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Y Pwyllgor Cyllid

Finance Committee

19/04/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Jane Hutt AM
Mike Hedges AM
Nick Ramsay AM
Simon Thomas AM Cadeirydd y Pwyllgor
Committee Chair

Y rhai eraill a oedd yn bresennol

Others in Attendance

Dave Street Llywydd, Cymdeithas Cyfarwyddwyr Gwasanaethau Cymdeithasol Cymru
President, Association of Directors of Social Services Cymru
Huw David Llefarydd Cymdeithas Llywodraeth Leol Cymru dros Iechyd a Gofal Cymdeithasol ac Arweinydd Cyngor Bwrdeistref Sirol Pen-y-bont ar Ogwr
Welsh Local Government Association Spokesperson for Health and Social Care and Leader of Bridgend County Borough Council
Sarah Rochira Comisiynydd Pobl Hyn Cymru
Older People’s Commissioner for Wales
Susan Elsmore Dirprwy Lefarydd Cymdeithas Llywodraeth Leol Cymru dros Iechyd a Gofal Cymdeithasol ac Aelod Cabinet dros Ofal Cymdeithasol ac Iechyd, Cyngor Caerdydd
Welsh Local Government Association Deputy Spokesperson for Health and Social Care and Cabinet Member for Social Care and Health, Cardiff Council

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Catherine Hunt Ail Glerc
Second Clerk
Georgina Owen Dirprwy Glerc
Deputy Clerk
Joanne McCarthy Ymchwilydd
Researcher

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 09:32.

The meeting began at 09:32.

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

Bore da, felly, a chroeso i gyfarfod o'r Pwyllgor Cyllid. Rydw i'n mynd i ddweud ar y cychwyn ein bod ni wedi derbyn ymddiheuriadau gan Steffan Lewis, wrth gwrs, Neil Hamilton a David Rees, ond rydym ni yma, yn bedwar, yn barod am y sesiwn. Mae offer cyfieithu, wrth gwrs, ar gael, ac atgoffaf bawb fod cyfieithu ar sianel 1, lefel y sain wreiddiol ar sianel 0, ac i chi dawelu unrhyw ddyfeisiadau electronig os oes angen. A oes gan unrhyw Aelod ddatganiad o fudd i ddatgan, gan ein bod ni'n dechrau tymor newydd yng nghanol ymchwiliad? Pawb yn hapus, felly. 

Good morning and welcome to this meeting of the Finance Committee. Just to say at the beginning that we've received apologies from Steffan Lewis, of course, Neil Hamilton and David Rees. But we are here, the four of us, ready for this session. We have interpretation equipment available, and I remind everyone that interpretation is on channel 1 and you can adapt the original sound on channel 0, and please put any electronic devices on silent if needs be. Do Members have any interests to declare as we're starting a new term in the middle of an inquiry? Is everyone content? Yes. 

2. Papurau i'w nodi
2. Papers to note

Cyn inni droi at y tystion y bore yma, a gaf i ofyn i'r Aelodau nodi cofnodion y ddau gyfarfod diwethaf a hefyd llythyr gan Swyddfa Archwilio Cymru ynglŷn ag adolygiad o daliadau ymadael yng nghynllun ymadael gwirfoddol Swyddfa Archwilio Cymru? Hapus i nodi'r papurau? Diolch yn fawr iawn. 

Before we turn to the witnesses this morning, may I ask the Members to note the minutes of the two previous meetings and also the letter from the Wales Audit Office with regard to voluntary exits 2016-17 review of exit payments? Everyone content to note those papers? Yes. Thank you very much.

3. Cost gofalu am boblogaeth sy'n heneiddio: Sesiwn dystiolaeth 5 (CLlLC ac ADSS Cymru)
3. Cost of caring for an ageing population: Evidence session 5 (WLGA and ADSS Cymru)

A gaf i droi at ein tystion ni y bore yma, a'ch croesawu chi gyd i'r Senedd ar fore braf iawn? Dyma sesiwn a ohiriwyd oherwydd eira dim ond rhyw fis yn ôl; mae'n dangos y gwanwyn rydym ni'n ei gael yng Nghymru. Felly, rydym ni'n ddiolchgar iawn eich bod chi yma heddiw a bod wyneb y ffordd ddim wedi toddi oddi tanoch heddiw yn hytrach nag unrhyw beth arall.

Jest ar gyfer y record, a wnewch chi ddatgan eich enw a'ch swyddogaethau, os gwelwch yn dda, ar ddechrau'r sesiwn? Os caf i ddechrau, efallai, gyda Susan Elsmore. Diolch. 

So, we'll turn to our witnesses this morning and welcome you all to the Senedd on a delightful morning. This was a session that was postponed because of snow only a month ago, and it shows the kind of spring that we have in Wales. So, we're very grateful to you for joining us today and that nothing has hindered you from coming today, such as the road melting beneath you rather than anything else.

But just for the record, if you could state your names and your roles, please, at the beginning of the session. So, if I start with Susan Elsmore. Thank you.

Susan. Councillor Susan—. Is this my sound? Apologies, apologies. Gosh, I'm going to shout everyone out. Is that a good level?

Councillor Susan Elsmore, Welsh Local Government Association deputy spokesperson for health and social services.

Huw David, leader of Bridgend and spokesperson for health and social care for the WLGA. 

David Street, representing the Association of Directors of Social Services Cymru.

Thank you for that. 

