechanisms linked to this. These focus on promoting independence and quality of life. As part of this there is scope for further innovation to develop a strong community of navigators in all of our settings who support residents and signpost to into universal and specialist services rather than solely operating in their siloed organisation or provision. Making the adult social care ecosystem more open and easily navigated by service users would greatly enhance their opportunities.
 LBTH Covid Resident Impact Survey, 29th May to 17th June 2020