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Y Pwyllgor Cyllid

Finance Committee

21/03/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

David Rees AM
Jane Hutt AM
Mike Hedges AM
Neil Hamilton AM
Nick Ramsay AM
Simon Thomas AM Cadeirydd y Pwyllgor
Committee Chair

Y rhai eraill a oedd yn bresennol

Others in Attendance

Kate Cubbage Uwch Reolwr Materion Allanol, Ymddiriedolaeth Gofalwyr Cymru
Senior External Affairs Manager, Carers Trust Wales
Mario Kreft Cadeirydd, Fforwm Gofal Cymru
Chair, Care Forum Wales
Mary Wimbury Prif Weithredwr, Fforwm Gofal Cymru
Chief Executive, Care Forum Wales
Sanjiv Joshi Aelod o'r Bwrdd, Fforwm Gofal Cymru
Board Member, Care Forum Wales
Victoria Lloyd Prif Swyddog Gweithredol Dros Dro, Age Cymru
Interim Chief Executive Officer, Age Cymru

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Bethan Davies Clerc
Clerk
Joanne McCarthy Ymchwilydd
Researcher
Kath Thomas Dirprwy Glerc
Deputy Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Dechreuodd y cyfarfod am 09:01.

The meeting began at 09:01.

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions and declarations of interest

Bore da. Felly, os gallaf alw'r Pwyllgor Cyllid i drefn a chroesawu pawb i'r cyfarfod yma. Ymddiheuriadau: rydym ni wedi derbyn ymddiheuriadau, wrth gwrs, gan Steffan Lewis, a hefyd, wedyn, wedi derbyn ymddiheuriadau gan un o'r tystion yr oeddem ni'n mynd i'w weld y bore yma, sef Comisiynydd Pobl Hŷn Cymru, Sarah Rochira. Mae hi'n methu â bod yma y bore yma, felly a gawn ni jest nodi ein bod ni wedi derbyn ymddiheuriadau ganddi hi?

Jest i atgoffa pawb bod croeso ichi ddefnyddio'r Gymraeg neu'r Saesneg, a bod offer cyfieithu i'w cael. Mae'r cyfieithu ar sianel 1 a'r sain gwreiddiol ar sianel 0.

Good morning. If I may call the Finance Committee to order and welcome everyone to this meeting. We've received apologies from Steffan Lewis, of course, and have also received apologies from one of the witnesses that was supposed to join us this morning, the Commissioner for Older People in Wales, Sarah Rochira. She is unable to join us this morning. So, we'll just note that we've received apologies from her.

Just to remind everyone that you're welcome to speak in English or in Welsh, and that interpretation is available, with interpretation on channel 1 and amplification on channel 0.

I just wanted to declare that I chair the cross-party group on age, and I deal quite regularly with Kate Cubbage, as chair of that.

Ie. A oes rhywun arall am ddatgan buddiant? Mae pawb arall yn iawn. Ocê.

Yes. Anyone else with any interest to declare? No, everyone else is fine.

2. Cost Gofalu am Boblogaeth sy'n Heneiddio: Sesiwn dystiolaeth 3 (Age Cymru ac Ymddiriedolaeth Gofalwyr Cymru)
2. The Cost of caring for an ageing population: Evidence session 3 (Age Cymru and Carers Trust Wales)

Gwnawn ni droi yn syth, felly, at y tystion. Croeso mawr ichi. Os caf i jest gofyn ichi ddatgan eich henwau a'ch swyddogaethau, jest ar gyfer y Cofnod i ddechrau, os gwelwch yn dda.

We will turn immediately, therefore, to our witnesses, and extend a warm welcome to you. If I could just ask you to state your names and functions, for the Record, please.

I'm Victoria Lloyd. I'm the interim chief executive of Age Cymru.

And I'm Kate Cubbage. I'm senior external affairs manager for Carers Trust Wales.

Diolch yn fawr am ddod atom ni y bore yma, a diolch am y papurau yr ydych chi wedi'u cyflwyno fel tystiolaeth hefyd. Os ydych chi'n hapus, fe awn ni'n syth at y cwestiynau a holi ynglŷn â rhai o'r agweddau yr ydych chi wedi'u datgelu.

Mae'n amlwg eich bod chi wedi gosod allan sut y mae'r gwasanaethau cartref a phreswyl wedi newid, a'r balans, os liciwch chi, rhyngddyn nhw dros y blynyddoedd. A fyddech chi'n gallu rhoi amlinelliad i'r pwyllgor o beth rydych chi'n rhagweld a fydd y patrwm dros y blynyddoedd i ddod, ac felly beth fydd yn heriol i ddarparu gwasanaethau ac adnoddau digonol er mwyn cwrdd â'r galw?

Thank you very much for joining us this morning, and thank you for the evidence that you've submitted. If you're happy, we'll move immediately to questions in order to cover some of the issues that you've mentioned in your evidence.

You've set out how the domiciliary and residential care sectors have changed, and how the balance between them has changed over the years. Can you give the committee an outline of what you anticipate the pattern being over ensuing years, and what will be challenging in providing sufficient services and resources to meet that demand?

Shall I start, Kate?

I think we're all well aware of the ageing population and the increasing numbers of people living with complex long-term conditions, and that increases the pressures on local authorities. We know that, by 2019, the population of Wales is expected to rise by 27 per cent. Healthy life expectancy is increasing, but the number of years people are living in poor health is also increasing, and we think that is going to have implications for demand in the future.

For older people living with frailty and complex needs, their quality of life is vulnerable to sudden change. A trigger, like a fall, for example, can mean that their life can change very quickly. Their need for care can change overnight sometimes. That requirement for care can be domiciliary care; it could be residential care. At the moment, we know that family and friends are providing increasing amounts of care for their loved ones, but there are limits to what they can do. For the increasing numbers of people living alone, without access to informal support, the care from local authorities and formal support services is becoming ever important.

We think that things like changing family structures, greater geographic dispersal, demands of the workplace are also likely to increase. We've only got to look at the increase in the state pension age. We know many of our carers are older, and older women. The increase in state pension age will also impact on that. As I say, with a reliance on older carers who themselves may be experiencing poor health, a trigger event could mean care needs for two people rather than one, and we think that this is only going to increase over time and impact levels of demand.

I understand that the committee has already received quite a lot of information regarding the change in demographics, as Vicki has set out, and the shift in the types of provision that are generally preferred, so I won't rehearse that. Rather, I'd like to focus on the impact that this will have on carers. We know, from the last census, that there are more than 370,000 carers in Wales. We'd suggest that this figure is a significant under-estimation of the real number of carers, with a significant number unidentified and unsupported. It's particularly true of older carers. Research suggests that three in five of us will become a carer at some point in our lives, and unpaid carers contribute £8.1 billion to the economy in Wales every year in terms of the care that they provide, and they deliver 96 per cent of care within the community in Wales. So, supporting them is of significant importance.

Carers are unpaid; however, they're not cost-free. Carers require care and support in their own right to enable them to live healthy and fulfilling lives alongside their caring role. So, from our point of view, it's essential when assessing the cost of caring, that you assess the cost of supporting carers to maintain their caring role. It's worth noting that Wales has the highest proportion of older carers in the UK and the highest proportion of carers providing over 50 hours of care a week. One in five people aged 50 to 64 are carers in the UK; 65 per cent of older carers—those aged 60 to 94—have a long-term health problem or disability themselves; and 68 per cent of carers say that being a carer has had an adverse effect on their mental health, with a third reporting that they have cancelled treatment or an operation for themselves because of their caring responsibilities.

The unpaid work of carers is a central component of the health and social care system in Wales and we must move quickly to make sure that we get the right support to the right people at the right time. Significant additional pressures could be placed on the health and social care system, if just a small percentage of carers feel unable to continue in their caring role. So, from our point of view, failing to understand and address the pressures facing carers will undoubtedly have economic consequences, as well as impacting adversely on those individuals who provide great care themselves. Additionally, we feel that failure to adapt the system to better identify and meet the needs of carers will risk the health, well-being and financial security of a whole generation of carers.

09:05

You've got a lot of double carers, haven't you: they're caring for their grandchildren and their parents?

I say because my wife is one of them. It puts huge pressure on people because you've got two groups to look after. Do you find a lot of that—people doing the double caring?

We do, and there's a fluidity in the caring role: people will move in and out of caring during different points in their lives and their caring role might be more intense at certain points of time. So, not only do you have a carer who might be caring for somebody younger than them and older than them, you might have numerous carers caring for the same person in different ways. So, I think it's important to reflect the different natures of caring and the types of support that will be needed to enable them to live well.

Do you have any evidence around—we know the basic demographics, of course, that's why we're doing the inquiry, and the challenges that arise from that—the length of period that people might be in need of particular social care, in particular, at any time in their lives? Is there any evidence about how that's changing and the challenges that that poses for local authority budgets in particular?

I think we understand that most people who need care need it perhaps in the last couple of years of their life. I think the issue that we have at the moment is that in terms of the care being provided by local authorities now, the eligibility criteria are tightening, so it's such that the people who would previously have been getting care aren't getting care now. I think that's been a change we've been seeing over the last, I guess, five to 10 years, but it's certainly becoming sharper now. I think that gives us some worries that the pressures there will be popping out in other areas of the system. So, it might be people seeing their GP; it might be people presenting at A&E; and it might be people getting to that crisis point that they wouldn't otherwise have done so. I think the concern we have is that community services that we wouldn’t necessarily bracket as care are the ones that are not statutory—you don't need to provide those on a statutory basis—so they're being cut, and those things then impact further into the care-giving situation as well. So, I think there are impacts at different points in the system, which I think take us to a point where there may be more crises, which may mean that more care is needed in different places.

Can you just explain that point? We've had evidence on this previously around the eligibility criteria being tightened. In what way is that happening and is that a result of a different approach to statutory services or a cutting away of discretionary services, and is it uniform across Wales or does it reflect different parts of Wales?

