Written evidence submitted by Councillor Jason Arthur, Lead Cabinet Member for Finance and Health for Haringey Council [SOC 159]
SUMMARY
The funding and demand challenges facing Haringey’s adult social care services are severe and growing. An increasing and ageing demographic base is causing long-term demand pressures for adult social care services, and at the same time Government funding to the local authority continues to shrink year on year.
Haringey’s population faces levels of deprivation and health inequalities that are more comparable to the profile of inner-city than suburban areas, yet Haringey has a comparatively smaller funding base to spend on adult care services than neighbouring inner city boroughs.
The introduction of the social care precept in 2016/17 alone will not be enough to bridge the funding gap faced.
Whilst we welcome the Better Care Fund as an approach to integrating health and care, it is important to highlight that this is the pooling of already existing budgets and is not new money.
The planned reduction to public health grants to local authorities will further increase the funding and demand pressures faced. Funding for public health is being used to fund the prevention and early help interventions that are critical to managing demand on adult care and health services over the longer-term.
We recommend that the Committee considers ways the Government could ease the short and medium term funding pressure on adult social care and public health budgets. Local authorities and health services need to be given the necessary resources to be able to invest in prevention and transformation of the health and care system.
Funding for local authorities to spend on adult services and public health should be more closely aligned to their demographic needs profile, better reflecting long-term demand challenges.
It is important that we recognise the impact of funding reductions and increasing demand on the whole health and care system. Pressures on the health system, such as non-elective admissions to hospital and delayed transfers from hospital back to the community, can be reduced by a strong adult care offer. If this is not available, the risk of increased pressures on health services is also increased.
We would therefore recommend that the Committee look for new opportunities to raise the profile of adult social care considerations into national and regional health system funding frameworks. A good opportunity would be the Sustainability and Transformation Plans (STPs) currently being drawn up for the delivery of the NHS Forward View. The initial guidance issued for STPs did not explicitly include addressing the funding gap on local adult social care services, and there is a risk that the Government’s investment here misses the opportunity to mutually support the sustainability of the whole health and care system.
With the need to respond to funding and demand challenges, we recognise the need to think differently about how the health and adult social care system operates going forward in Haringey.
Critical to our response is a focus on enabling people to remain independent in their local community and intervening earlier to prevent the needs of vulnerable people escalating. This will help manage longer term demand pressures on adult care services, and help people to live healthier, longer and fulfilling lives in their communities.
This is why Haringey is taking a lead in promoting healthy living, putting in place effective information, advice and guidance services, developing intermediate care pathways, assistive technology options, care navigators and social prescribing approaches.
As we shift our focus to promoting independence and the resilience of communities, this means that we need to take a wider perspective and look at the effectiveness of the whole system and range of support available to people in our communities.
To achieve this, we recognise the need to build stronger partnerships and integrated working with carers and families, community organisations, health providers and neighbouring local authorities.
This is why Haringey is working on expanding our support services for carers and families, and partnering with Haringey Clinical Commissioning Group through our Integrated Care Programme, supported by the Better Care Fund. We are also exploring new ways of working with the neighbouring borough of Islington, and the wider North Central London group.
The Care Act 2014 outlines that local authorities have a clear role in ‘market management’ as part of the commissioning of adult services from both private and voluntary sector providers.
One area of focus is the quality of employment and working practices that some providers adopt. We have concerns over national reports that some providers are not paying care workers for time travelled between clients or are increasingly adopting zero hour contracts.
Yet the ability of local authorities to secure the right supply and assess standards of quality could be undermined if funding continues to fall short and demand pressure grows. We would therefore also urge the Committee to consider the supply side challenges for adult care when scrutinising the Government’s policy on funding.
One avenue Haringey is keen to explore further is how to strategically leverage major regeneration and development schemes that in turn will strengthen access to local health and care support options within the community. This is why for example we have prioritised new shared living accommodation sites in the Tottenham Regeneration scheme.
Part 1 - Is the funding available for social care sufficient to enable local authorities to fulfill their duties under the Care Act 2014?
