Agenda item

This report sets out the budget proposals for the services covered by the Health and Social Care Policy and Accountability Committee (PAC). An update is also provided on any proposed changes in fees and charges in the budget. 

Cabinet Member overview

Councillor Rowan Ree introduced the Medium Term Financial Strategy 2023 (MTFS) presentation by commending officers and thanking member colleagues for their significant efforts and commitment to preparing the council’s budget proposals. This was a remarkable piece of work as final figures from the Local Government Financial Settlement were only released two days before the parliamentary Christmas recess. This was also the fifth consecutive year of having a single year financial settlement and many assumptions had informed the MTFS.

This was a balanced budget, in response to the difficult financial future predicted by the Bank of England, a 10.5% inflationary rate, and interest rates of 3.5%, all of which were expected to have a significant impact on council finances. For residents, financial pressures had seen no variation in the delivery of high quality services and the council had gone further by removing home care charges, providing free breakfasts for primary school children, maintaining weekly refuse collection and the introduction of the Law Enforcement Team. These were significant achievements and continued to be part of a package of proposals designed to protect frontline services for residents. Approximately £1 million in ring fenced funding had been provided as part of the council’s cost of living response to support residents and help to mitigate the financial difficulties.

Director of Finance – Corporate Overview

Sukvinder Kalsi explained that the proposed revenue budget strategy 2023/24 sought to preserve key front line service priorities which included weekly waste collections and free home care, recognising that this aligned with the expectations of residents and acknowledging that not all local authorities had been able to maintain them. The 2023/24 proposals reflected an increased growth investment of £10.7 million, of which £4.1 million would support social care (adult hospital discharges) and allowed for a cautious 5% inflationary uplift on prices.

With careful monitoring this could be managed through strategic procurement, and within council tax proposals. Savings of 2.9% (set out in the report) had been modelled based on how services were procured. This would ensure greater resilience, building in contingencies and continuity of provision in response to the current, difficult financial climate. H&F had frozen council tax for five out of the previous eight years. A 1% increase represented about £8 per year, per household, impacting about 53% of residents who did not qualify for exemptions.

Future risks included an anticipated budget gap in 2024/25 of about £17 million. Reserves represented 26% of the council’s overall budget and these were within the recommended range of between £19-25 million, some of which had been earmarked for an IT upgrade, necessary to protect business continuity and increase resilience. He anticipated that the fiscal environment for 2024/25 would continue to be challenging.

Co-optee Keith Mallinson sought further clarification about the treasury’s position on financial provisions to support homeless people in the borough and commented that the governments levelling up agenda had excluded urban areas like H&F. Councillor Ree felt that this was a political decision and that funding had been directed to areas that most likely to vote conservative in areas outside of London. There was a perception from these areas that London was wealthy, and generated significant income, with the result that H&F had to work much harder with a targeted budget, and to communicate this perspective to residents. Keith Mallinson suggested that this point should be more clearly communicated to the public.

Councillor Coleman endorsed the views expressed by Councillor Ree. There were few who would not attribute the anticipated costs of council tax and mortgage repayments to the conservative government, a message that himself and Councillor Ree regularly communicated to residents. The government’s position ensured that local authorities were having to take difficult decisions, however, although the administration remained proudly committed to ensuring that services such as free home care continued to be protected, a 2% increase in council tax had been necessary.

Co-optee Jim Grealy commended the council’s commitment to continue to protect people who would not normally be protected and endorsed the view that a clear distinction should be communicated between this localised approach compared to a conservative government that had imposed 12 years of austerity. He sought clarification about the demographic pressures which he felt were unclear in the report. Sukvinder Kalsi responded that the Census 2021 had highlighted some key trends for the borough, the most significant of these being that the H&F population of 55+ would significantly increase over the next few years. This could lead to additional demands on social care services and the council was working closely other local authorities to formulate a response. The need to ensure that this point was reflected in communications about the budget was accepted.

