INTEGRATED PLAN PART B - STRATEGIC DIRECTION AND FINANCIAL CONSEQUENCES - Adult Care, Health & Wellbeing Portfolio - Hertfordshire ...
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INTEGRATED PLAN
PART B - STRATEGIC DIRECTION AND FINANCIAL
CONSEQUENCES
Adult Care, Health & Wellbeing Portfolio
Contents
Portfolio on a Page
Section 1: Future Strategic Direction 2022/23 - 2025/26
Key priorities for the portfolio over the period
Key pressures and challenges facing the portfolio
Key projects / programmes that the portfolio will deliver
Benchmarking and other information used in setting Strategic
Direction and assessing service outcomes
Key Risks, mitigation and resilience plans
Section 2: Revenue Budget Information
Key Budget Movements:
o Technical Adjustments
o Exceptional Inflation
o Pressures
o Savings
Revenue Budget by Objective Area
Section 3: Capital ProgrammeAdult Care, Health & Wellbeing Portfolio
Strategic Direction: Key services provided:
Services for adults who need care and support, promoting • Care and support services for:
independence, personalisation, choice and control and
• Older people
prevention.
• Adults with learning disabilities
• Adults living with mental health problems
• Adults with physical disabilities
Key priorities and programmes:
• Family carers
Implementing Social Care Reform • Information and Advice
• Charging Reform • Strategic oversight and development of provider market
• CQC Assurance Framework
• Safeguarding services for vulnerable adults
• Social Care Reform White Paper
• Working with NHS to deliver integrated services
Recovery from impact of Covid-19
• Support to providers Care Workforce Pay
• Support for carers
Connect and Prevent
• Transforming Connect & Prevent alongside the Connected Key risks in achieving IP proposals:
Lives Gateway
Connected Lives & Connected Communities • Workforce supply
• Employment, volunteering and education opportunities • Population pressures and fragility of care market,
• Community opportunities for people with a disability exacerbated by Covid
Accommodation and Housing • Maintaining financial contribution from NHS
• Extra Care Housing for older people • Ability to deliver transformation in context of response to
• Supported Housing for younger adults Covid
• Services and accommodation for people with mental health • Implementation of Social Care Reform and Liberty
related care and support needs Protection Safeguards
Keeping People Safe
• Tackling Domestic Abuse
• Strengthening safeguarding arrangements
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 59Adult Care, Health & Wellbeing Portfolio
£m ACH&W Net Revenue Budget Key Revenue Pressures:
500.000
• Older people demography
400.000
• Learning disability demography
300.000 • Mental health and physical disability demography
200.000 • Care workers pay
100.000 • Domestic Abuse
- • Supported Living in-house
2021/22 2022/23 2023/24 2024/25 2025/26 • Hertfordshire Equipment Service
• Nursing Home Development Strategy
Summary Revenue Budget Movements
2022/23 2023/24 2024/25 2025/26
£m £m £m £m Key Revenue Savings Proposals:
Service Specific • Demand management / Promotion of independence /
2.420 4.808 7.096 9.402
Inflation enablement
• Developing education, work and volunteering
Reversal of time limited opportunities for younger adults with disabilities
(2.720) (2.795) (2.795) (2.795)
expenditure • Reducing reliance on residential care
Demography 21.645 31.820 41.995 52.270 • Better value for money in the nursing care market
Legislative 7.179 11.809 14.597 23.000 • Younger people’s accommodation strategy
Other Pressures 16.977 21.823 24.972 24.824 • Efficiency proposals in services for people with mental
TOTAL PRESSURES 43.081 62.657 78.769 97.299 health related care and support needs
Existing Efficiencies (4.408) (7.381) (7.640) (7.640) • Procurement and cost control strategies
Existing Policy Choice (0.600) (0.600) (0.600) (0.600)
New Efficiencies (0.065) (2.829) (5.771) (7.841) Key Capital Schemes:
TOTAL SAVINGS (5.073) (10.810) (14.011) (16.081) • Older People Care / Nursing homes
• Extra Care Housing
• Adults with Disabilities Accommodation Strategy
2022/23 2023/24 2024/25 2025/26
• Day Opportunities
Capital Programme £m £m £m £m
• Hertfordshire Home Improvement agency / DFG
24.480 37.477 30.284 20.580 • Telecare / Assistive Technology
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 60Adult Care, Health & Wellbeing Portfolio: Future Strategic Direction
1 What are the key priorities for the portfolio over the period 2022/23 – 2025/26
and how does it support delivery of the corporate plan?
The Council’s new Corporate Plan (Hertfordshire – Our County of Opportunity,
2022-2025) was approved by Council in February 2022, alongside this Integrated
Plan.
The Corporate Plan outlines that Hertfordshire will continue to be the county of
opportunity for all, a place where our people thrive, our places prosper, and our
planet is protected.
To achieve this, our vision is to create a cleaner, greener and healthier
Hertfordshire.
The Corporate Plan sets out our commitments on how we will work with our
partners to deliver this vision through the following themes:
A cleaner and greener environment
Healthy and fulfilling lives for our residents
Sustainable, responsible growth in our county
Excellent council services for all
This Integrated Plan provides significant additional investment in this portfolio,
including:
£18m of investment in care providers, allowing for an increase in the wages
of the lowest paid care staff across the Hertfordshire. This should enable
wages to rise to a minimum of £10.30 per hour, above the national living
wage (with many care workers earning above that level). This reflects the
remarkable efforts of these staff throughout the pandemic, and also their
critical importance in caring for vulnerable people moving forward, and
ensuring the wider care and health systems can operate effectively. The
proposed Adult Social Care precept (council tax) increase will be used for
this purpose.
£22m to ensure there is sufficient funding to support increased numbers of
older people and adults with disabilities needing support, including
responding to the impact of hospital discharge arrangements.