1.1 The cost of growing demand pressures on adult social care services and wider system
An increasing and ageing demographic base is causing significant demand pressures on Haringey’s adult social care services. By 2021 Haringey’s population is expected to rise to 289,700, up 10% from today. The 50+ population is expected to show the biggest increase out of all age groups, rising from 60,870 now to 72,820 by 2021.
In 2015/16, it was estimated that 5.6% (3,492) of Haringey’s 50+ populations are adult social care clients. The top 3 primary presenting reasons for adults approaching adult social care for help are physical support (69%), support with memory and cognition (12%) and learning disability support (7%).
Haringey’s total expenditure on adult services and public health for 2016/17 is £80.5mn a year. Taking up the largest share of this budget is spending on residential and nursing care placements, which in 2015 was around £27mn. The median yearly cost per person for residential care in 2015 was £19,903 and nursing care is £13,541.
These growing demand pressures are also placing significant knock on costs and resource strains on acute health services through non-elective admissions to hospital. The total cost of non-elective admissions for those falling under Better Care Fund definitions in Haringey was estimated to be £44.6mn in 2014/15, equating to 23% of Haringey Clinical Commissioning Group’s Acute Care spend. The average cost of a non-elective admissions in Haringey is around £1801, and the average cost of a delayed transfer of care per hospital bed is £267 a day.
1.2 – The 2015 spending review and local government finance settlement
Adult social care accounts for around 30% of all that Haringey Council currently spends. Between 2010 and 2018 the Government have cut Haringey Council’s funding in real terms by 40 per cent (£190mn). The local government finance settlement confirmed that constraints on local authority funding would continue. Haringey Council’s budget for 2016/17 was supported with 4% less external finance (e.g. Government grants) than in 2015/16.
Haringey’s population faces levels of deprivation and health inequalities that are more comparable to the profile of inner-city than suburban areas, particularly in the east of the borough. For example there is a 7 year life expectancy difference between the west of the borough and the east. Yet Haringey has a comparatively smaller funding base to spend on adult care services than neighbouring inner city boroughs.
Haringey Council’s Medium Term Financial Strategy aims to deliver £70m of savings from 2015/16 levels across all service areas through to the end of 2018/19.
Adult care services in Haringey have savings targets of £24m by 2018/19. A transformation programme in adult services has led to savings with most of the measures on track for delivery. However the rate of finding savings cannot keep pace with the expected demand pressures from demographic change that Haringey faces in the short to medium term. Even after all of the £24m savings measures, Haringey’s funding gap for adult services is still expected to be around £22.3m in 2018/19.
1.3 - The introduction of the 2% council tax precept
Because of the demand pressures within adult social care, Haringey chose to apply the 2% precept in the Council Tax for 2016/17, which is projected to generate £1.7m. The average Haringey family will pay an additional 46 pence per week on top of their average council tax bill.
100% of the Precept has been applied to cover current adult social care pressures. £1.2m (70.18%) has been offset against pressures from clients with learning difficulty needs, and £510,000 (29.82%) against clients with physical support need. The number of clients with open care packages in April 2016 was 5% higher than the previous year, with the costs having also increased by 6%.
The precept only addressed around one-third of the cost of net demand increase experienced in 2016, and will not be enough to bridge the huge gap we face in funding for adult social care. The Government needs to look at other ways to fund adult social care services beyond the introduction of the precept, avoiding the disproportionate impact on lower income households that putting the onus on increasing council tax in the long-run would cause.
1.4 - The Better Care Fund – Supporting Haringey’s Integrated Care Programme
The Haringey integrated Better Care Fund budget for 2016/17 is £19.5m. Haringey Council’s contributing proportion of this is £7.7m (including the Disabled Facilities Grant). The Better Care Fund is expected to spend in full this year and represents an increased change on 2015/16 of £1.5m of pooled funding.
Whilst we welcome the Better Care Fund as an approach to integrating health and care, it is important to highlight that this is the pooling of already existing budgets and is not new money.
1.5 - Public Health Grant Funding
As part of the Government’s deficit reduction plans, the Department of Health was asked to deliver in-year savings of £200mn from non-NHS spend in 2015/16 through reductions to the Public Health Grant to local authorities. This cut was outside of the local government finance settlement that had been agreed. The Spending Review confirmed a further £160mn reduction in public health grants over the next two years. As a result, Haringey’s public health grant fell by £0.7mn in 2015/16 and is being reduced by around 2% year on. There are reports that the Government is planning to phase out ringfenced public health grants to local authorities altogether after 2018/19.