In terms of whether it's uniform across Wales, I haven't got the evidence to say one way or another. We run an advice line for older people, and, as you'd expect, a lot of the people who call us for advice or call us to speak to us are calling when things aren't going well. We're hearing of people in situations where you would expect a need to have been assessed and for some services to have been provided, not—. I was looking at some case studies before I came in. There's one of a lady in her 80s, discharged from hospital, having broken her hip, assessed as not needing any care on leaving hospital—it's those sorts of situations. People dealing with continence issues only having a care visit in the morning and in the evening, nothing in the middle of the day, so potentially being sat in wet pads throughout the day. So, the eligibility for services, I think, isn't what it would have been. I think, as I say, that impacts on people's quality of life, and I think that can affect their mental health, their dignity and how their illness and their well-being progress.

09:10

Just on that particular point and that particular example, is the assessment being done appropriately by the appropriately qualified staff, in that case? Because that's the concern: if they're not assessing correctly, they're not getting the care plan and, obviously, we don't want them to be in that position.

In that particular case, I haven't got the information about who did the assessment. One of the concerns that we're having is that, actually, people aren't reaching assessment. We are seeing more and more people who are receiving information, advice and assistance from local authorities, they're being directed to the sector providers, they're being directed away from the assessment process. We did a freedom of information request last year. The variation in needs assessments across local authorities bore no relation as to what we could see in terms of the population, the demographic, the disadvantage in those communities. So, we're concerned that there is something that's not right there in terms of the levels of needs assessments that local authorities are making.

So, there are two concerns then: it's possible that they're not getting the assessments; secondly, they may be getting inappropriate assessments.

Exactly that. The other thing we hear about assessments is that, even when somebody's in hospital, on hospital discharge, they're not being able to access an assessment. They're being told that they can leave, 'You're fit to leave hospital, we can't provide an assessment now, but you can buy this package of care.' But equally we hear that, if people are paying for their own package of care, when they are assessed, they're deemed to be managing, because that support is there, and that's not how we would necessarily anticipate the system working.

If I could pick up on one point there around carers' needs assessments, as you'll be aware, the Social Services and Well-being (Wales) Act 2014 sets out that carers have the same legal rights to an assessment and support to meet those needs. I think that we would argue that this isn't being consistently delivered within the spirit and the letter of the law. For example, we are aware of waiting lists for carers' needs assessments, and additionally there are quite low levels of awareness amongst carers and professionals themselves of the right to have an assessment and what that assessment should mean. We have examples of where 'What Matters' conversations are being had instead of proper formal assessments, and carers have reported to us being steered away from needs assessments because there aren't the services in place to support them properly should they be formally identified. So, there's a concern there that the mechanisms in place aren't actually being used effectively or used at all. I think that's something we're particularly keen to pick up on.

The roles undertaken by carers are obviously of significant benefit to delivering the support and care that individuals need at home. I think that's particularly important in such a challenging financial climate and a challenging climate in terms of delivering support to individuals. But to help people maintain their own caring role, we need to maintain their health and well-being. So, they do need a proper carers' needs assessment, delivered by somebody who understands the type of support that they might need to continue caring.

We would argue that there needs to be a greater national steer in terms of monitoring the effectiveness of carers' needs assessments. At the moment, we have some concerns not only that the number of assessments really isn't being looked at, but how and where they're being delivered, what they're picking up—it's not being considered. I would be concerned that there is some level of unmet need that hasn't been identified and therefore can't be factored in. When we're looking at the funding gap, we don't know what gap we're bridging because we haven't fully assessed the need that is there in the broadest possible sense of the term. It's not about supporting carers to be able to cope with their caring responsibilities. It's about supporting them to live healthy and fulfilling lives alongside their caring role.

Thank you, Chair. I'd like to take this a little bit on because you've both highlighted the workforce issues in domiciliary and residential care. I recognise that. There's also a recognition of the impact of Brexit. I assume Brexit would impact more on residential care than domiciliary care. It would be interesting to see if you've got the figures that can break down the percentage of the workforce in domiciliary and the percentage of the workforce in residential care that would be affected by Brexit. That would be interesting.

09:15

I don't have any figures to that effect.

You don't have them, okay. But another question now: can I ask the Carers Trust first? We're looking at financial aspects rather than the policy—based upon the fact that we are seeing this turnover, and there's a likelihood that we may see a reduction in staff, is it your expectation that we're going to see far more unpaid carers taking on the roles that might become vacant as a consequence of that?

I think we're already seeing unpaid carers taking on a lot of work, as I stated earlier—96 per cent of care in the community is already provided by carers in people's homes. But as services contract, gaps have to be filled. We have an example from a local network partner of a dementia group for carers of people, for cared for people living with dementia. The thresholds are such that people with high-level need can't access that service. Commissioners aren't willing to commission a service that would meet that individual's need. Therefore, that person can't attend. The impact on the carers is that there's no respite, therefore they can't give their cared-for person the time in a social group. So, I think, when we're looking at commissioning patterns, it's very clear that some of the services that might best support carers aren't being commissioned.

You've both highlighted the fact of low pay and perhaps the role is undervalued in one sense and perceived to be that way by many people, which is also has an implication on this. There's clearly a financial aspect. In that sense, other than—which I think we should be looking at—regulation and ensuring that there's a career path in this, is there anything we can do to look at how we can improve the financial situation to ensure that staff are not leaving simply because it's an undervalued, low-paid job?

I was going to say, if I just start off by reflecting on your question about carers to start with, because I think one of the things that concerns us is that, potentially, carers and family carers are at the limit of what they can provide. That's already been increasing in the circumstances where we are now. So, it's about how much more we can take. If you take into account things like people working for longer, you're having fewer people who aren't in work to provide the caring role. So, it's juggling those things. It's about how far we can actually stretch that point, which I think is something really important for us to consider, which is why I think the esteem with which we hold care workers needs to be increased. I think it is about making sure that we have got proper career paths for people, that we are investing in their skills, and that we are rewarding them correctly. 

If you look at the way commissioning impacts in areas like the third sector, for example, I think there are still issues there with contracts not being let in good time and the rates at which local authorities are paying for contracts. All of those impact on how the individual care worker can be paid at the end of the day. So, I think there's quite a long chain of action that needs to be taken to improve that situation.

And there's no consistent cost or charge across the authorities. Local authorities can vary. Therefore, we haven't got an all-Wales figure? 

Exactly that. If I go back to my third sector examples, it's making sure that when organisations are being commissioned that the full cost recovery is part of that. I've seen evidence given to—it wasn't this committee, it was the health and social care committee, I think, when they were looking at loneliness, about organisations moving away from delivery. I think you see that when organisations aren't getting full cost recovery and they can't afford to deliver those services, not for any other reason but purely that.

So, we're going to see—don't take this the wrong way, but we're likely to see an increase in individuals not getting the service they require because of the finances.

I think so, and I think if you take Kate's point about unmet need, I think that's one of the issues that we'd like to highlight, because our colleagues at Age UK can look at England and use things like the English longitudinal study on ageing to put that together with the demographics and give some estimate of unmet need that's there. We can't do the same here because we don't have the same information available to us. So, even those estimates are difficult. So, maybe that's something else that we'd need to look at—the data.

09:20

We are living longer—thank goodness, in one sense—but of course that means more conditions becoming complex. What impact is that having on the care service and the providers and their ability to deliver the complexities that people and clients need? 

I think as people are choosing to live at home with more complex needs, the types of skills needed to deliver care at home are growing, both for informal carers and paid carers. And while upskilling the workforce presents challenges, it has to be a good thing, but it has time and cost implications that often aren't passed on through the commissioning process. So, the challenge of affording to appropriately train and support care workers and retain them within the social care sector, when their salaries might be significantly lower than, say, for example, if they moved to work in health, can be a real challenge, especially for smaller providers. We have examples within our network of closures, merges and cessation of services, simply because the commissioning process made it unaffordable to deliver those services.

I'd like to give you—if you would give me some time—some examples of where commissioning processes have impacted on the sustainability of local providers. We've noted that we're seeing a significant increase in demand, but they can't consistently afford to deliver the services needed to meet that demand. Local authorities are regularly commissioning services at well below the levels that they pay their own staff, which makes it very difficult to keep a diversity in terms of the supply chain, particularly the smaller and high-quality providers. As you've referenced earlier, we've seen a rise in salary costs for care workers, meeting the national living wage, and whilst fair and appropriate remuneration is important, this, alongside the costs of training, registration and retention and recruitment, means that they can't sustain it—there's too much additional cost within what they're being contracted to deliver.

Have you seen a change in commissioning services as a consequence of these complexities and theses changes in people's needs, or has the commissioning process basically been very similar to what it has been for years? 

I think there have been changes, and, to be honest, I could come back to you in more detail following the committee session. There have been changes in the way that services have been commission, but fundamentally those changes haven't moved quickly enough with legislative obligation, the needs that are now being identified or should be being identified and met. Commissioning has presented challenges, certainly for our network partners. There are some financial disincentives, for example providing domiciliary care, the cost of travel between calls in rural areas—it's not being paid for. So, this cost is prohibitive both in terms of meeting the pay of the care worker to drive to that appointment but also the cost of the travel. So, for some rural areas, our network partners have reported ceasing to provide domiciliary care in rural and remote areas, because they can't be commissioned at a rate at which it's affordable to do so. Fifteen-minute calls, for example, is another issue that some of the associated benefits of attending a call at home, particularly for our network partners who are there to provide respite for carers themselves—. To give that human contact, potentially to signpost and support, to engage them—they can't do that in 15 minutes. So, it doesn't meet the values and the purposes of that voluntary sector organisation, so they don't engage in delivering that type of service. So, again, it narrows the market.

There are other examples that I'd like to give you in terms of commissioning processes. Providers have not been paid for cancelled calls by local authorities, so, again it impacts on the viability of the service, and in the same vein, some local authorities have changed the methods through which they're paying, from paying in advance to in arrears. That has a huge impact on the cash flow of small organisations, and within our own partnership, larger organisations have had the reserves to withstand those kinds of last minute changes—that's not something smaller organisations can do. So, if we want to keep a plurality of providers and more innovative approaches, really, different approaches to how care is provided within a community, we need to support all types of providers, and I would have some concerns that commissioning processes haven't supported that. 

09:25

Just one point on that last point. Are you seeing, therefore—? You've already highlighted that providers are withdrawing, is there an increasing trend to see providers withdrawing?