£1m investment in Domestic Abuse, working with partners to expand the
service
Investing in a new model for Adult Social Care working to strengthen
prevention to reduce preventable admissions to hospital and long-term care.
£15m of investment in a new accommodation strategy for adults with
disabilities, due to go to Cabinet in February 2022, that will set out an
ambitious project of redevelopment.
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 61During 2021 Adult Care Services have refreshed the ACS strategic plan for 2022/23
– 2025/26, outlining five key changes and improvement activities, designed to
deliver the outcomes we know are most important to people.
Communication and relationships (including
information and advice)
Maintaining wellbeing
Providing care and support
Supporting people who look after others
(carers)
Organisations working together to support
people
The five themes are consistent with wider Council strategic priorities as follows;
Healthy and fulfilling lives for our residents - Hertfordshire is the county of
opportunity, and as such our focus is to ensure everyone has the opportunity to
achieve their full potential, and live healthy, fulfilling, safe and independent lives.
Recognising the significant effect that remaining healthy and safe has on people’s
happiness and life chances, our services work together to improve the overall
wellbeing of our residents, including using effective early intervention measures to
help tackle inequalities.
However, the pandemic has exacerbated income inequality, socio-economic
inequalities and intergenerational inequalities, and there has been increased
pressure in areas such as education, mental health, domestic abuse and
homelessness, and it is essential we provide to support those individuals and
communities who have been most impacted to prevent societal inequalities being
widened.
A cleaner and greener environment -- Hertfordshire’s natural environment is our
county’s greatest asset. The effects of climate change are without doubt one of the
biggest challenges of our times, and as such, protecting environment for future
generations must run through all we do as an organisation.
The County Council has been responding to the climate change challenge for a
number of years and our Climate Emergency declaration in July 2019, and
commitment to being a council with net zero emissions by 2030 is a recognition of
how important this is to us.
The pandemic has also had several effects on the environment and climate,
including improvements in air quality, lower greenhouse gas emissions, and lower
levels of noise pollution, highlighting the interrelations between societal and
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 62community resilience with environmental resilience. As we move into recovery,
there needs to be a focus on environmental sustainability, reshaping our behaviour
and consumption patterns to maintain these positive impacts long term.
As we develop the ACS model as part of the council’s “Ways of Working”
programme we will work with staff to offer services in an environmentally
sustainable way. We will support the people we are in contact with to access
information and advice, including on how to reduce their carbon footprint, and will
work with care providers to ensure their development plans include consideration of
the environmental impact of their services. Our ambitious capital programme will
deliver to excellent sustainability standards.
Our influence is wider than the services we directly deliver. With the ability to
influence carbon emission reductions, improve air quality, promote energy
efficiency, reduce waste production and promote better land use practices we can
drive forward our commitments to creating a cleaner, greener, healthier
Hertfordshire for all.
Sustainable, responsible growth in our county - As with other parts of the UK,
Hertfordshire is facing the challenge of how to accommodate and support a growing
population. Alongside our district and borough council partners, who are the local
planning authorities in Hertfordshire, we are preparing for around 100,000 additional
new homes over the next 15 years. It is essential that the necessary infrastructure
and other community resources are in place to support these new developments.
This includes planning for significant growth in quality housing for older people and
people with a physical and/or a learning disability
Hertfordshire is a prosperous county with one of the strongest economies in the
country. We have a thriving business community and are home to specialist
industries of both national and international significance. With the growth
anticipated in the county in future years, it will be vital that Hertfordshire’s strong
economy continues to grow, with resilient and successful businesses that offer good
employment opportunities, including to people with disabilities, and helps to
maintain a high quality of life for all.
By sustainable growth we mean ensuring Hertfordshire is prepared to meet the
challenges of the future, whilst minimising our impact on our natural environment.
Excellent Council Services for all - In 2018 we published the 15-year future
direction and strategic ambitions for adult social care in Hertfordshire. This set out
our ambition for the future, to guide the development and transformation of our
services for all the people we support. The aspirations outlined in this document
continue to be the basis on which we work together with those who have an interest
in this area to develop and deliver vital services, united in a common understanding
and vision of the role of adult social care. ACS 15 Year Direction. :-
• The whole council and our partners in the county work to create a place where
people lead healthy, purposeful, self-supporting lives, and so help to prevent
and reduce care and support needs.
• People who need care and support will have the same opportunities for a good
quality of life as people who do not.
• We will offer services to maximise people’s independence and support the
freedom to choose, helping people at risk to be safe.
• All care and support will be personalised to the individual and directed by them
over their life. It will be based on their own strengths and their connections
with family, communities and professionals.
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 63By strengths, we mean things the person, their family, their friends and neighbours
and local community have or do that can help the person live a good life.
The ACS Strategic Plan will mean delivery of the following activities:
Theme 1: Communication and relationships (including information and
advice)
This priority is about how we work with everyone involved in social care, including
local people, carers (family and friends) and partner organisations. It is about
information and advice, as well as the way we work with individuals who need care
and support and their unpaid carers.
Key activities will be:
• having the right people working across social care to deliver good services
and information and advice (Workforce Strategy)
• improving the way people experience being financially assessed and
charged for their care.
• improving information and advice and how people can access it
• developing co-production across all services
• putting in place new arrangements for contacting or re-contacting ACS and
making referrals (our front door)
Theme 2: Maintaining Wellbeing
This priority is about connecting people with tools, services and other support so
they can realise and maintain their potential for staying fit and well, both physically
and mentally. We will support people to make a good recovery from illness,
bereavement or other setbacks and promote personal resilience. People will be
protected from harm and/or neglect.