This reduction is likely to have a knock on effect and further exacerbate the funding and demand challenges faced on adult social care. Funding for public health is being used to fund the prevention and early help interventions that are critical to managing demand on adult care and health services in the longer-term.
Part 2 – Strategically rethinking the delivery of adult care services in Haringey
With the need to make significant savings and demographic demand pressures, the Council recognises the need to think differently about how the adult care system operates going forward. In November 2015, following a three month consultation the Council approved plans to transform the adult social care system in Haringey.
The new target operating model aims to create an adult social care system in Haringey that does more to promote and support individual independence, dignity and choice, and at the same time is financially sustainable in the long-run. The model seeks to shift the focus from delivering care in institutional settings, towards enabling people to access the support and care they need earlier, at home or within community settings, reducing the demand for more costly complex services. The overriding focus is providing the right support at the right time, preventing needs escalating and reducing future demand on care services.
To support this, the following are some of the initiatives that will underpin the approach:
2.1 - A focus on intervening earlier to prevent the needs of vulnerable people escalating
Having access to effective information, advice and guidance services plays a vital role in prevention and early intervention and the reduction of health inequalities, as well as promoting self-help and empowerment. Earlier this year, Haringey Council entered a new commissioning arrangement with Haringey Citizen’s Advice Bureau to deliver an expanded IAG service to residents across the whole borough. This replaces a previously fragmented IAG system with multiple contractors.
Haringey’s new IAG service is now embedded into the transformation of adult social care plans, ensuring that people have information earlier on the support and care available in their local community. The new IAG service will provide multiple access points and channels, including home visits for adults with low mobility and local community locations including GP surgeries.
Complementary to this, Haringey also has an integrated lifestyle and wellness programme called ‘Live Well, Be Well’ commissioned to be delivered by Reed Momenta. The programme aims to support adults to become more physically active, stop smoking, drink moderately and have a better diet. These health behaviours are closely linked to the development of chronic diseases such as diabetes, respiratory and cardiovascular diseases. A reduction in the number of adults developing chronic diseases will reduce demand on adult services in the longer term.
The programme includes:
Stop smoking services, NHS community health checks, weight management, and some physical activity programmes. These services are targeted at groups and areas in the borough where we know that health inequalities are greatest.
The recruitment and training/skills development of Health Champions. The champions are volunteers working within a range of community settings (e.g. community centres, shopping centres, GP surgeries, local events) to raise awareness of healthy living and recognise the early signs and symptoms of common health conditions. They help signpost people to support services available in the community, such as leisure services, primary care, mental health and stop smoking services.
The Council are also employing a ‘Well London Co-ordinator’, to facilitate health improvement/wellness events, and to train local people in key health skills, encouraging them, and their neighbours, to take charge of their own wellbeing.
The training of frontline staff in prevention and lifestyle behaviour change programmes, such as Making Every Contact Count (MECC), and Motivational Interviewing.
Every day in Haringey, frontline workers from across the public and voluntary sector have numerous interactions with local people when dealing with a range of issues. MECC training is about learning how to use these engagements to raise the raise the issue of healthy lifestyles, promoting the benefits of healthy living and signposting to further support available in the community.
All Council staff in customer services, adult social care, housing and education are encouraged to take part. MECC training is also promoted to staff in voluntary and community organisations; as well as employees within the local healthcare sector, including primary care and NHS Trusts.
More broadly Haringey Council is developing a ‘health in all public policy’ approach and aims to move to being a ‘health promoting’ organisation, with health a specific consideration by services such as alcohol licensing, parks and leisure, planning and transport. The Council is committed to reducing health inequalities by developing and implementing strategies that tackle the wider determinants of health, including housing, employment, and education.
2.2 - Increasing capacity to provide re-ablement, intermediate care services and the use of technology:
Re-ablement services are for people with poor physical or mental health to help them adjust to their illness by learning or re-learning the skills necessary for daily living. Intermediate care is short-term care for people who no longer need to be in hospital and do, however, require extra support at home or in a community setting to help them recover.