I think there will be, if we don't get a handle on how the commissioning processes work fairly.

Nick Ramsay, I know you had some questions in this sort of area. Do you want to follow up with anything here?

Just following on from Dave's last point, actually, and the sustainability issue, we've heard evidence that 13 of the 22 local authorities had told the BBC that they had contracts handed back to them by providers. Is this your understanding? And why do you think that might be?

I haven't got the figures, but it is my understanding that that is taking place, and I think it's basically what Kate's just described. It's that the rates that providers are commissioned at don't cover the costs and therefore it's uneconomical for those organisations to continue to deliver at those levels.

And sometimes it's as simple as changes in systems and processes. We have an example of a network partner that has moved from a core grant to spot purchasing, and that's had huge implications in terms of reporting mechanisms and how money is drawn down. So, the volume of paperwork and evidence that's required—. In this case, it involves moving to electronic call monitoring and submitting every call sheet. Payment won't be made until all queries against that have been answered. Now, this organisation has coped because they have reserves. If they didn't have reserves, they couldn't take on the contract. So, I think a lot of risk is passed on to the sector.

The picture that you've both been painting in answers to questions that we've heard so far is that if the system is sustainable—. It really is, at the very limit, currently on sustainability, and it wouldn't take much, if you lost some of this provision, for it all to come tumbling down. Is that an over-negative view, or is that your concern?

I think our position would be that, actually, the system as it stands today needs an injection of additional funding, because without that we can't sustain where we are.

I think I would add that sustaining where we are isn't good enough. We need to be more ambitious for the people who require care and those who are providing care.

This is probably more for Victoria: you said that commissioning practices are fundamental to good-quality social care. Can you give examples of good and/or bad commissioning practices?

I think it goes back to what I was saying earlier about making sure that that full cost recovery is there. It's making sure that the commissioners are talking to the providers to look at exactly what it is that they need and what they can do, rather than things being driven down to the lowest unit cost.

Finally, because you answered the questions really fully earlier, in terms of the informal carers, you've said that that's not a sustainable basis for the future. Clearly, they have a role—they always have had and they will have. But can you explain a little bit more about why informal caring—why the Government shouldn't rely too much on that in the future, or have it as a growing chunk of the overall caring package?

I wouldn't say it's that they shouldn't rely on it, because, actually, that is the vast majority of the care that's provided right across the country, every day of the week—it's informal, as Kate's described in the numbers. But I think the issue is that, potentially, we're reaching the outer limit of that because we don't have the people who have the additional hours to put into that, because of, as we've already discussed, things like people working for longer, people living with their own ill health and the numbers of people who need care increasing. So, it's just weighing all of those up and the balance, and I think we're probably edging towards the outer limits of where we can cope.

I think we'd agree. It's important to recognise that unpaid carers are going to be a long-term part of the health and social care system in Wales. We can't change that and we wouldn't want to change that, but I think, to an extent, we need to take it back to the aspirations of the Social Services and Well-being (Wales) Act 2014 and really truly deliver against those. Supporting carers well has economic benefits. Within our written evidence, we've set out some of the monetised benefits of supporting carers. It makes sense to invest in supporting carers. That's not happening. The idea is there, but the mechanisms to achieve that need to be improved, and I think if we provided adequate support to carers, that would have a huge impact on the sustainability of the system, rather than seeing individuals reaching crisis point. 

09:30

I always find it interesting with the figures for informal caring in Wales and the UK. I think that a lot of people are carers and don't even realise they're carers. I see people, when I go to house visits in the constituency, and they wouldn't necessarily identify themselves as caring, but they clearly are—even if they've got support from the professional sector doing a minimal amount. So, I think you're right; it's always going to be a big part of the system and should be, but if it's at that level now, then I think that's an interesting comment for the committee.

We might explore some of the alternative ways now with Mike Hedges.

Age Cymru—I have to say I agree with you—say that care should be provided in exactly the same way as the national health service, free at the point of use. Many of us, if not all of us, have come across people who've had disagreements over whether somebody has been put in a home because they've got a care problem or it's a health problem, and of course, if they need that level of care, there are those people who argue—and I would be one of them—that obviously it's a health problem or they wouldn't need that care. Is there anything more you'd like to say on that?

I think paying for care, when we're looking at older people, is a huge issue, because that impacts on people in different ways. One of the case studies that I think we used in our evidence was a lady that got in touch with us when the capital limits increased back last year. We'd put out a statement in the press saying that older people would welcome this, and the lady contacted us to say, 'I don't understand. I don't have that much capital and I'm paying £200 a night for the care for my husband because I'm not eligible for overnight care'. So, I think that sort of thing really makes us step back and think the system's not necessarily working for all of these people. This lady was in her 80s herself, she was providing care for her husband with dementia who'd had a long spell in hospital and then came out with multiple needs, and needing really in-depth support, but she wasn't entitled to overnight care because she was able to pay for it—or she was deemed to be able. But no financial assessment was done, so her capital limits were well beyond what we'd expect, and she was buying her own equipment. She was just not getting the information she needed.

We understand that, as you said—. We'd see that care should be paid for. It should be a shared risk amongst everybody. We understand that that's difficult because nobody wants to make that payment, but we think that that's the only way that we'll be able to get more money into the system, and we think that ought to come from various different mechanisms, and it might be different payment methods for different people.

The last question I've got is that we're moving away now from people going into homes in large numbers to more care at home. There are certain problems with that, because care at home is not necessarily cheaper, if it's done properly, than care in a nursing home or in a residential care home. But how does it affect older people? I think people much prefer to be cared for at home, but if the cost of caring at home is going to be kept below the cost of the nursing home, then some people may not get the full amount of care that they actually need. Do you see any of that?

I think what we'd say is important is quality of life for each individual, whether that's in a nursing or residential home or care at home. Because we see that some people are cared for at home, and actually they're isolated because they'll see somebody perhaps at each end of the day, and their quality of life would be far better if they were in the community of a residential home. So, there are different drivers for different people in terms of what they need, and I think it's that quality of life and the quality of care that then comes behind that that's important for each individual. Then the funding decisions around that care should be—. I think we go back to the point that it should be something that we look at on a national basis that we all contribute to, rather than making those decisions based on the ability of somebody to pay at that moment in time.

All I'd say is that I meet lots of elderly people, many of whom don't have much social contact, but they don't want to leave their house for all sorts of reasons—it's the house they brought their family up in, it's the house that they've got their memories in, and even though they might be better off in terms of social contact in a nursing home or a residential care home, they don't want to leave it. Do you see any of that?  

09:35

We do hear that, and I think some of that is around how residential care has been portrayed, largely, to older people. We know that there are fantastic care homes in Wales that are delivering really good care and really good quality of life for individuals, but you don't necessarily always see that portrayed widely. What we hear in the media are the bad news stories, and I think that really impacts on older people's decision making around some of these things. 

Just on that, are you aware, outside of Wales perhaps, of any alternative methods of caring and giving social support in—. We hear about retirement communities, we hear about alternative ways—. The Swansea bay city deal has an idea of a wellness village that has an element of this built into it as well. Is that something that should be looked at in the Welsh context? 

I think it certainly should, because extra care is a very popular model, but, again, it's about how you fund that, because for people that are funded by the state, that can be an option, for people that are well-off, that can be an option, but the model probably isn't fit for the vast majority of people who would be self-funding. It doesn't work in those contexts. So, I think that's the sort of model where we need to be looking at how you could financially make that sustainable for people. 

In a similar vein, I'd quite like to pick up on respite care, if that's okay. It's evident to us that carers really do value access to flexible breaks. They can help maintain that caring role and ensure that carers maintain their well-being and maintain their quality of life. But, despite their rights to access respite care, it can be particularly difficult. Services across Wales have been particularly squeezed in terms of respite and quality breaks, and we'd argue that commissioning is focused again more on price rather than on quality and diversity of respite breaks. Respite doesn't necessarily mean the person you care for going somewhere else for a week; it can simply be giving you an hour out of the house to help tackle some of those loneliness and isolation issues. 

We've argued or contended for a number of years that we believe it would be a good investment to create a carer well-being fund, similar to the short breaks fund in Scotland. Investing £1.4 million a year would generate 53,000 hours of additional breaks for carers, and that would have a huge impact on their own health and well-being but also on the sustainability of caring for increasingly complex needs at home. It can be very time-intensive if you're caring for somebody with complex needs. You might not get a break overnight, and respite can be absolutely essential to maintaining that caring role. So, I think it's something I'd really urge the committee to consider when we're looking at the changes in patterns of care—that respite has to be factored in.  

Just on the question of respite, have you seen a loss of—? You said councils are squeezing. Have you seen a loss of respite beds as a consequence of some of that squeeze? And have you seen, particularly, a loss of respite beds in some specific areas such as for individuals with dementia? Because, clearly, the need to move from location to location for a dementia patient is going to really upset that individual, and the family who are caring for that individual will get upset and probably not do it because they see the stress it puts that person through. So, do you have the evidence that there is a loss of beds and, particularly, perhaps, a loss of dementia-type beds available?     

Absolutely. There is evidence there, and I can provide it to you, in terms of the loss of beds. I don't have specific evidence other than anecdotal evidence around dementia care beds, but something I would flag is that for people living with dementia at home, domiciliary care is obviously very important. Continuity of care of the care worker who is coming into the home to provide respite or support is important. We have evidence where some services end up with the individual having tens of different people coming into their home, and that makes a huge difference if you're not seeing the same person in terms of having to hand over that person's care, the particular needs they might have in terms of reassuring that individual that they are safe, to stay with the care worker that has come to support them, but also for the family to have the confidence that they're leaving them with somebody that would provide the same level of care that they would. So, I think we can see that opportunities for respite are narrowing, and the definition of respite mustn't be seen just in terms of beds and somebody taking a short break; it's a much more complex important area than that. And I think it's something that warrants significant consideration. 

09:40

And that turnover of staff, and providers perhaps handing the contracts back, is having another major impact upon those individuals. 

You've mentioned the Social Services and Well-being (Wales) Act 2014 and the aspirations—it is now about delivery, isn't it—and the difficulties that you've described already about applying eligibility criteria. So, can you say a little bit more about that in terms of the evidence, and in terms of losing what hopefully was going to be a real guide to eligibility commissioning?