Key activities will be:
• working in partnership to support the voluntary, community, faith and social
enterprise sector (VCFSE) to recover following Covid
• developing and delivering new strategies including:
– VCFSE Preventative Strategy
– Dementia Strategy
– Hertfordshire Supporting Adults with Complex Needs Strategy
– Learning Disability Mortality Reviews (LeDeR) 2021 policy
– Countywide Domestic Abuse Strategy
– Sensory Strategy and Action Plan
– Whole Housing Approach pilot
– Tackling inequalities
• evaluating our assistive technology pilots and developing our assistive
technology offer
• improving employment opportunities for adults with disabilities
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 64Theme 3: Providing care and support
This priority is about putting choice, independence, enablement and citizenship at
the heart of our work with people that supports them to live their lives to the full,
taking a proportionate approach to risk. It’s about emphasising people's self-
determination, skills and assets in every conversation and prioritising the things that
are important to them.
Key activities will be:
• working with and monitoring care providers to ensure they provide safe, high
quality, effective and sustainable services
• continuing to develop social care practice by embedding Connected Lives
• reviewing and improving how we carry out safeguarding of adults and apply
mental capacity legislation
• planning to increase extra care and nursing home places and transform in-
house supported living, short breaks and day opportunities services
• implementing our direct payment strategy action plan
Theme 4. Supporting people who look after others (unpaid carers)
We will deliver the new Carers’ Strategy, working with unpaid carers and the people
they care for to have real control and choice over how they are supported. We will
focus on the things that make the biggest difference, so carers feel respected and
heard, as carers and partners in care and experts in the needs of the person they
care for.
Key activities will be:
• supporting carers through Covid recovery, learning from its impact to shape
future ways of working with carers
• a refresh and meaningful delivery and implementation of the multi-agency
Carers’ Strategy under the direction of the Carers’ Co-production Board
• evaluating the Connected Lives approach for carers
Theme 5. Organisations working together to support people
This priority is about ensuring all organisations involved in social care in
Hertfordshire, including health partners, local councils and care providers, work
together to support people with services that are good quality, good value and
joined up. We need to use resources efficiently and effectively, avoiding
unnecessary duplication, addressing gaps in services and continuously improving
the way people are supported.
Key activities will be:
co-producing monitoring arrangements for the new ACS 4-year plan and the
Local Account
working with the NHS and wider partners to support people who are frail
including a new approach for people with Learning Disabilities
working with all partners around preventable admissions to hospital,
discharge to assess and urgent emergency care. This will include better co-
ordination regarding falls, early intervention and re-ablement and improved
community services including social prescribing.
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 65 addressing areas of inequality such as economically induced health
inequality, digital exclusion, fuel poverty, food insecurity amongst adults,
and the training needs of front-line staff in benefits awareness.
preparing for social care funding reform
responding to joint priorities and actions as equal partners with the NHS in
the Integrated Care System (ICS)
working with local district councils to deliver a range of accommodation
options for people with care and support needs
These have been developed in partnership with people who use our services and
with colleagues in the Hertfordshire and West Essex Integrated Care System which
was established in May 2020. In an Integrated Care System, NHS organisations,
local councils and others, work in partnership to take collective responsibility for
managing resources, delivering standards and improving the health of the
population we serve. The new ACS plan supports the move towards closer working
with the NHS as set out in A healthier future.
2 What are the key pressures and challenges facing your portfolio for 2022/23 –
2025/26?
Over the next three years we will be dealing with the consequences of Covid, due to
the increased health and social inequalities that have been sustained in parts of our
communities, but in addition there are a number of ongoing pressures that underpin
our IP assumptions.
Demographic pressures; changing expectations and needs
Demand for support is forecast to grow as a result of population growth, building
on already significant growth seen since 2010, as set out in the table below. The
population of people aged 85 and over is forecast to increase by 21% while adults
with learning disabilities will increase by 34% through to 2030. In both cases the
greater incidence of dementia and frailty will increase the need for social care but
in the latter group we are seeing a combination of a longer life expectancy, with
physical disability, and rising aspirations amongst younger people to live an
independent life.
Table of population growth forecasts
Adults# (18-64)
Older People* 65+ Older People 85+ with Learning
Disabilities
% Rise in population
20.2% 29.3% 6.9%
since 2010
Population in 2020 205,909 31,501 17,609
Forecast population
223,061 32,300 22,699
by 2025
Forecast population
245,987 38,100 23,587
by 2030
Forecast percentage
19.5% 21% 34%
increase 2020-2030
*HertsInsight – Population profiles
# JSNA Learning Disability
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 66Our main strategy to address the increased demand for support is our Connected
Lives approach which is emphasising a preventative and enabling way of working;
our prevention and demand management work; and our information and advice
strategy which aims to equip people to make well-informed choices and help sign-
post people as early as possible towards non-formal types of care and support
where appropriate.
Demography pressures are shown in lines D1, D2 and D4 of the IP Movement
Statement. There has been a significant increase in the number of older people we
are supporting during the 2021/22 financial year and we are seeing higher levels of
acuity and complexity because of the impact of the pandemic; the older people
demography pressure (D1) includes the impact of this increase. In addition, we
continue to support increasing numbers of adults with disabilities and the
demography pressure (D2) reflects this increase.
Care market & workforce pressures
The Care Quality Commission’s (CQC) State of Care Report 2020/21 outlined that
the adult social care market nationally was a sector under pressure, even before
the pandemic but Covid-19 has increased this further, threatening the financial
viability of some providers and services. The CQC reports operational challenges
from decreased occupancy, reduced admissions, increased costs and difficulty
recruiting and retaining staff.
The impact in Hertfordshire of this trend is a loss of between 150-200 bed spaces
in the last year and a homecare market increasingly struggling to respond
effectively to heightened demand. This is despite achieving highest number ever
of homecare hours being provided in 2021/22. While the council established a
Local Authority Trading Company called ‘Herts at Home’ in December 2018, which
offers an alternative strategy when market conditions are challenging, this service
does not operate everywhere in Hertfordshire and demand pressures are
increasing significantly, affecting all providers, as outlined in the chart below.