Councillor Perez enquired about the white paper ‘People at the Heart of Care’ (https://www.gov.uk/government/publications/people-at-the-heart-of-care-adult-social-care-reform-white-paper) which had been delayed to 2025. She asked what impact the delay would have in the context of local provision. Lisa Redfern explained that the fair cost of care element had been delayed for two years.

Lucia Boddington commented with reference to Appendix 3 of the report that there were similar funding difficulties for special educational needs and children transitioning from Children’s Services to Adult Social Care, where there remained significant delays, and queried the available data as not offering an accurate reflection, based on anecdotal resident experiences. Prakash Daryanani concurred that this was fluctuating situation, but they had collaborated closely with colleagues in Children’s Services and the Learning Disabilities team, The Economy department and Housing Services to address this.

The report contained an initial bid based on the anticipated number of residents that were transitioning. There were high costs associated with this which had been identified as a risk where there was no provision if these costs were exceeded, and this was being closely monitored. Lucia Boddington was hopeful that increased funding for both autism assessments and transitions services could be made available to address the delays. Keith Mallinson endorsed this view, commenting that the delays had a wider impact on the families of children who were transitioning and who required financial assistance.

Strategic Director of Social Care – Overview

Lisa Redfern provided a view on how the MTFS allocation would impact on Adult Social Care and Public Health services, and how this would affect the future provision of services, in the context of both acute local priorities and national pressures. Focusing specifically on services for people with Learning Disabilities that enabled people to live independently, Lisa Redfern reported that the work undertaken by Jo Baty with residents to develop an autism strategy was an exemplar of engagement on SEND (special educational needs and disability). Although it was acknowledged that further work was required, the aim was to work with people so that they could live fulfilling lives, enabled through independent living. Work on the Dementia Strategy 2021 for people with dementia evidenced how the council was co-producing services.

It was also reported that considerable preparation and planning had been undertaken in response to the new Care Quality Assurance regime to be introduced in April 2023. The last entire inspection of social services had been undertaken in 2011, although some providers had been inspected during the interim period. Commenting on care providers, Lisa Redfern alluded to the volatility of the market and post-pandemic sustainability which had caused further instability, exacerbated by the cost of living crisis. There was a recognition that continued improvement in the quality of free home care service, provided to 2000 residents, was required.

This would be sustained by proposals in the MTFS and reflected the council’s ongoing commitment to free home care, a significantly subsidised meals on wheels service, for which residents were only charged £2.00 per meal, and Careline. The council’s reablement service was rated as “outstanding” by the Care Quality Commission (CQC) for the third successive time placing it within the top 4% nationally.

The council was working closely with care providers in response to the cost of living. It also continued to closely monitor the payment of a London Living Wage (LLW) by all provider contractors and subcontractors, ensuring that the payment was being passed directly to care staff rather than the providers. The council remained as one of the leading London boroughs ensuring timely discharges. The quality of the provision had been reflected in the 200 compliments that had been received about the service since April 2022 which was a real achievement.

Head of Finance, Social Care and Public Health

Prakash Daryanani described the financial breakdown of social care and public health allocations within the MTFS. Proposals covered £105 million of expenditure, an increase of approximately £10.4 million on 2022/23 and reflected significant amount of investment, £4.1 million. Modelling had indicated that there were concerns about the demographic trajectory and a future demand on services. A base budget adjustment was planned to mitigate intense hospital pressures and an inflation rate of 3.4% had been factored in, with a projected increase of 7.4% anticipated for 2024/25. Ongoing dialogue and negotiation with providers would continue to help address financial challenges and market sustainability.

Short term funding alluded to by Lisa Redfern amounted to £2.9 million, consisting of new government grant funding awards in 2024. Of the social care budget, about 70% was spent on community or residential care providers, in house reablement services and third sector community funding (£5.5 million). These key areas equated to approximately £90 million, or 85% of the total budget.