I think we've already mentioned where we've had people coming to us in terms of issues with those eligibility criteria and instances where we would have anticipated there being a service delivered and that not taking place. And I think some of that is around the subjective nature of the eligibility criteria now. It's quite difficult for people to understand where their eligibility might fit, because it's outcome based. People at the moment, because of the Act being so new in terms of the delivery, don't understand what the level of need they have might be for them to actually get—. Our understanding is that the amount of care being delivered is all indicating that the people who are accessing it have the most complex needs, so it's all being delivered at the higher end, and therefore people that would have been receiving services previously, if they're being assessed now, are perhaps not being eligible. 

You say it's early days still, isn't it, for the social services and well-being Act. You're indicating really that guidance and helping implement it is perhaps not as robust as it could be. That's obviously a policy issue as well, but it has an impact then on who is receiving the care and how that's being decided. That's a question for local government as well, I'd say, in terms of delivery. And moving on to how Welsh Government policies and legislation can—how we should address these issues in terms of the cost of caring, you've mentioned extra care in terms of housing. I think we've all got an extra care facility in our constituencies—

Not yet? Oh, right. They are tremendously—. Well, they're certainly very popular in my constituency, but it is costly. It's not so much the capital, it's the actual money—it's how you pay for that. But I think, as you say, it's either if you're very well-off or you're state funded. It's everyone in the middle that it's difficult for. But it does have all the ingredients of breaking down isolation, having care and being independent. Are there any other ways in which you feel Welsh Government housing policy could assist with older people in terms of the costs of caring?

I think the other area would be around adaptations. And I think organisations like Care & Repair do a fantastic job in making sure that those adaptations are there. So, I think it's just making sure that those services are maintained and are available right across Wales. 

Yes, I think adaptations and—. Certainly, we probably all have constituents who need adapted homes, and there's still too few of those in terms of just the obvious—walk-in showers, bungalows et cetera, and social housing. But that can actually help that person or couple be independent, which is critical, and also safe within a new environment. 

We talked earlier about older people—I think, Mike, you mentioned it—not necessarily wanting to move. So, in that context, the model of lifetime homes, when we're looking at new housing stock, is a really important one, so that the houses that are built, the houses that do go through planning, do have the wider doors that are accessible to wheelchairs, and those sorts of things, because they're not just suitable for older people then, they work for families. So, it's making sure that the system has that kind of age-friendly element to it, so that, potentially, if somebody wants to age in place, they have the opportunity to do so. And I think, potentially, it's broader than housing—it is that whole planning policy around how we do develop communities so that housing estates aren't isolated outside of community facilities, but that they are integrated, and so that community facilities become part of an overall development.

09:45

Have you got any comments on other Welsh Government policies in relation to older people and also to supporting carers as well—strengths and weaknesses?

I think one of the items that I wanted to highlight that I haven't had the opportunity so far was around top-up fees and older people. Because we've mentioned that residential care is suitable for some people, and some people are quite comfortable to go into care. But what we're seeing is an increase in the use of top-up fees, and, in some cases, when we think that people perhaps haven't had the right information—we've had instances of families who are living on benefits being asked to pay top-up fees, and that's just simply unaffordable, and the pressure that puts on families is awful, in terms of how they manage that. But we think there's a real information gap for people; they don't necessarily understand what they're being asked to do at the outset. And I think that's something that, in policy terms, we need to tackle.

I'm interested in the fact that caring and carers—you're talking about informal carers, as well as carers—. When we first—some of us who were here at the beginning of the Assembly, I think the first thing we did, or I did as a Minister, was support a carers' strategy many moons ago. But the fact is: do you feel that there is enough focus of Welsh Government policy on the needs of carers, especially informal carers?

I think it's important to recognise the scale and the scope of the problem. And the comment that I would make is that it's important that we look at the issues impacting upon carers in all areas—so, for example, education, health, social care. I think we would contend that the linkages between the two are not necessarily as strong as we would like to see. If we look at the health, well-being, educational attainment outcomes, life outcomes, they're all significantly impacted by caring, and sometimes the interventions and opportunities to identify, support and signpost carers aren't taken when dealing with the individual problems—they're looked at in isolation, rather than looking at the individual as a whole. So, I hope that the Welsh Government's focus on better identifying and supporting carers, and prioritising that life alongside the caring role, will result in mechanisms like carers' needs assessments being better utilised, to really be ambitious for carers, to look at—. For example, a modification that a young carer needed was simply to have someone to sit with his grandmother so that he could attend football practice. It was having that linkage between the school, to have the conversation, to have that need assessed, to have that need met, which doesn't necessarily organically happen through the structures that are currently in place. So, fundamentally, it's about implementation. And, to implement properly, I think we need to be better at setting standards of what we want to see implemented, and genuinely monitoring that that is happening properly.

You also talked about monetised benefits from investing in carers. Can you say a bit more about that?

Yes, absolutely. I provided some details in the written evidence around some research that was done in terms of the benefits of investing in carers. The evidence is from England, but I still think it has some weight. It comes from the Royal College of General Practitioners, who worked with Baker Tilly to identify the social return on investment that can be made when CCGs invest in services that support carers. And that study found that the saving equated to almost £4 for every £1 invested. Additionally, the Department of Health in England—it is in October 2014, the study, but still fairly relevant—makes an estimate of the monetised health benefits of supporting carers. They estimated that spending £293 million would save councils £429 million, so that would result in a monetised health benefit of £2.3 billion. So, the ratio of that showed that supporting carers could save councils £1.47 in replacement care costs and benefit the wider health system by £7.88. So, it is significant, joining up those dots, both for the individual, so that they get the support that they need, but also in wider economic terms. 

09:50

I think the conversation has moved on, really, since I indicated. But, yes, it was just going back to the point about futureproofing houses. I visited Monmouthshire Housing Association recently, a new development that they'd opened, and not just were the doors wide enough so that, in future, wheelchair access is possible, but even the ceiling joists were done in such a way that lifts can be put in in the future. So, I was really amazed at how far we've come in terms of futureproofing those houses. I'm not sure whether that's standard practice across all the housing associations, but I think it's an area where, if the Welsh Government want to, they could really push for the highest standard—I mean, a lot of this is high standard anyway, but you could really roll that out, because it's an enormous difference if then people, as they do get older, don't have to move. It was more of a comment than a question.

Reform of the funding of social care is obviously the big problem that we're going to have to grapple with in the future, and Age Cymru's evidence has reflected on Age UK's eight principles for reform, and two of the points are conjoined: providing suitable quality and quantity of care for those on low incomes, and perhaps looking at new financial products for those who are on middle to high incomes, given the tension that's inevitably going to get more problematic of how to pay for the demographic changes and health needs changes that are inevitable with an ageing population living longer. Would you like to expand a bit on that particular point?

Yes. I think that, at the moment, it's something that we're really looking to develop our position on, because, as I've already said, I think, we are—our key position is that we do need to get more funding into that care. So, we do understand that that needs to be paid for. Our overall preference would be for it to be part of general taxation—so, income tax or national insurance—because everybody should benefit from social care. It's not just the individual receiving the care—as we've heard, it's the wider impact on families, it's got a broader economic impact. We all benefit in some way if that's provided, and provided well.

As I mentioned, we're keen that those decisions about paying for care should be separated out from getting care, so that they're not made at the same point, because of the stress that causes to older people and their families. And we think that, probably, in order to get the scale of investment we need, we'd be looking at a range of measures so that, collectively, those will contribute what we need.

But, actually, in terms of people's willingness to pay, I think that will very much depend on what they receive. The tangible improvements in quality and quantity of care need to be there—you know, the service improvements, the ability to pay staff, committed staff, to spend enough time doing the care that needs doing, and the support for carers, particularly those people who are providing care for older people with dementia. So, we do recognise that that's a big ask in terms of investment, but we do think that we should be spreading that risk and that we should all be contributing to that.

Professor Gerry Holtham has produced a plan for the future funding of social care that is based on the original idea of the national insurance fund, which was, as it said on the label, on the tin, that a fund would be built up, the income from which would ultimately pay for the long-term costs. The national insurance fund was raided almost as soon as it was created, and so it never worked in that way. So, you are, I suppose, therefore dependent upon the decisions of politicians, who are here today and gone tomorrow, sticking to the original intentions. But, in the longer term, it's difficult to see how these increasing pressures can all be funded from the current tax system, because, over long periods of time, and regardless of who's in Government, which party is in Government, and, in fact, regardless of the progressivity of rates of income tax, the total amount raised from direct taxation has rarely exceeded 35 per cent. So, there's a kind of limit there to the size of the pot, apparently, if you look at the figures. We don't fully understand why this is so, but that seems to be the case. 

So, do you think there has to be more long-term acceptance that we have to pay for the services that we receive? When you get to my age you're looking at this very closely, of course. We have to accept that we've built up, for example, significant capital assets, which we've done very little to deserve in a way—the value of our houses and so on. So, these are non-productive assets in terms of income producing, so, there are lots of people who are asset rich and income poor. Is there some scope for, do you think, using that as a means of paying for the long-term care of people who are on, shall we say, middle to high incomes, at least? 

09:55

I think, as I said, there's a range of mechanisms we could look at, and we don't have a definitive one at the moment. I think it does very much come down to what the benefits are that those people will get, because, if people are being asked to pay for something and we don't get that investment at the same time, I think that's going to be a really difficult decision to make. So, I think there is that need for dual running, so that we make improvements and we make investments at the same time as we're asking people to pay, notwithstanding that I take the point about needing to invest some of that take for the future.  

Yes. Are you looking at these plans for the future in the same way that we're trying to do, to produce practical or more detailed proposals? Obviously, we can't explore the details around this table today.  

Yes, it's something that's very much at the forefront of our minds, because it's the same issue in terms of individuals being in different positions and having different perspectives. It's trying to bring some of that together—synthesise some of that—to come up with some broadly acceptable principles and proposals. 

Moving away from that particular question, are there any other proposals, do you think, for reform that we should be looking at that are relevant to this issue? I'm asking for your guidance here on how we should be conducting this inquiry or perhaps thinking of others. 