New Requests for Support ending up in long term care -
Hosp vs Community
(65+)
1416 1338
1268 1263
1160 1095
917 934
751 742
616 601
16-17 17-18 18-19 19-20 20-21 21-22 (FYE)
Hospital (Front Door)- Total Into LTC Community (Front Door)- Total Into LTC
Linear (Hospital (Front Door)- Total Into LTC)
Workforce pressures are a particular challenge, and are expected to continue over
the next three years. Historically high levels of employment in Hertfordshire, the
pressures of working in during the pandemic, low pay and competition with other
sectors for workers make it difficult to attract people into the care profession and
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 67an ageing care workforce and high vacancy and turnover rates mean that the
challenge is continuous.
In the immediate future, these issues will be addressed to some extent by the
DHSC announcement on 3 November, and then again on 10th December, of a
workforce and retention grant, worth £2.8m and £5.2m in Hertfordshire, this in
addition to funding from Health and HCC Covid funding provided a total of
£13.05m which will be spent on financial incentives to retain existing staff, but this
does not address medium to longer term recruitment issues and the workforce
investment announced in the white paper ‘People at the Heart of Care’ will take
time to have the required effect.
To address the workforce challenges over the last few years the council has
made significant investments targeted to care workers’ wages, funding
increases for homecare workers to over £12.58 per hour and residential and
homecare pay rates to a minimum of £9.50 in 2021/22. The infographic below
summarises the challenges and shows the further significant investment in
care workers pay in the current proposals taking the minimum to £10.30 and
home care rates to £13.64 and £13.83 in 2022/23. (L1; OP21) resulting in an
investment of a £18.5m in 2022/23 in the care workforce.
Discussions with market representatives to understand and monitor the range
of inflationary and financial pressures that providers are experiencing have
informed our ongoing fee strategy. Additional support will be provided to care
providers to cover the additional National Insurance costs of the social care
levy (L13)
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 68Legislative pressures
Health & Care Bill 2021
The Health & Care Bill, currently progressing through parliament, includes a number
of proposals that are likely to provide some challenges over the next three years.
A new legislative framework to facilitate greater collaboration with the NHS,
and a requirement of the integrated health and care system to address the
health and wellbeing challenges of our population.
Significant charging reforms
New proposals around the collection of data
A new assurance framework including a new duty of CQC to assess
councils’ delivery of their adult social care duties
Changes to the legislation framework regarding the Discharge to Assess
model and changes to the Better Care Fund.
Liberty Protection Safeguards
The Liberty Protection Safeguards (LPS) were introduced in the Mental Capacity
(Amendment) Act 2019. LPS will provide protection for people aged 16 and above
who are, or who need to be, deprived of their liberty in order to enable their care or
treatment and lack the mental capacity to consent to their arrangements. These
replace the Deprivation of Liberty (DOLS) safeguards currently in place.
The new Act broadens the number of people that will be affected by safeguards and
will require significant training and support of staff to understand and implement the
new requirements. While the government’s initial intention was implementation of
LPS by April 2022 (this may now be deferred to 2023) the Department for Health
and Social Care also made commitments to a 12-week consultation period on the
draft regulations and those have not yet been published. The additional costs
associated with delivering this new approach are shown at L11.
3 What are the key projects/programme that the portfolio will deliver 2021/22 –
2024/25?
Investment and efficiency proposals starting in 2022/23 for Adult Care Services
comprise:
Investment in a transformational prevention programme which will strengthen our
‘Connect and Prevent’ model linked to Social Care reform and the development of
the Connected Lives Gateway model to improve outcomes for people we support
enabling them to remain more independent for longer. This will deliver efficiencies in
the care purchasing budgets which relate to ‘Connect and Prevent’ by improving the
effectiveness of preventative and enabling approaches, reflecting ambitions to
better signpost people to sources of support in the community, and offering short-
term support in helping people remain independent. (References OP137 – NE24).
Further investment in Domestic Abuse to increase support for high, medium and
standard risk domestic abuse services to meet currently unmet demand. This will be
delivered in conjunction with the Hertfordshire Domestic Abuse Partnership and
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 69provides additional permanent funding to support victims of domestic abuse
(OP124).
Investment in nursing provision forms an integral part of our capital programme and
we are increasing the support to develop new models for nursing care to meet the
expanding requirement for this form of care in response to changing requirements
(OP122).
The White Paper People at the Heart of Care signals a strong emphasis on the
need to develop housing choices for people. We propose to establish a lead for
housing to lead on building partnerships to embed housing plans as part of the
health and care system, boosting the availability of specialised housing and make it
easier for everyone to adapt their homes to promote living independently and safely
(OP138).
Existing proposals brought forward from the 2021/22 Integrated Plan cover:
Work with Hertfordshire Partnership Foundation Trust to deliver an annual efficiency
target of 4%. Proposals are based on establishing a Connected Lives approach
within the service and moving away from provision based on long term
accommodation, to an ‘Intensive Enablement’ approach which, where appropriate,
can ready people to return to daily living in the community. The savings in the first
two year have been impacted by the Covid pandemic but the full level of original
savings will still be achieved by 2024/25. (EE11).
Reviews of smaller teams and identification of opportunities to assess delivery
models and consolidate management arrangements (EE14 and EE15).
There are a number of efficiency and service development areas in the Adults
Disability Service (ADS): developing within the Adult Disabilities Service a new
employment opportunities strategy and ‘move-on’ approach, coupled with a new
approach to day opportunities; placing particular emphasis on opportunities for
people transitioning into services for adults from Children’s Services (EE4).