Trend data indicated that there had been a 40% increase in spend that was predominantly linked to hospital discharges and increased acuity of need. The cost of providing a LLW was expected to increase by 8-9%. Increased acuity of need equated to residents receiving more than 14 hours of care services per week. Another pattern had been the decrease in the number of residential care placements, reflecting the loss of life unfortunately attributed to the pandemic. Post pandemic, numbers had increased by 13% but with greater acuity of need. A 10% uplift in unit costs was expected, however, negotiations for block and spot contract purchasing of placements compared well to the average cost, bearing in mind the competitive nature of the marketplace.

Director of Public Health

Dr Nicola Lang provided an overview of funding for public health services against a backdrop of numerous health challenges. Post-pandemic this included a response to the recent monkey pox outbreak, polio vaccinations, norovirus and Streptococcus A in children. A decision to appoint a senor nurse to support investment in infection prevention and control had boosted public health protection. Innovative work in care homes had seen the introduction of bespoke environment and hygiene regimes that mirrored the CQC inspection process. This unique infection control offer would be expanded to include hygiene training for cleaning staff.

An easy read guide had been produced for primary care networks, GPs and acute trusts about the impact of damp and mould infested housing on residents resulting in poor health conditions. 150 vulnerable residents with complex care needs were currently being supported, with others in temporary accommodation. A plan was in place to build a bespoke model of specialist mental health care, and a similar response was planned to support rough sleepers who often had concomitant conditions linked to alcohol and drug misuse. Additional areas of focus included innovative work on suicide prevention, the preparation of shorter, easy read joint strategic needs assessments (JSNAs).

NICE (National Institute for Health and Care Excellence) guidelines set out how to reduce suicide rates through the prevention and commissioning of high quality services. This had helped to inform the borough’s Suicide Prevention Needs Assessment, setting out a suicide prevention strategy (October 2021). Services were supported by the Public Health Investment fund, which amounted to £23.3 million for 2022/23. Funding for the next financial year would be announced shortly and Dr Lang anticipated a slight inflationary uplift.

Merril Hammer commended Lisa Redfern and her officers on the outstanding work undertaken by social care and public health teams, which was much valued by residents, highlighting this with the example of a friend with a neurological condition who had received 6 weeks of home care support that had enabled her to continue in her work and ensured that the quality of life was maintained. Merril Hammer suggested also that the excellent work that the council was undertaking on discharges and reablement services should be shared with other local authorities as an example of good practice. Lisa Redfern welcomed the suggestion and attributed this success to strong performance management and a whole systems approach.

On behalf of colleagues, Lisa Redfern thanked Merril Hammer for her kind words. Councillor Coleman responded that H&F officers exhibited compassion for residents and also worked with efficiency, qualities that allowed the council to deliver outstanding services year on year.

Noting that the borough had the fifth highest rate of suicide in London, Lucia Boddington enquired about what steps the council had taken to reduce suicide rates. Dr Lang responded that NHS Fingertips, public health and coronial data indicated that suicidal ideation was linked with alcohol and drug misuse and exacerbated by circumstances such as rough sleeping and self-medication.

This was being supported by more detailed work to audit people who have self-harmed and presented at A&E. An ‘in reach’ model was being developed that was anticipated to revolutionise what people usually experienced by creating access to seamless services. An action plan detailing eight recommendations had also been formed. Councillor Coleman commended the extraordinary work of Dr Lang as an exceptional practitioner who had the ability to identify priorities and deliver on identified priorities.

Councillor Perez thanked members and officers for their work in developing and presenting the MTFS, and the committee for their scrutiny. Councillor Perez summarised key highlights from the presentation and the following actions were identified:

ACTIONS

1.    That the council’s financial commitment to protect local, frontline services that ensured that the most vulnerable H&F residents continued to be supported by the council, as distinct from the government’s national position on social care, be more clearly reflected in communications about the budget.

2.    That the Strategic Director of Social Care, Director of Finance and Head of Finance, Social Care and Public Health further explore the level of funding currently available for transitions and how delays in the service might be alleviated through further provisioning.

3.    Census 2021 data on the growing number of young people transitioning to Adult Social Care services to be appended to the minutes of this meeting.

4.    To provide details of whether Careline and related available support was offered in different languages.

RESOLVED

That the report was noted.