I think to take you on two slight tangents, if you'll give me some leeway, as Victoria's already outlined, it is about getting more money in the pot, and, from our point of view, it's doing that in the most equitable and transparent way. To an extent, that's a very difficult thing to do if you don't have the evidence upon which to begin. As I outlined earlier, if we're looking at a funding gap, we're looking at the gap from what is being delivered now to what money there is. We're not looking at what should be being delivered, what would be best delivered and how that would impact more broadly. So, for example, the benefits of investing in caring would produce financial savings. So, I think there's a piece of work to be done in terms of identifying what needs are out there to better support carers and there is a need to support the third sector to have the capacity to deliver that.

I think everybody would appreciate that the third sector has been particularly stretched in recent years. We have strong links with communities and with the groups that we represent, and to truly engage with them and get a genuine understanding of the situations that they face and the ways in which they would be willing to engage with different mechanisms of raising funds is very difficult if we don't have the capacity with which to do that.

Similarly, with making decisions around current funding, an example given to committee in the last evidence session was around the integrated care fund delivered through regional partnership boards. This is an excellent example of health boards and local authorities and third sectors working together where it works. In other areas, the third sector have not been equally as engaged. I think our network providers would say access to applying for ICF is challenging, it's not equitable. And, when you look at the composition of regional partnership boards, the third sector reps aren't paid to be there; the carers' representatives are not paid or supported to be there, or supported to engage more broadly. So, I think there's a piece of work to be done in terms of looking at how we can make coproduction fair. It certainly can have the best outcomes and it can deliver services that really do maximise the investment, but short-term funding doesn't work. 

Year-on-year funding, where projects are having to be wound up—we have an example of a fantastic project that provides a Saturday club for carers of adults or older children with complex needs. These are the types of children that need 24-hour care. So, when they're not in school, the parents might not sleep Friday night through to Monday morning. That intervention for them, a Saturday club, is when they get to have a cup of tea. It's when they get to sit down and breathe. It's very important. The impact it has had on them is quantified; it makes a big difference. It's funded through ICF. They don't know whether they're funded from April onwards. It is an innovative programme that has worked. Where's the budget to mainstream it? There is no budget to mainstream it, so the organisation themselves are having to bear the cost of keeping that club running until they potentially access further ICF funding in the future. So, I think that short-term approach, and the pressure on the sector, really, the lack of capacity to do that engagement work, to really work with regional partnership boards, to deliver things as effectively as possible, isn't there.

10:00

Well, that's very interesting, and I'd certainly like to hear more about things of that nature, which would be a very valuable addition to the evidence that we receive.

My last question is about informal or unpaid care, going back to what we were talking about earlier on. The figures that you provided to us are: 370,000 individuals—12.1 per cent of the Welsh population—at an estimated cost for their time of £8.1 billion a year. Given that the Welsh Government is not entirely in control of its own budget, and the total amount the Welsh Government spends per annum is £15 billion, £8.1 is a vast figure as a proportion of that. It's difficult to see how Welsh Government or, indeed, the UK Government, which is in control of the size of its overall budget, could possibly make more than a small dent in that by providing some kind of payment for informal care, vital though I think that's necessary for all the reasons that you've already laid out.

How should we approach the future funding of this? Because I can see the common sense of the argument that, in a large proportion of cases, you could actually save public money by keeping people in their homes and providing alternative services to residential care et cetera, as well as that the capital cost is obviously significantly reduced to the public sector if we can keep people in their own homes or the homes of their close relatives. Have you got any extra thoughts on funding?

I think it's about the importance of personal choice, and I bring you back again to the carers needs assessments, and the assessments for the cared-for people that sit alongside that. It's about truly understanding what is needed to keep people caring and keep people well, and I don't think we have the data to do that. So, investing properly and developing services in the most effective way demands going back to basics, to an extent, and really asking those organisations that work in our communities, and individuals who are providing that care, what it is they need. The interventions that are asked for, the support that is asked for, is often very limited. It's not complex support that is often needed to support a carer who is providing complex care; it's often the very simple things like being able to get that break to go to a social group, to maintain connections, to attend doctor appointments. I gave you figures earlier around the rates of carers that will cancel their own medical appointments, including operations, simply because of their caring responsibilities, and that shouldn't be happening.

I can endorse what Kate says there. I think the provision of those respite services and the services that support carers to keep going are key to this. Nick made a point earlier about carers that don't actually recognise that they're carers; it's making sure that we're in a position to support those people, to recognise where they are caring, and to get that level of support in.

We'll have to bring the evidence to a conclusion there. Time has beaten us.

Diolch yn fawr iawn am y dystiolaeth, ac fe fydd yna drawsgrifiad i chi wirio am unrhyw gamgymeriadau neu eiriau a gollwyd. Diolch yn fawr iawn i chi. Diolch.

Thank you very much for your evidence, and there will be a transcript available for you to check for any errors or words missed. Thank you very much.

We'll go straight to the next witnesses, if that's okay.

10:05
3. Cost Gofalu am Boblogaeth sy'n Heneiddio: Sesiwn dystiolaeth 4 (Fforwm Gofal Cymru)
3. The Cost of Caring for an Ageing Population: Evidence session 4 (Care Forum Wales)

Rŷm ni nawr yn derbyn tystiolaeth gan Fforwm Gofal Cymru. Croeso i chi, y rhai sydd yma. A gaf i eich atgoffa chi fod y cyfarfod yn gallu cael ei gynnal yn y ddwy iaith, ac felly mae offer cyfieithu ar gael? A gaf i ofyn ichi’n gyntaf jest i ddatgan eich enwau a swyddogaethau ar gyfer y cofnod, os gwelwch yn dda, yn dechrau gyda Mary Wimbury?

We will now move to evidence from Care Forum Wales. A warm welcome to you all. I'll remind you that the meeting will be held bilingually, and interpretation equipment is available. If I could ask you, first of all, to state your names and positions for the record, thank you, beginning with Mary Wimbury.

Mary Wimbury ydw i, Fforwm Gofal Cymru. Prif weithredwr.

I'm Mary Wimbury, Care Forum Wales chief executive.

Mario Kreft, chair for Care Forum Wales.

Sanjiv Joshi, board member, Care Forum Wales.

Diolch yn fawr ichi. Croeso eto, a diolch ichi am y dystiolaeth rŷch chi wedi'i rhoi hefyd. Dymuniad y pwyllgor yw i ofyn rhai cwestiynau nawr, yn seiliedig ar yr hyn rŷm ni wedi bod yn clywed. Os caf i ddechrau, mae'n amlwg eich bod chi wedi gosod allan, yn y dystiolaeth, y pwysau cost cyfredol sydd ar y system yn gyffredinol. Ond a fedrwch chi amlinellu sut mae'r costau hynny'n amrywio ar draws y system, o le i le, ac o ddarpariaeth i ddarpariaeth: preifat, trydydd sector, rhannau gwahanol o Gymru ac ati? A oes yna un pictiwr neu a ydy hi'n gymysg yn yr hyn rŷm ni'n ei weld?

Thank you very much. Welcome once again and thank you very much for the written evidence that you've provided, and the committee would like to ask some questions based on that evidence and what we've heard. If I could start, you have set out in your evidence the current cost pressures on the system in general terms. But can you outline how those costs vary across the system from place to place, geographically, and from one provision to the next: private, third sector, different parts of Wales and so on? Is there a consistent picture or is it varied?

I should start by saying that our members probably represent the sector in Wales in that they're predominantly private, but also include third sector housing associations, et cetera.

I think in terms of the costs, the biggest cost in both domiciliary care and care home provision is staffing, ultimately. We are seeing public sector services commissioned on the basis of staff being paid generally at, or just above, the legal national minimum wage. But there are variations in different areas, and that can vary over time as well. So, in terms of recruitment and retention of staff, you're looking at issues around a new supermarket opening, offering people higher wages and, therefore, attracting staff, and you need to, in order to retain your staff, look at those costs. There were also obviously differences in land costs. Those vary geographically across Wales, but also within areas sometimes as well.

In terms of the costs needed to function, actually we see the same pressures on our members, whatever sector they're in, whether that's third sector or private sector, because, ultimately, the primary costs are the staffing, and then for care homes it is the land and property build and equip costs as well. I don't know if anyone wants to add anything from personal experience.

Sure. Mary's right about the main cost being wages. You have the push from the national living wage upwards, but you also have a pull where there are shortages of staff. So, providers compete for the same staff. There's a double factor there that causes a little bit of a variation between areas, but it is patchy. However, the underlying push is the main prevalent force on the wages.

The other thing that's perhaps worth adding as well is that we see both health boards and local authorities then offering staff who have been trained in the independent sector better terms and conditions than those independent providers can offer, based on the costs that are being paid for the services they're commissioning. We don't necessarily see recognition of that training and input that the sector is doing.

Obviously, as a committee, we're not in a position to step in on a society that values supermarket workers above care assistants or care providers, but that's what you're faced with, as you set out. Is there anything that you specifically as providers can do within that, in ways that you might try and deal with the cost pressures, in ways of sharing training or other things that you do as providers? Is there something innovative that we should be aware of and try and look at?

10:10

Well, if I could just come in there, I think one of the things that has greatly affected the sector adversely has been the effect on differentials—the erosion of differentials, and I think that's really behind what Mary and Sanjiv have referred to. So, it isn't that providers of both domiciliary care and care homes want to have people at the national living wage or, indeed, the minimum wage as it used to be; it's actually a toolkit that's forced on you, and I think the difference here in Wales is that the overwhelming majority of provision is funded by the taxpayer. These are small and medium enterprises, they're based in local communities. I think people are really trying to eke out things as best as they can. And, of course, it isn't about going bankrupt per se. You have to be viable, you have to be sustainable, because otherwise the Government regulator will have something to say about it. And I think the backdrop for all of us is the social care Wales report, based on the national statistics that we heard just before Christmas of an increase of the over-85 population by some 120 per cent in 18 years. I seem to remember 18 years ago celebrating the millennium and it doesn't seem that long ago, so, you know, we really have got something that's coming down the tracks, and, with the greatest of respect, things like training are hugely important, but the best training is work-based learning in the setting with good mentors, with good support. The biggest cost is wages, and we have to find a way to ensure that we've got enough people of the quality and the calibre to do this very demanding job, and at the moment we see that as an even bigger challenge than actually getting people to invest in the sector per se.