A further element of work in ADS (EE5) relates to ensuring optimal
accommodation for all by:
- Targeting access to mainstream housing for people with care and
support needs
- Working to increase the opportunities for people to live in Supported
Living settings instead of residential accommodation
- Providing opportunities for older people with learning disability to live
in ‘mainstream’ older people’s services where appropriate
- Developing our ‘Shared Lives’ service, giving people opportunities to
live in the community with families and individuals to support them
- Looking at opportunities to use Assistive Technology for example to
reduce the use of sleep-in or waking night cover.
A review of in-house day and supported living services will assess the options
for a future operating model for day services, supported living and short breaks
(EPC1). The ability to progress this review has been impacted by the Covid
pandemic and the savings reduced in 2021/22 but are expected to be achieved
by 2022/23 in full.
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 70 A further range of proposals across the Department relates to improving the
value for money achieved when care is purchased by robust procurement and
cost control strategies (EE7) and also in relation to ensuring that all available
sources of funding (such as Transforming Care and Continuing Health Care
funds) are maximised (EE6).
4 How has the portfolio reviewed its effectiveness / value for money in
delivering service outcomes?
The Local Government Association (LGA) produce an annual Use of Resources
(UoR) report for adult social care that looks at a variety of cost and activity metrics
to help us review and understand the use of our resources and compare them with
the average for the ADASS East region and our CIPFA nearest neighbours group
(Councils with the most similar statistical characteristics in terms of social and
economic features).
The information in the table below is drawn from that report and shows that
Hertfordshire overall is spending in line with the national average across all adults,
but when broken down it is clear that there are significant differences between care
for people aged over 65 and those aged between 18-64.
For people aged 18-64 we are in the top 10th percentile for what we pay per adult,
while for people aged 65+ the costs are in the 90th percentile.
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 71While the multiple factors that contribute to these costs are difficult to evaluate and
influence, the adult social care department recognises the need to deliver effective
value for money and work towards a position of alignment with other councils.
In terms of understanding our 18-64 costs we aware of the following issues:
Our position (rank) in comparison to other Councils has not changed since
2017 and our closest neighbours are CIPFA councils such as Essex, Kent,
Surrey and Hampshire.
A significant strategy to reduce packages of care for people in stable
Supported Living services, (the Provider Review Programme) was put on hold
during Covid.
The individuals that moved or were reviewed during Covid were often those
with the highest needs or in crisis, meaning an increase in the average
package during this time.
While the older people’s market is subsidised to some extent by self-funders
the same cannot be said of the market for younger adults.
There are significant costs coming through from younger adults with very
complex needs. While the numbers of individuals needing social care is lower
than older age groups a single package of care for one individual with
significant physical and learning disabilities can be 10x the cost of supporting
an older person.
The costs of our large in-house services are included in the figures and we
have some overhead and void costs that other providers don’t have.
In recognition of these issues the Adult Disability service has committed itself to the
challenging efficiency programme and includes:
Negotiating with providers and drawing on the expertise of social work teams,
commissioners and providers themselves to systematically review care
packages, to increase enabling support and reduce the overall hours we
commission.
A strategic review of residential options, particularly out of county, to ensure
the optimal accommodation for individuals. This will include the de-
registration or closure of some services and redevelopment of others to meet
complex needs.
The new ADS Accommodation Strategy recognises the impact of property
issues on increased costs and sets out an ambitious programme of work to
improve housing and reduce voids, with a focus on our in-house supported
living service.
A review of how we work with the 0-25 service in Children’s Services to
ensure we have more visibility of the needs of our young adults and can plan
accordingly.
Operational effectiveness data is collected nationally via the Adult Social Care
Outcomes Framework (ASCOF) indicators. These represent a ‘basket’ of measures
across a variety of social care areas. In the latest available set of data relating to
2020/21, which only captured 13 rather than the normal 23 indicators due to Covid
restrictions, Hertfordshire performed better than the England and East of England
averages in 77% of the measures (10/13). The Adult Care and Health panel
receives quarterly updates on ASCOF indicators.
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 72The Department plays an active role in national and regional work that gives great
insight into the work of other local authorities and how HCC compares.
ADASS is highly active in the Eastern Region and often works to compare activities
on a regional basis. The cost of care is also regularly monitored and compared
across the region, including as far as possible, tracking costs in the self-funder
market. In our approach to fee-setting we are setting the standard for authorities in
the region - recognising the pressures on the social care market acting responsibly
as a commissioner in line with our care act duty to ensure a healthy market in so far
as we are able.
5 What are the key risks in delivering projects and programmes for this
portfolio, and what mitigations are in place? What steps are being taken to
ensure resilience?
As outlined in the Risk Focus Report that was due to go to the Audit committee
during December 2021 (subsequently cancelled) now due March 2022 a current
and significant risk for adult social care is that, in light of the intense pressures on
the market, providers may fail to provide care and support to adults this winter
resulting in safeguarding issues and reputational damage to Hertfordshire County
Council. The budget impacts of this risk are outlined below:
Cost pressures emanate from the fragility of the care market, which has been
exacerbated by the additional pressures of the Covid-19 pandemic, and the
restricted supply of care creates a risk of further escalation in prices for care.
Increases in the National Living Wage that come into effect from April 2022
are currently a key factor in ongoing negotiations with care providers about
the inflationary cost pressures they are facing, and will put upward pressure
on our future fee strategy.
Our response to these challenges includes a number of control mechanisms:
The council works in partnership and funds the Hertfordshire Care Providers
Association (HCPA) to support care organisations to recruit, support and train
the care workforce and improve the attractiveness of careers in care.
In order to manage the risk of supplier failure, and hand back of care
contracts, we monitor care providers closely and have passed on all Covid19
funding from DHSC as quickly as possible.
An early commitment to our adult social care providers, that we would pick up
any additional costs they faced due to Covid, either through extra staffing
costs or the need for additional PPE was made. That commitment remained
throughout the pandemic, and has been in place for all of the 2021/22
financial year.