As part of this earlier help offer we are also developing approaches that will embed Technology to support people to remain independent for longer. This is looking at the use of existing and emerging technologies at all stages of the care pathway, from early prevention to supporting complex needs. Examples may include Healthy Lifestyle ‘Apps’, Community Alarms (protecting people at risk of falling), Assistive Technology (automated medication dispensers), Self Care/Self Management tools (blood pressure monitoring) and Tele-Health & Care (remote monitoring of health conditions).
2.3 Increase the availability and flexibility of day opportunities within the borough
Day services provide both respite for carers and opportunities for vulnerable adults to be active and socialise during the day.
Haringey is looking to move away from traditional buildings based day care services, towards developing increased opportunities and activities in the wider community for those who may be at risk of becoming socially isolated. Working with the community and other businesses to develop day services is intended to promote more flexibility, availability and access to mainstream activities, including leisure, educational and employment opportunities.
A key approach going forward will be social prescribing. Social prescribing is a way of linking patients in primary care with sources of support within the community. It provides GPs with a non-medical referral option that can operate alongside existing treatments to improve health and well-being.
We are also introducing ‘care navigators’ who will help users and carers to understand what options for support are available in the community and how many this costs. The care navigators then provide support to help users and carers to take up these options, including speaking to providers, diary planning, transport options etc.
Part 3 – working with partners
As we shift our focus to promoting independence and the resilience of communities, this means that we need to take a wider perspective and look at the effectiveness of the whole system and range of support available to people in our communities. To achieve this, we recognise the need to build stronger partnerships and integrated working with partners.
3.1 Partnership working with Haringey Clinical Commissioning Group
The Integrated Care Programme, supported by the Better Care Fund is a joint budget (£19.4mn in 2016/17) which underpins a work programme developed by Haringey Clinical Commissioning Group (CCG) and Haringey Council to direct services towards early intervention and integration to ensure people have healthy long and fulfilling lives and prevent the need for more complex costly services such as avoidable hospital admissions and long term residential care placements .
For 2016/17, Haringey CCG and Haringey Council have agreed the following targets to stem from Better Care Fund initiatives. If the targets are met this would equate to savings of £1.84mn of savings in 2016/17. The targets aimed for are to either catch Haringey up to the national average or to the London average for comparison boroughs by 2019-20.
740 fewer non-elective admissions to hospital, which would equate to £1.3mn of savings (average cost of a non-elective admission in Haringey is £1801)
8% reduction in delayed transfer of care to bring the borough in line with London trajectory within three years, which is 599 fewer delayed days in 2016/17. This would equate to a saving of £159,933 (average cost of a delayed day cost per excess hospital bed is £267)
7% reduction in care home admissions to bring the borough in line with London trajectory within three years, which would mean 10 fewer permanent admissions to care homes in 2016/17. This would equate to a saving of £337,480, with the average cost of a permanent care home admission at £33,748 in Haringey.
The 2016/17 priorities for using Haringey’s Better Care Fund are as follows:
The Locality Team model began in pilot form in January 2015, initially working with 2 GP practices. After a successful proof of concept for the pilot, the scheme was expanded across Haringey in December 2015, with 30 out of 46 GP practices signing up to the scheme. Up until May 2016, 224 people had been referred into the Locality Teams.
3.2 Working with regional partners
The Wellbeing Partnership
A recent development is the establishment of a new ‘Wellbeing Partnership’ across Haringey and Islington organisations. The partnership has been established to accelerate the transformation of health and care system across Haringey and Islington, supporting residents to achieve healthier, happier and longer lives, and to deliver value and financial sustainability.
The current Wellbeing partner organisations are:
Haringey Council, Islington Council
Whittington Health, Camden & Islington NHS Foundation Trust,
Barnet, Enfield & Haringey Mental Health NHS Trust (New partner as from June 2016)
Islington Clinical Commissioning Group, Haringey Clinical Commissioning Group
UCL Partners
Haringey GP Federation, Islington GP Federation (new joiners August 2016)
The Wellbeing Partnership intends to look at business plans to develop the following population wellbeing and care pathways across the two neighbouring boroughs:
A model of care that supports independence in frail older people with health and social care needs
A new model of care for people with learning disabilities
A re-designed musculoskeletal care pathway
A model of care that improves the prevention, identification and management of diabetes and cardiovascular disease.