And is there any part of the sector you represent that's under more pressure, or exposed more to these pressures than any other part? I mean, the pressures, as you've described, are fairly uniform and they're mainly around wages, but, as a result of the different structures in the sector, is there a part of the sector that's more exposed than others?

If I may say, I think the domiciliary—. I mean, it's bad enough in care homes, but at least in care homes there is a cohort of people. We saw that recently with the adverse weather across Wales and how people made every attempt to come in and do the work, and even if you're down on numbers. The real issue for people in domiciliary care is that we're just finding that we cannot recruit enough people. Many providers are giving back—England also —huge contracts because they're simply not viable. I don't want to be too anecdotal at a meeting like this, but only on Friday I was being told by a senior representative of a health board of somebody being in hospital now in their fourth month. That was last Friday—waiting for a domiciliary care package, and that was not because of just the money; they cannot get the people to do the job. We have got to do something very substantial to change the status, and, I have to be honest, it's not going to just be registering people because if we don't register—. If we simply register them—and Care Forum Wales is on the record from 1998 as believing that that was the way to go—and we don't have a proper financial structure that people can understand, and that they can see a future, we're not going to get people to want to come into the sector and stay in the sector, and that is going to be a massive issue.

I'd just like to add to that from a care home sector perspective. The shortage of nurses is at crisis point and we're seeing homes deregister their nursing beds simply because they're not able to provide 24-hour-a-day nursing cover. This has been building up and it's now at crisis point. So, we see huge strains in nursing home finances and recruiting nurses. Mary touched on this. Over the last few years, we've seen the NHS have a recruitment drive for nurses, and unfortunately care homes have been the victims in that.

Yes. But it should all be part of one system, of course.

Absolutely. I'd endorse everything that Mario and Sanjiv have said. I just wanted to add that we also have a shortage of managers in Wales as well. There are not enough qualified managers looking to fill every vacant position, and we know that management and leadership is what drives a good care service. But, also, to add to what Mario said about domiciliary care work, the other issue, and the reason people often move from domiciliary care work into care homes, is, the way we're commissioned, you end up with a lot of work at sort of breakfast time, getting people up, work at lunch time, working dinner time and in the evenings. It's often difficult to offer people eight-hour shifts, which is what they want, rather than bits of work at different times of the day. And we need to be able to change our commissioning processes and use those workers to do other work that needs doing in the community—things like falls prevention, et cetera—so people can be offered regular shift patterns. 

10:15

We'll continue to explore some of these, I think, and move on with David. 

You've mentioned the managers, and you actually highlighted the fact that you felt there was a difficulty because of the additional qualification required. Can you just explain, because I don't yet understand why the requirement for that additional qualification should be a barrier?

The way the qualification works for managers is that it is a vocational qualification. So, it's quite difficult to achieve it without actually doing the job or being in a very clear deputy position. And because we have a lot of small and medium-sized enterprises, there isn't necessarily the ability to do the level of succession planning there would be in a bigger organisation. But also, because it's a higher level of qualification in Wales than England, sometimes—and I think, actually, Sanjiv's got experience of this—you interview people and you feel the best candidate is someone who would come from England, but doesn't have the requisite qualification, and you therefore know, in your next inspection report, it will be noted that you have a manager who doesn't have the appropriate qualification. I think we just need to find a way of easing through that process effectively, but at the moment, there are not enough people out there with the qualification, looking for work, to fill all the vacant positions. 

How long will it take them to gain that? If they're almost there, how long would it take to gain that qualification?

It could take six months to a year. Recently, it's taken one of our managers about a year, not because of intent, but more because the training companies, et cetera, were not able to support the process any faster. So, it can take up to a year. It's very, very difficult for a care home to have a manager in situ, but not a manager, if you see what I mean. So, it causes an issue, supporting a manager to be in a post where you do need a registered manager. 

So, do you, therefore, address this through, perhaps, succession planning better?

If we had the funding for that. If you look at our funding, we really do struggle with trying to have additional resources, which aren't, if you like, on the front line. 

If I can just come in on that point about succession planning, if you look at the make-up of care homes in Wales, most of them are small and medium enterprises still. Most of them were set up by people, even small charities, where the drivers, the trustees, or indeed the owners, if it was a private sector home, were actually doing the day-to-day running. That has changed as people have naturally got older, have retired. Some of those homes have changed hands and, of course, even pretty decent wages—I mean, a 40 to 50-bed nursing home in Wales, probably you're looking at about £45,000 to £50,000 as a salary, and it's still very, very difficult to recruit people, and it's because the job is so tough. It is a really, really tough job. 

Okay. So, it's not just the qualifications then. There are other aspects to this.

You talked about the viability of care homes and providers. Is there a real risk to the viability of many, because we've heard elsewhere that the viability is something that they're deeply concerned about. Where are we in the sense, percentage-wise, of businesses and providers that may be facing difficulties in being sustainable?

We get a lot of anecdotal information through our members. We have about 400 care home members currently. Again, most of them are small and medium enterprises. Most of them are relying on the people who run them to keep the thing moving, particularly if you're talking 30 to 40 beds and below. In terms of the viability, if you look at the report from the parliamentary review, which questioned the sustainability of the sector; if you look at the commissioner for older people's report, again highlighting this, something we've been highlighting. I think it goes back to that statistic of the increase in those over 85 as we move through the next period of the next 18 years. And what we're seeing is that homes are closing much more quickly than they're opening. You won't, in your constituencies, I don't think, have found too many new care homes opening, and those that do in Wales almost certainly will be for the private market. So, we're seeing a loss of homes that traditionally have supported those poorer people, if you like, those local authority- or health board-funded individuals, and that is becoming a great pressure on the NHS itself. So, when you look from a financial point of view at how the NHS itself is starting to really get that backlog, if you like, coming through from social care failing, you know it can only become more critical.

So, it's not just about, 'We need more money.' I'm sure that everybody who comes here says that. What we have to have is a system that takes away some of this bureaucracy, where people are encouraged to sustain those services they already have, particularly in small communities, because I could take you to a nursing home—a care home with nursing, I should say—on the Denbigh Moors: it has 20 people; it is always full; it serves a local Welsh-speaking community; and nobody in their right mind would replace that service once it's gone. So we need to cherish those, but equally there are parts of the country where we've got to bring in a way to invest. Either the public sector has to invest or the private sector or third sector have to be encouraged to invest. And the investment in new care homes is approximately £100,000 per bed. So, when you lose those three or four small homes that nobody really notices in a large city, you've suddenly got to find £10 million to replace them, even if you can. And we're seeing that there is no appetite for people to invest in Wales. That is the real issue. I know there are all sorts of issues around whether care should be state-funded or—. But we are where we are, and we have a massive challenge coming down the tracks right now.

10:20

And you said that the new entrants tend to be privately funded, and therefore that's going to add more pressure to the health service and local authorities as they try to find places, I assume, in that case.

Hugely, hugely.

And in relation to staffing, we've often heard about this turnover, that there's this vast turnover. What are the issues that you see? Is it purely a financial aspect as far as the wages that are being offered to staff, or are there other things such as career pathways? What are the issues that you are facing to retain your staff?

It's primarily wages, I think. There are alternatives. We also have, demographically, a workforce that is ageing. So, if you like, your nurses and your carers who've been caring for 20-odd years are now coming up to retirement. For the new recruits now, we're having to compete with different career paths and better career paths than what we can offer financially and progression-wise, and that's putting on a lot of strain. I believe there was an economist who looked at the Welsh demographics and said that we're sitting on a demographic time bomb, in the sense that we have an ageing population that needs to be looked after, but we have a contracting workforce, and social care is probably getting a smaller slice, year by year, of that contracting workforce.

I think it's worth adding as well that, because we are seeing increasing dependency—both in terms of people who are being cared for at home, but then also the knock-on effect of that is increasing dependency of people in care homes as well—people need increased training and skills to be able to care for those people, but we aren't necessarily able to offer the rewards that you'd want to for the increased training and skills, so I think this is something that we are quite concerned about with the introduction of registration. We have a number of people who, as Sanjiv has said, have worked in the workforce for a long time. We've now been told that, provided they've undertaken the necessary training, even if they haven't got the requisite qualification, they will be able to register in the first instance. So, I think that's positive because, otherwise, we did potentially see more of those people leaving the workforce. But, equally, we're actually asking people to take on qualifications and registration, but we aren't able to reward them in the way we'd like for undertaking that training.

Thanks. Morning. In your written evidence, you've noted changes in the views of providers of finance and spoken about fluctuations in risk and the viability of the sector. Can you explain a little bit more about the difficulties faced by providers?

10:25

The care home business and providing care in a residential setting is capital intensive. Mario just mentioned that it costs approximately £100,000 per bed for a new build. It's extremely capital intensive. Investors and the sources of those capital would want a return for that level of investment. The primary source tends to be banks—retail banks—but since the credit crunch, the care sector is not a favourable area for bankers to be looking at, since there have been some spectacular failures. So, we find that the funding coming from retail banking is contracting, and it's now being replaced, where it can, by equity finance. Equity finance, because of the higher risks related to equity finance, demands a higher reward, and that is the issue that Mario alluded to. That's the reason we're not seeing investment into care homes that are local authority-funded, because the returns aren't there to reward that sort of investment.

And the returns required now are higher than they were in the past because the source of the funding has moved from the banks to—.

Well, banks are still in the market, but they've reduced the level of lending. So, for example, loan to value 10 years ago would have been 80 per cent to 85 per cent. Today we'd be lucky to have 65 per cent. So, you now have, instead of over 15 per cent equity play, you have a 35 per cent investment required for the same care home. So, it's at the margin. It's not as if the banks have completely retreated from the sector, but that has a big effect on the level of investment and attracting capital into the sector. But starting a care home is one element of it. Existing care homes have to continually reinvest to maintain standards. The renewal cycle on equipment, on your beds, et cetera, is now three to five years, and we need to find capital for that, and it's not generated from the revenue stream in—

You've already said about the cost of providing the beds to start with, so if you're having to find that every five years, I mean, that's—.