In recognition of the increasing number of people waiting for care the
voluntary sector has received £240k from the Hertfordshire and West Essex
ICS to support people in the community.
To ensure the delivery of our efficiency programmes governance is well
embedded in the Department via the ‘ACS Connect’ structure which monitors,
reports and delivers on transformation, efficiency activity and associated risks
across the department.
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 73ANALYSIS OF REVENUE BUDGET BY OBJECTIVE AREAS
Gross
Net Budget Budget Net Budget Net Budget Net Budget Net Budget
2021/22 Objective Area 2022/23 Income 2022/23 2023/24 2024/25 2025/26
£'000 £'000 £'000 £'000 £'000 £'000 £'000
Adult Care Services
Older People (inc Specialist Mental Health Team)
Care and support services for older people who meet the council’s eligibility criteria for social care
93,233 including care home placements, homecare, day services and social work teams who assess those 182,737 (63,201) 119,536 125,620 130,483 138,160
in need.
Disability Services (People with a Learning Disability and People with a Physical disability or sensory
loss)
Care and support services for people with a learning disability and physical disability who meet the
187,662 council’s eligibility criteria for social care including residential care home placements, supported living 232,276 (28,782) 203,494 211,512 221,028 231,303
accommodation, support at home, day services and social work teams who assess those in need.
Mental Health Services
Care and support services for people with mental ill-health who meet eligibility criteria for social care
16,320 including residential care, support at home, day opportunities delivered by the voluntary sector and 21,003 (5,059) 15,944 15,568 15,802 16,302
social work assessments delivered by Hertfordshire Partnership Foundation Trust on behalf of HCC.
Transport SLA
Day services associated transport delivered by county council staff from more than 20 locations
4,714 5,170 (347) 4,823 4,905 4,988 5,073
countywide to older people and people with physical and/or learning disabilities.
Preventative Services
Short-term services available to people who may need adult social care in the future but who can
16,160 remain independent for longer including services delivered by the voluntary sector or enabling 15,886 (240) 15,646 15,894 16,223 16,576
services that encourage people to regain functional skills at home.
Provider Services
Comprises in house operations such as day centres, supported living services, Herts Equipment
28,866 Service, Gypsy and Travellers Service, Money Advice Unit, Work Solutions and the Hertfordshire 31,785 (1,794) 29,991 30,626 31,270 31,928
Home Improvement Agency.
Strategic Centre
Central support services including Senior management, commissioning teams, delivery and oversight
10,726 of legal and statutory duties (Mental Capacity, Safeguarding), professional and provider workforce 12,354 (957) 11,397 13,569 13,743 13,621
development.
357,681 Adult Care, Health and Wellbeing Total 501,211 (100,380) 400,831 417,694 433,537 452,962
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 74KEY BUDGET MOVEMENTS 2022/23 - 2025/26
2022/23 2023/24 2024/25 2025/26
TOTAL TOTAL TOTAL TOTAL
£000s £000s £000s £000s
Technical Adjustment 2,235 2,235 2,235 2,235
Service Specific Inflation 2,420 4,808 7,096 9,402
Reversal of time limited (2,720) (2,795) (2,795) (2,795)
Demography 21,645 31,820 41,995 52,270
Legislative 7,179 11,809 14,597 23,000
Other Pressures 16,977 21,823 24,972 24,824
TOTAL PRESSURES 43,081 62,657 78,769 97,299
Existing Efficiencies (4,408) (7,381) (7,640) (7,640)
Existing Policy Choice (600) (600) (600) (600)
New Efficiencies (65) (2,829) (5,771) (7,841)
TOTAL SAVINGS (5,073) (10,810) (14,011) (16,081)
Approximate
Type of budget 2022/23 2023/24 2024/25 2025/26
Ref Description Dept current budget
movement TOTAL TOTAL TOTAL TOTAL
£'000
£000s £000s £000s £000s
Technical Adjustments
Technical
TA1 No pay inflation was allocated for 2021/22 - this reflects an uplift of 1.75% - ACS 1,284 1,284 1,284 1,284 -
Adjustment
Technical
TA6 Health & Social Care Levy ACS 952 952 952 952 -
Adjustment
Service Specific Inflation
Older People, Physical and Learning Disability residential and Learning Disability Nursing - Fees to Service Specific
SSE1 ACS 514 1,486 2,440 3,394
external providers Inflation
Service Specific
SSE2 Learning Disability Supported Living - Continuing care to external providers ACS 1,428 1,590 1,746 1,899
Inflation
Older People, Physical and Learning Disability private & voluntary daycare - Continuing care to Service Specific
SSE3 ACS 78 78 78 78
external providers Inflation
Older People, Physical and Learning Disability direct payments - Continuing care to external Service Specific
SSE4 ACS 78 78 78 78
providers Inflation
Service Specific
SSE5 Mental Health contribution to pool - Continuing care to external providers ACS 188 228 267 308
Inflation
Older People, Physical and Learning Disability residential and Learning Disability Nursing - Service Specific
SSE24 ACS - 1,170 2,283 3,396
Homecare Inflation
Service Specific
SSE25 ACS - various other ACS 134 178 204 249
Inflation
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 75Approximate
Type of budget 2022/23 2023/24 2024/25 2025/26
Ref Description Dept current budget
movement TOTAL TOTAL TOTAL TOTAL
£'000
£000s £000s £000s £000s
Pressures
ADS Transformation - Supporting the transformation of ADS services to support the delivery of Reversal of time
RTL5 efficiency savings whilst improving outcomes for the people we support. The reduction in funding ACS limited (1,500) (1,500) (1,500) (1,500) -
from 22/23 reflects the fact that funding of £1.5m was agreed for one year only in 21/22. expenditure
Strengthening Volunteers Support - ACS commissions a range of preventative services from the
Reversal of time
Voluntary and Community Sector (VCS). The reduction in funding from 23/24 reflects the fact that
RTL9 ACS limited - (75) (75) (75) -
additional funding of £0.230m agreed in 21/22 would reduce to £0.155m from 23/24, due to 3 posts
expenditure
being funded only for 2 years.