Mental Health: Recovery and Enablement
The partnership will also be looking at the potential for cross-borough collaboration on commissioning practices, workforce development, ICT and estates management.
The North London Central Group
The North London Central Group is a forum that brings together Clinical Commissioning Groups, NHS Trusts and local authorities across the neighbouring London boroughs of Haringey, Islington, Camden, Barnet and Enfield.
Haringey Council is keen that the good work developed with Haringey CCG and through the emerging Wellbeing Partnership with Islington (outlined above) will positively influence this work, ensuring that both the health and social care needs of our all of our residents are able to be supported in a financially challenged system.
A key piece of work that the regional group has been tasked with is the formation of a Sustainability and Transformation Plan (STP) to deliver the NHS Five Year Funding View, ensuring that Health and Care Services are able to deliver suitable and good quality care into the future. However national guidance has removed explicit consideration of the adult social care funding gap from STPs.
It is important to recognise the impact the funding gap in adult social care will have on increasing demand on the whole system. Pressures on health, such as increases in non-elective admissions to hospital and delayed transfers from hospital back to the community, can be reduced by a strong social care offer. If this is not available, then the risk of increased pressures, market failures and the potential for ‘cost-shunting’ rather than system transformation are increased.
This is why we would recommend that the Committee look for new opportunities to raise the profile of adult social care considerations into national and regional health system funding frameworks, such as the Sustainability and Transformation Plans. There is an opportunity to strategically align the STP process to invest and build upon local adult social care transformation developments, and health and care integration programmes.
Part 4 – supporting the market for adult care services
The Care Act 2014 outlines that local authorities have a clear role in ‘market management’ as part of the commissioning of adult services from both private and voluntary sector providers.
4.1 Impact of funding on the market
One area of focus is the quality of employment and working practices that some providers adopt. We have concerns, and are monitoring the market to reduce the risk outlined in national reports that some providers are not paying care workers for time travelled between clients or are increasingly adopting zero hour contracts
Yet the ability of local authorities to secure the right supply and assess standards of quality could be undermined if funding continues to falls short and demand pressure grows.
The Care Quality Commission’s recent inspection report into practices at Sevacare, a home care provider that was operating in Haringey among other London boroughs, highlights the risks of market failure. The provider fell well-below the high standards we expect in Haringey and following the investigation we have ended our relationship with Sevacare and advised all clients not to use them.
We also know that significant funding pressures are also being felt by voluntary sector groups that support vulnerable adults in the borough. One recent example was Age Uk’s difficult decision to close its Haringey’s branch in April 2016, a very sad development after the group had been established for 25 years in the borough.
4.2 - Leveraging the opportunities of major regeneration and development
One avenue Haringey is keen to explore further is how to strategically leverage major regeneration and development schemes to support local health and care supply needs.
For example, strategically integrated into our regeneration plans for Tottenham is a multi-million pound development partnership between Haringey Council and Season to develop two new Supported Living Accommodation facilities (Lorenco and Protheroe House) opening this summer.
When completed Lorenco House will provide 44 one bed and eight two bed apartments, alongside award-winning care and support provided by a specialist on-site team .The facility will also boast first class facilities including a medical and wellbeing centre, landscaped gardens, guest bedrooms for visitors and a dining area. Eight of the rooms are specially designed to provide high quality care for people with dementia. Nearby Protheroe House will deliver a further 50 senior living homes. The supported living accommodation will be put on the market at affordable rent levels and the design standards mean each flat should cost an average of £5 per week to run for residents.
Another example is the housing redevelopment plans for the partly decommissioned NHS St Ann’s Hospital site in Haringey. Local residents have established a community land trust organisation which has collaborated with architects to put forward a development design bid which reflects community priorities, including health and wellbeing. Key priorities advocated for include affordable independent living housing, the protection of green spaces and integrating the remaining mental health services on site to strategically support early intervention and preventative health outreach work in the neighbouring community. A recent Guardian article explores the success of the resident’s led group in influencing development.