Well, the renewal, the refurbishment programmes and so on.

If I may say as well, there's also a thing that a lot of people don't realise, and that's a 20 per cent tax on everything you try to do—

A 20 per cent tax. There's value added tax on everything we try to do in a care home to improve it that you cannot reclaim because we're outside of the scope. Maybe that's one of the the things, in the next few years, with all of the other changes in Europe, that maybe can change. Because, when we've taken this forward, it was always a case of, 'Well, you'd have to have 27 countries that would agree to it.' One of our members—

Because currently, we can't reduce VAT, can we? Once it's been applied—.

You can't reduce it. There was a time—there was a time—and, quite frankly, the sector itself was responsible for not being strong enough, but I'm going back to the 1990s. The sector wasn't strong enough to make that case, and that has made a really big issue because a lot of these old homes do take a lot of extra costs. It's like anything else: modern buildings are usually cheaper to run, cheaper to upkeep.

And, of course, when you see the level of dependency increasing—and I think that's what's been so helpful about these recent reports that you will have seen, that we've all seen now from the parliamentary review, from the commissioner— we are in a society, for the foreseeable few decades, at least—. We're going to need some form of housing, with all the innovation as well, but we're going to need something for this small cohort of people who need a great deal of care. If we cannot sustain our domiciliary services now, how are we going to sustain them into the future with a doubling of that issue?

One other thing I would say on the question of return on capital: the recent Knight Frank report is probably one of the best to get a real appreciation of that. We can forward that through to you.

Knight Frank, the agents.

They've come up with an excellent report. One of the things in that, which affects exactly what Sanjiv was saying, is the ratio of wages to turnover. Now, in Wales, it's actually gone up. It's one of the highest in the UK. It's currently about 63 per cent. If you think of any business, and these are care businesses, where 63 per cent of your income each week goes straight out in wages, you've got to make it work. I come back to this point of the toolkits that we have. As some of you will know, I'm based in north Wales, and all of the six authorities there work to a toolkit, and Mary has worked on this now for six or seven years, where they take half of your care staff up to what was the minimum wage, or the national living wage as it is, and another half at something about 80p an hour more. That has totally eroded all differentials. We're all for people having—. It is counterintuitive for people to nurture good staff and these are not people with ologies and degrees primarily—these are kind, considerate, compassionate people—

10:30

They are the people who have those skills. They're often innate skills that we've got to find and draw out, and we're going to need a lot more people like that in future.

Just to add a couple of points: I think we need to recognise as well that we have a lot of SMEs, as we've referred to, particularly sustaining care home provision in rural areas. A lot of those are only able to do it, as Mario referred to earlier, because they've actually paid off the initial finance and were they to leave the sector as they get older, no-one is going to be able to raise the money to replace that provision, effectively.

I wanted to just raise one other point as well, which comes back to the point we were making about managers and qualifications. Not having a qualified manager can lead to a non-compliance notice on your report from the inspectorate, as can other things. That can then have a knock-on effect on things like insurance costs and you can find that you're in breach of covenance with the bank et cetera, which can put up your lending costs because of that. So, there are all sorts of knock-on effects, effectively, from other decisions that we're taking in terms of care regulation.

Just one more. You've mentioned the potential benefits of Brexit in terms of VAT if the Government was so minded to change that. What about staffing? Are there concerns about the—? You're nodding already. Would you like to elaborate a little on that?

We saw difficulties when the income threshold for people from outside the EU coming into work—. We saw that that had a knock-on effect on the ability to employ care workers. We know that we need, for the sector to work, to have nurses coming in from across the world, and we've already heard about the shortages there, and also we're recruiting care workers from, in particular, eastern Europe. The uncertainty about immigration changes and immigration rules, going forward, has made that more difficult. It's also more difficult in parts of Wales, where people think—. If you're in Pembrokeshire or Gwynedd, for example, it's going to take you a long time to get to an airport to get home, if you want to be able to regularly do that. So, that already has a disincentive effect. But we need to have clear rules that aren't just based on potential income, if we are to keep up the workforce that we need to keep the sector going.

Thank you. In their written evidence to the committee, some stakeholders have reported that the higher cost charge to self-funders are being used to cross-subsidise the cost of individuals placed by local authorities. Is that true?

No, I don't think, in an ideal world, that it is right, but that is the situation. We saw that, I think, very clearly outlined as a situation across the UK in the report by the Competition and Markets Authority just before Christmas, for example. Providers are faced with a situation—sometimes you make extra charges for better rooms and extra facilities et cetera, which I think is a slightly different thing, but ultimately you have to find a way to be viable, and if you can't negotiate higher public sector fees—. This is something I think that both local authority and health board commissioners have turned a blind eye to, not because they think it's right, but because they recognise that the alternative involves them paying more.

Thank you. In your written evidence, you note that the Welsh Government's policy decision to increase the value of caps and thresholds to social care has taken money out of the care system.

The feedback we get from local authorities when negotiating fees is that although there is some grant to replace the money that they are having to spend in addition because of the increase in the capital limit—we certainly have had feedback from a number of authorities that that doesn't cover what they are paying and that that is one of the reasons for the pressure on their costs and how much they can therefore afford to pay to providers.

10:35

And finally, also in your written evidence, you say that the public debate needs to move on from discussing inheritance to discussing the care provided to older people, including how to pay for it.

Absolutely. I think what we need to have a discussion about is what level of care we want, what the standard should be, work out what a fair cost for that is, and how we're going to pay it. I think at the moment we feel that there is understandably increasing pressure on both standards of care, in terms of physical standards in terms of care home provision, but also levels of training et cetera, and that actually there isn't recognition when it then comes to calculating fees of the pressures that that is placing and what the costs of those pressures are.

Can I just come back on the first point that you made there? You see, I personally agree with you—I don't think it is fair that people should have dual rates. The issue is, in my particular—where I actually live, the local authority there have just set a rate of £80 for 24 hours. It's about £3.35 an hour. Now, typically, in that part of the world, 20 per cent of people would be private payers, and most people would accept that probably something closer to £100 for 24 hours of full care, about £4 an hour, would not be unreasonable. So, that really is what you're really struggling with, I think—issues about fairness.

I think it's also an issue as well that, as we're losing care homes, we're finding that a lot of people are having to remain in hospital a lot longer. That is an actual fact. We're finding the bureaucracy is doing that. I think these are also things that are quite unfair. I think the only way we can get out of this cycle is through a no-blame culture where we have a single system, although it will take some years. I mean, Care Forum was set up 24 years ago last St David's Day, and it might be a while yet before we get where we need to be, but I think everybody has to work at this with one goal, and I think we've got to accept that, at the moment, there are a number of unfair aspects to this system.

Just to ask one follow-up—looking at the caps and the thresholds and the changes that have just been introduced there, you say that local authorities say that the money provided by Welsh Government wasn't sufficient. Do you have a view on that? You have an idea of what the costs are in the system. Do you think that—? I think it was between £4 million and £5 million, but I might be wrong on that. Was that enough put in the system or not?

When the significant increases in the national minimum wage started happening a couple of years ago, we did a calculation on what we thought the costs were, as did the Association of Directors of Social Services. I think ours came in slightly higher than theirs, but not a lot, and our expectation was that the costs were about double the grant money that Welsh Government gave to local authorities.

I mean, local authorities obviously have large budgets to cover a number of areas and they have to decide on their priorities within that. So, I think it would be possible to give more money to the sector, but they would have to deprioritise something else, and those are decisions for them to make, ultimately. But I think we all know that the overall envelope is too tight to provide everything we would want in every sector, and I think this sector has been hard hit, not least because I think we've made some unrecognised efficiency savings, effectively, because people have been caring for increasingly dependent people without seeing an increase in rates that reflects that.

I just want to move back to the challenges facing domiciliary care. I think you mentioned that earlier on, Mario and Mary, because obviously there is an increasing focus on providing care at home, but that requires a robust, sustainable domiciliary service, as well as we've been having evidence about informal carers and the role of families et cetera—. So, do you have anything to say in terms of the cost on social care services, with this focus on caring at home?

I think we've already talked about the ability to recruit and retain being even harder in domiciliary care services. It would be great to have the ability to offer people the sort of shift pattern that they would want, effectively. I think the other thing—and I think this has grown out by accident—in public policy terms, is that we almost have an upside-down workforce, in that if you're looking at nurses or midwives, for example, you'd start off, do your training, work in an institution alongside other people, and then go out into the community. We seem to have, inadvertently I think, set up a system where, because of the way it's commissioned, people often start in domiciliary care, working on their own in quite pressured environments, and then find they can get better terms and conditions working in an institution, so move into that. And I think, probably, if we're to actually enable those domiciliary care packages to be provided and to keep people in their own homes, we need to find a way of reversing that.

10:40

I think this also takes us back to the Social Services and Well-being (Wales) Act 2014 and how it's being implemented. Can you say anything about that in terms of the change in the way services are being commissioned, because we've been having some evidence about eligibility and differences and difficulties in terms of commissioning, and yet, obviously, that was there to try and simplify and integrate.

I think, from the front line where our providers are, we're still not seeing the implementation of that Act working through to a significant extent at this point. I think the focus has been on looking at the earlier preventative services so far, and by the time people reach the point where they're receiving domiciliary care or moving into a care home, then much of that is still being commissioned in the way it always was.

I would draw attention, though, to—actually in your constituency—a very good example of one of our members, where they've done a pilot in terms of domiciliary care commissioning. It is commissioning on an outcomes-based basis and has had some excellent results to the extent that they're now rolling it out amongst other providers. So, it is the process whereby you're not just saying, 'Right, this person needs this many minutes of care provided at these times of day' and being very stringent about it, but 'This is the rough package of care that person needs, let's give them a budget', which works over, I think, 13 weeks, and that then enables people to say things like, 'I don't need my care today because my daughter's coming, but, actually, can I save that up, and therefore, next week, you can take me out to do x?' That's having a massive effect on people's well-being but also, actually—and I think this was less expected or less thought about—staff satisfaction and therefore, hopefully, the ability to retain staff, because they feel they are being empowered to do what's right for the person, rather than feeling they just need to tick boxes and then if they need to do anything out of the ordinary, they need to refer it up and get it authorised et cetera and go through massive bureaucratic hoops. So, I think there are starting to be some good examples, but we're not there yet in terms of seeing the effects that were hoped for from the Act in terms of commissioning paid-for services.