Support for VCS and Homeless - Developing an enhanced Voluntary and Community Sector
Reversal of time
(VCS) and homeless (adults with complex needs) preventative offer during 2021/22, as an essential
RTL10 ACS limited (1,220) (1,220) (1,220) (1,220) -
element of the COVID recovery efforts. The reduction in funding reflects the fact that the additional
expenditure
funding agreed in 2021/22 of £1.510m was temporary and reducing to £0.290m from 22/23.
Older People Demography - Around 55% of the Adult Care Services budget for older people is
spent on the 85 and over age group, 30% on the 75 to 84 age group and 15% on the 65 to 74 age
group. The projected increases in the numbers in these age groups have been used together with
D1 the estimated spend on these age groups to produce the year on year budget increases required to ACS Demography 14,498 18,957 23,416 27,975 93,233
meet demographic pressures. There is a significant increase in 2022/23 reflecting a growth in
placement numbers in 2021 as a result of hospital discharge activity and additional demand in the
community post COVID.
Adult Disability Demography - The trend of placements in the previous five year period has been
D2 overlaid with projected increases in population of people with learning & physical disabilities in order ACS Demography 6,826 12,388 17,950 23,512 187,662
to forecast likely future additional funding requirements.
Mental Health Demography - The projection for demographic pressures is based on the number of
D4 ACS Demography 321 475 629 783 16,320
net new/additional people that will require support estimated from activity data.
National Living Wage for Commissioned services - This reflects the continuing pressure in costs
L1 for care providers due to the impact of increases in the National Living Wage. This pressure links ACS Legislative 5,234 7,864 10,652 19,055 144,486
with Ref: OP21 (below) in providing a significant investment in pay for the care market.
Liberty Protection Safeguards (LPS) - The introduction of new Liberty Protection Safeguards will
L11 ACS Legislative - 2,000 2,000 2,000 863
result in revised burdens and additional costs to deliver.
National Insurance increase for Commissioned services - Pressure arising from the
L13 Government increase in national insurance of 1.25% from April 22 to fund health and social care. ACS Legislative 1,945 1,945 1,945 1,945 -
The additional cost will impact on rates paid to providers for commissioned services
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 76Approximate
Type of budget 2022/23 2023/24 2024/25 2025/26
Ref Description Dept current budget
movement TOTAL TOTAL TOTAL TOTAL
£'000
£000s £000s £000s £000s
Pay Rates for Care Workers - The Council wishes to sustain the care market by increasing the
attractiveness of careers in care. Traditionally this is a low paid area but the role increasingly
requires a high level of skill. The inflation requirement across the sector has been reviewed in the
OP21 ACS Other Pressures 13,288 16,390 19,539 19,691 144,486
context of the care market and the need to ensure sufficient capacity and sustainability of
providers. This pressure links with Ref: L1 (above) in providing a significant investment in pay for
the care market.
Hertfordshire Equipment Service (HES) staffing and systems - Investment in staff and
infrastructure in HES to enable the service to effectively respond to increased demand for
OP119 ACS Other Pressures 125 125 125 125 -
equipment to support ACS and health partners’ shared objectives. This represents HCC adult
pooled budget element.
Hertfordshire Equipment Service Pooled Budget contribution - There has been a significant
increase in demand for community equipment in 21/22 and this is expected to be on-going with
OP120 increased inflation anticipated on many items. Partners have agreed to propose a funding increase ACS Other Pressures 760 760 760 760 -
to support additional equipment prescribing and this reflects the HCC adults element of increased
funding of the pooled budget to meet prescribers’ requests for community equipment.
Nursing Home Development Strategy - Developing new models for nursing care to meet the
OP122 ACS Other Pressures 300 300 300 - -
expanding requirement for this form of care in response to changing requirements.
Domestic Abuse - Increased funding for high, standard/medium risk Domestic Abuse (DA) services
OP124 to respond to unmet demand. Delivering this ambition will require a partnership approach across the ACS Other Pressures 1,000 1,000 1,000 1,000 -
Hertfordshire Domestic Abuse partners.
OP131 Supported Living in house - This is related to staffing in Supported Living establishments. ACS Other Pressures 360 360 360 360 -
Connect and Prevent Investment - Investment in strengthening Connect & Prevent in line with
OP137 Connected Lives Gateway to enable people to live their lives as independently as possible for a long ACS Other Pressures 1,044 2,788 2,788 2,788 -
as possible. This links with the new efficiency saving Ref: NE24 below.
Social Care Reform - Housing - Investment in housing to lead on building partnerships to embed
OP138 housing plans as part of the health and care system, boosting the availability of specialised housing ACS Other Pressures 100 100 100 100 -
and make it easier for everyone to adapt their homes to promote living independently and safely
Savings
DS Strategy 1: Education, work, vol and personal budgets - linked to day ops - To work
alongside preparation for adulthood to develop employment and post college voluntary work
pathways as a positive alternative to traditional day care type services. To develop an operational Existing
EE4 ACS (300) (500) (500) (500) 7,533
initiative to support people receiving social care to access employment opportunities, linking with Efficiencies
development of new employment projects within work solutions to increase the number of
individuals in employment.
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 77Approximate
Type of budget 2022/23 2023/24 2024/25 2025/26
Ref Description Dept current budget
movement TOTAL TOTAL TOTAL TOTAL
£'000
£000s £000s £000s £000s
DS Strategy 2: Optimal accommodation options for all - housing and Shared Lives - This
strategy is to ensure that timely reviews are completed and that care and support provided within
social care accommodation settings is appropriate, outcome focused and value for money. To Existing
EE5 ACS (1,200) (2,200) (2,200) (2,200) 60,027
ensure that all new accommodation supported living packages are developed via the framework to Efficiencies
ensure good value for money and improved provider opportunity to develop innovative services
within Herts.
DS Strategy 3: Review Out Of County (OOC) placements and Transforming Care Placement
(TCP) clients and CHC income - This strategy is to review where appropriate OOC and TCP with a
view to, where possible, commissioning more appropriate provision in Herts at a more suitable Existing
EE6 ACS (785) (895) (895) (895) 60,027
price. To actively increase number of people we support who receive the Continuing Health Care Efficiencies
funding to ensure they have access to the free care they are entitled to, thus reducing the burden on
social care budgets.
DS Strategy 4: Negotiating strategies with key providers - This strategy will focus on developing
Existing
EE7 and implementing negotiating strategies for key areas of ADS provision across residential (including ACS (1,000) (1,800) (1,800) (1,800) 131,626
Efficiencies
out of county) and Supported Living.
Hertfordshire Partnership Foundation Trust (HPFT) - An annual efficiency requirement on HPFT
of 4% which is to be delivered via service transformation supported via Invest to Transform funding
and capital investment. Areas for efficiency would be around income identification and collection, Existing
EE11 ACS (1,023) (1,886) (2,145) (2,145) 16,570
review of packages, and improvement in unit costs for residential and nursing placements which are Efficiencies
comparatively high, by developing a new service model which emphasises recovery and support
within the community, and a reduction in out of area placements.
Work Solutions service re-design - Work Solutions service re-design with defined employment Existing
EE14 ACS (50) (50) (50) (50) -
pathways & new model for support. Efficiencies
Existing
EE15 External Provider Workforce - A review of role and future delivery model for workforce strategy. ACS (50) (50) (50) (50) -
Efficiencies
Other savings: Community & Specialist Services - This represents a reduction in operational
costs and increased income in the in-house day opportunities service combined with the design of a
Existing Policy
EPC1 new service model aligned to Connected Lives, and the development of services for adults with ACS (600) (600) (600) (600) 25,041
Choice
more complex needs. A fundamental review of in-house supported living provision will also be
commenced to align with the ADS accommodation strategy and Connected Lives model.
Renewal of HCC mobile phone contracts - Cross cutting saving identified by Resources
NE21 ACS New Efficiencies (65) (65) (65) (65) 231
Technology team due to mobile phone contract renegotiation
Connect and Prevent - As a result of enhancing and strengthening our capacity to work with
people when the first come into contact with social care, and therefore to work increasingly
NE24 effectively with people to prevent, defer and delay needs for more intensive care and support, we ACS New Efficiencies - (2,764) (5,706) (7,776) -
will deliver efficiencies in our care management budgets. This links with the investment shown at
Ref: OP137 above.
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 78Adult Care, Health and Wellbeing capital programme 2022/23-2025/26
The total capital programme 2022/23 to 2025/26 for the portfolio is £112.821m and for 2022/23 is
£24.480m This includes all new bids and re-programming from 2021/22 at the end of quarter 2.
2022/23 2023/24 2024/25 2025/26 Total
£’000 £’000 £’000 £’000 £’000
HCC funding 19,080 32,077 24,885 16,180 92,222
Grant 5,100 5,100 5,100 4,100 19,400
Contributions 300 300 300 300 1,200
Total 24,480 37,477 30,284 20,580 112,821
New capital bids
The portfolio has five new bids compared to the previous Integrated Plan as shown in the table
below:
Total Total
Total
HCC Other HCC other
Cost cost
funding funding funding funding
Scheme 2022/23 2022/23- Description
2022/23 2022/23 2022/23- 2022/23 -
2025/26
2025/26 2025/26
£’000 £’000 £’000 £’000 £’000 £’000
Day Opportunities
offer an enabling
service providing
activities and support
to adults with learning
disabilities, mental
health issues, physical
Transforming Day disabilities, sensory
Opportunities 1,474 1,474 - 1,894 1,894 - needs, and age-
related conditions.
This scheme will help
transform existing
properties to help
ensure effective and
high-quality delivery
for Day Opportunities.
Alongside the annual
programme of
property work for the
benefit of adults with
disabilities, the ADS
Accommodation
strategy, due to go to
Cabinet in February
ADS
2022, sets out an
Accommodation
920 920 - 15,400 15,400 - ambitious project of
Strategy
redevelopment, to
deliver a suitable and
sustainable pipeline of
accommodation for
adults with disabilities,
that will start in 2023
and take place over
several years.
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 79Total Total
Total
HCC Other HCC other
Cost cost
funding funding funding funding
Scheme 2022/23 2022/23- Description
2022/23 2022/23 2022/23- 2022/23 -
2025/26
2025/26 2025/26
£’000 £’000 £’000 £’000 £’000 £’000
Provision of a new, fit
for purpose building,
providing an enabling
Day Opportunities
and sustainable
– Older Person’s - - - 3,500 3,500 - environment for older
New Development
people who have age-
related conditions
and/or disabilities.
This scheme will help
overcome the
Transforming Day technological barriers
Opportunities and facilitate the
476 476 - 536 536 -
Technology transformation of the
day opportunities
service model.
To provide additional
IT infrastructure and
equipment across in
house
accommodation-based
services. Delivering
In House
support to 500 front
Supported Living - 108 108 - 108 108 - line/support staff,
IT Review
allowing them to
deliver effective
services across
supported living and
the short break
community.
Total 2,978 2,978 - 21,438 21,438 -
IP Part B: Strategic Direction - Adult Care, Health and Wellbeing Portfolio 80You can also read