It's interesting that there is that initiative in my constituency, but it goes back to—where did that come from? Was that the provider taking that initiative? How much has the regulation and guidance of the Welsh Government or any funding initiatives helped stimulate that kind of development of best practice? Because, obviously, hopefully Care Forum Wales will be helping to spread good practice as well in terms of implementation, but has it come very much from the provider's initiative? 

I think the local authority initially asked for expressions of interest and then my understanding from the provider is that they were the only one to express interest. Actually, they had to—. The local authority had some ideas about how it was going to work, and they almost had to rip those up and start again, effectively. But they have really put the effort in and worked to make it work. But I think it is now seen as something that can be rolled out amongst other providers and it's certainly something that I'm sharing, and I know other people within Care Forum are also sharing with other local authorities and commissioners as well, in the hope that we can see something similar happen. But, yes, it does need the provider to engage with that process and make it work. But we also think there are massive potential benefits for the provider as well, and I've talked about the staff satisfaction elements.

That's another example of—. Because we're looking at costs of where that initiative, as you say, could be more job satisfaction, which is going to have to be a way you're going to recruit and retain, isn't it, and the outcome focus, but also for the older person as well and their family? And it must be a win-win in terms of costs, prevention and job satisfaction.

Yes, and there was a requirement that it be cost neutral, and my understanding is there have actually been slight savings, because of the reductions in bureaucracy. Because it was the case that, if you went in, and found someone who has fallen and was on the floor, you'd then have to stay with them longer, to wait for an ambulance, you'd have to put a form into the local authority to authorise that—there are all sorts of issues around that. So, actually, you can save some money through these initiatives as well.

10:45

For me, it's a very good example of innovation, of partnership working, and it wasn't brought about by tendering. I think tendering, in some parts of Wales, has been nothing less than a disaster for social care. I think it's been a disaster for the people who have to go out in all weathers—like this morning, in the freezing cold—to do 15-minute calls. One provider in north Wales gave back some 1,400 hours a week, couldn't make it work, and in that 1,400 hours they were doing about 700 15-minute calls a week. Going back to your point, if I may, about the Act, that totally contradicts everything that we've worked for to bring that Act. The Act, I think, is a great credit to all those concerned. It came about from this place, but many of us were involved in that for some years—your colleague Gwenda Thomas obviously, had a huge involvement in it—and it's exactly the direction of travel, but then you have to unlock these areas. And one of the key elements, I think, in the Vale, has been trust, where providers and local authorities have come at this, with the staff, on a basis of trust, not on a basis of, 'Well, what can we get away with?' and so then putting the person at the heart, where it should be.

Reform of funding of social care for the future is the big hot potato that we've all got to grapple with. My own instinctive feeling is that we can't go on as we are, seeing the gradual erosion of private sector provision. On the other hand, we're unlikely to be able to increase very substantially the proportion of public sector budgets that are going to go into health and social services—there's bound to be some increase, but it's not likely to keep up with the growth in need. Therefore, we have to have longer-term solutions. Now, you've said in your written evidence that you're attracted by schemes such as Professor Gerry Holtham's social care levy proposal. Do you feel that this is the best way to go? Would this be your preferred option, or do you have any fully-formed views, as yet? Are you prepared to take a risk?

I think the bottom line for us is that we see the need to get more money into the sector, and therefore we're very grateful to see any proposals that are looking at that. I've seen the Holtham proposals—I haven't seen other proposals. And I'm not sure we would, as an organisation, take a decision about which was the best proposal, apart from we want something that's going to work, that's actually going to get money to the front line, and isn't just—. I recognise if you're asking the public to pay more, there needs to be some sort of pay back for that, but what I wouldn't want to see is something that just raised capital limits and reduced the public's requirement to pay, but didn't actually put that money into the sector. My only other slight reservation about the Gerry Holtham proposals, which I think is probably something in the detail that needs working through a bit more, is that I wouldn't want there to be a disincentive to people to come and work in Wales, if they thought it was only for part of their career, which might be the case if you move in, are paying an additional tax rate—as I understand the Holtham proposals—and then, if you leave after a couple of years, or aren't sure if you're going to leave after a couple of years, you've effectively paid that for nothing. We've already talked about the difficulties in recruiting managers from over the border; there are issues in terms of recruiting all sorts of care staff—nurses, et cetera. So, what I wouldn't want is anything in the detail of proposals to act as that sort of disincentive on staffing for the sector.

Well, obviously, this particular inquiry isn't of the level of detail that would enable us to go into all the ramifications of any individual possible proposed solution. But are there any other models that you're currently looking at, with a view to providing some kind of long-term solution?

It's got to be, surely—you know, there are only three places that the finance is going to come from: it's going to come in tax, it's going to come through private funds, or some form of insurance arrangements. And I think most of us, probably, on reflection, think a combination, where possible, of all three is probably the way forward. I think that, for younger people, some form of—. I think we have to be careful about things called taxes and levies and rather upsetting people, but I think something has to be done for younger people to know that, in their later years, if they need some sort of support, it's going to be there. I think people are very generally concerned about this now in a way that, maybe even 10 years ago, they were not. In terms of the private market, I think we've got to find ways, as Mary said, of trying to leverage in some extra cost. One very interesting example is continuing healthcare in Wales. Quite rightly, in my view, people with dementia are being diagnosed and being able to satisfy the criteria for CHC, but a lot of those people previously would have been private paying. Now, there is an issue there about fairness—is it fair under the NHS Act? So, possibly there could even be some reform there. Should everything be free? If somebody with dementia comes into a care facility, in most parts of Wales, that's probably just over £100 a day all in. That's right, isn't it?

10:50

So, you know, again, we're back to that £4 an hour. If you take somebody who is profoundly unwell who's met the CHC criteria, you know, it's quite a job, and I really don't believe—and my colleagues, I think, in the forum don't believe—that the independent sector can do a great deal more. It's probably stretched that elastic as far as it's going to go, really, and we are now down to whether we can retain enough people with the skills. So, unless we're going to find a way of leveraging in something with some real innovation—and I think it's got to be funded better and I think the general view from Care Forum would be that we're going to have to ensure that people who do have funds pay a bit more. The domiciliary care cap is a very good example of how the Government, for the right reasons, has ended up actually putting a disincentive into local communities, where people—you know, it gets to £70, I think it is now, and that's it, and they might be having hundreds of pounds' worth of care and can quite easily afford to pay a bit more. So, there's got to be a really—do people call it now an 'adult conversation'? That's really what we need because it's coming really to a crisis point.

Having navigated through the labyrinth of criteria of qualifying for continuing healthcare myself on behalf of my mother, I do fully understand the point that you make. The Welsh Government is in a bit of a fix compared with the UK Government because it's not fully in control of its own budget. Health takes half of it to start with. It has limited powers to raise extra funds through taxation and, obviously, a social care levy would be a new form of taxation. It doesn't have the freedom, even within the current devolution settlement, that the UK Government has, if we're looking at this in a UK context. So, that introduces limitations to what long-term solutions we could find in Wales, but I hope that bodies such as yours will come forward with some practical suggestions along these lines, so that we can work through them and feed them into the mix.

You say in your evidence that it's important not only to decide how to raise the money but also how to spend it. Can you explain a bit more what you mean by that and what related changes you'd like to see implemented?

Quite understandably, because that's where he's coming from, Professor Holtham has put together a proposal for how to raise some extra money for social care. We've already heard about the pressures on the system, in particular in terms of staffing, and it's very important to us that any extra money goes to actually improving the rewards for staffing, which we think will also improve the quality of care that people are receiving. My concern is that there's a danger that we get very bogged down in a debate about how to raise more money, and that we haven't actually thought through how to spend it.

If I could just pick up on Mario's point about CHC, continuing healthcare, as well, I do think that, at the moment, we're looking at that paying for an element of accommodation and an element of care, and maybe what we need to do in future is separate those two things out a bit more, particularly when you have got people who are profoundly ill, being nursed in bed, receiving significant pensions but are not in a position to spend any of that money apart from on their accommodation and care, effectively.

10:55

If I could go back to that point of fairness earlier, you can have a care home facility where you've got two people in adjoining rooms: one loses all their pension except for a small personal allowance; the other person, who might actually be of a very similar need—you understand about the CHC criteria—basically gets everything free. That person could have £1 million in the bank, and that person that's losing their pension might just about make the threshold. So, there is a real serious review needed of this, because we have to leverage more into that system, and it has to be quickly.

Well, there is a huge element of artificiality in the CHC decisions that are made, and with a professional understanding of how to navigate around the system, you have a much higher chance of qualifying. There's a basic unfairness in the system that is based on knowledge and your ability to play the system, as it were. So, it's clearly got to change.

Diolch yn fawr. That concludes this evidence.

Diolch yn fawr iawn ichi. Diddorol iawn. Diolch yn fawr. Wrth gwrs, bydd yna drawsgrifiad, jest i chi wirio bod popeth wedi cael ei gasglu a'i gofnodi yn gywir. Felly, diolch i chi. Diolch yn fawr eto.

Thank you very much. It was very interesting evidence. Thank you. Of course, you will receive a transcript, just for you to check that everything has been recorded accurately. So, thank you very much again. 

5. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o weddill y cyfarfod
5. Motion under Standing Order 17.42 to resolve to exclude the public from the remainder of the meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

Os caf i ofyn i'r pwyllgor—rydw i'n cynnig ein bod ni'n mynd i sesiwn breifat nawr, o dan Reol Sefydlog 17.42. A ydych chi'n gytûn? Pawb yn gytûn. Fe awn ni i mewn i sesiwn breifat, felly, os gwelwch yn dda.

I propose now that we move into private session, under Standing Order 17.42. Is the committee in agreement? Everyone agrees. We will move into private session. 

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 10:56.

Motion agreed.

The public part of the meeting ended at 10:56.

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