Diolch yn fawr i chi am hynny. A gaf i ddechrau drwy ofyn cwestiwn? Rydych chi wedi cyflwyno papur cynhwysfawr, rwy'n gwybod, ond liciwn i gael sgwrs ar ddechrau'r sesiwn jest ynglŷn â rhai o'r pwysau mwayf rŷch chi wedi'u gweld dros y blynyddoedd diwethaf sydd wedi effeithio ar gostau yn y sector yma, yn enwedig, wrth gwrs, o safbwynt awdurdodau lleol, a ble rydych chi'n gweld y pwysau'n datblygu ar gyfer gwariant ar bobl hŷn yn ystod y blynyddoedd i ddod hefyd. Nid ydw i'n gwybod pwy sydd eisiau dechrau gyda hynny. 

Thank you very much for that. May I start by asking a question? You have put forward a very comprehensive paper, but I'd just like to have a discussion at the beginning of the session about some of the greatest pressures that you've seen over the past few years that have affected costs in this sector, especially, of course, from the point of view of local authorities, and where you see the pressure developing on expenditure on older people over the coming years as well. I don't know who wants to start on that. 

09:35

Thanks, Chair, and thanks for the invitation for us to come here today. Obviously, we anticipate that the biggest pressure will be around the rapidly ageing population. We anticipate the number of people over 85 will more than double over the next 20 years, and over a third of people over 85 require some sort of support, whether that's a domiciliary care package or residential care. So, that's where we anticipate the biggest increase in costs will be.

We have obviously made significant efforts in recent years to modernise and change services. People spend less time in residential homes than they've ever done and they also come into residential homes at a much older age than they've ever done. So, they come into residential care at 86 or 87 years of age on average and they spend about two years in residential care. Ten years ago, they would be coming in at an average age of late 70s. So, we have made significant progress in keeping people in their own homes, but when the number of people over 85 is going to double then those cost pressures will rise.

So, there have been increasing cost pressures because of demographics, but also—I don't need to go into details here because you'll all be aware of the significant increases in employee costs, because of course, care is about people. So, the people provide the care; it's all people costs. People costs are rising because the people that work in the care sector are low paid—they're some of the lowest paid people in our society—and so they will benefit from the minimum wage increasing and they will benefit from increased pensions, but that comes at a cost and that cost will be met by local authorities and that is a significant increase in costs.

The minimum wage for low-income members of staff is rising by about 8 per cent, I think, this year, so that's translating into costs. This year, for example, in Bridgend, we've had to increase the fees that we pay to the independent sector by 4 per cent. On that 4 per cent, we had a lot of discussions with the care sector. They actually showed us their books to show us that, you know, this is how the national insurance costs are rising, this is how the pension costs are rising, this is how the pay costs are rising and all the rest, and it's increasing by 4 per cent. So, that's the pressure we're facing. I don't know whether Susan wants to add any more. 

I think, if I can follow up, because that's a very good overview of the overall pressures—I'd like to just follow up and perhaps others could come in on this then, on the specific way that that then transfers into this sector, and particularly from an age perspective. So, we had other evidence in the committee that not only have you got these overall costs but the actual spend per head on older people is declining. Obviously, one of the drivers of that is this national context, if you like, and, also, you've done very well not to mention austerity so far, but I'm sure you would want to mention that as well as that's a particular context to it. But are there specific things that are responsible for this also, within the overall envelope—actual declining spend on older people? Is that being driven by other factors as well or is it all related to just the cost factors? 

I think there are a number of factors to it. Certainly, the cost factors are part of that. We have to look at what we've been trying to achieve in the context of the Social Services and Well-being (Wales) Act 2016 and, wherever possible working with people, having different conversations, and looking at what people's strengths are within their immediate families and communities and not quite using statutory services as services of a last resort, but certainly heading down that journey where, actually, it's statutory services that come in for people who are in the greatest need. So, I think that's part of that impact. I think—to support Councillor David—one of the things we're also seeing is that, because we are so successful at keeping people in their own homes, that is now coming at a far greater cost. The complexity that we support people in their own homes—five, certainly, definitely 10 years ago, those people would have been in care homes or even in hospital. We are now—. Certainly in my own experience, perhaps five years ago, the average domiciliary care package would have been around 12 to 15 hours a week. They are now regularly 30 or 40 hours a week. So, we have these high-end needs, which are drawing the resources—significant resources—across, and we're having to find other solutions for those people in not as much significant need.

09:40

And then, in terms of trying to plan, in your financial planning as local authorities, trying to look ahead and seeing where you might be taking this and where you might need to meet future needs, you can see trends at the moment as well, obviously, but we've also had evidence in committee of a longitudinal study in England. The Daffodil system has been mentioned as well. What are the tools that you have to allow you to plan for future needs and to get the necessary finance or financial instruments in place to meet those needs?

So, we know the pressures are here, because I think every authority in Wales is facing those pressures now. We know that will increase. The problem is that we just don't have the finance to meet those needs, as I'm sure you've heard from the Health Foundation and Wales Public Services 2025. Independent research—it's quite clear that the pressures that we face are actually more significant than the pressures that the health service face because of this demographic pressure. Authorities are struggling now, and they will struggle in the future, to meet it. So, we know it's going to increase. It is increasing now, and, despite what we're doing—because the rate of increase is so significant, then, despite the success of changing things, the overall budget is increasing. So, the reason why the spend per head has fallen by 13 per cent is simply because we are supporting far more people, because there are far more older people. We have been successful in keeping more of them at home, and keeping them at home for longer. But, as they do come into care, as Dave has said, they then need far more bigger packages, and that's why the overall cost will continue to rise. Because even keeping people at home has a cost implication. That is not cost-free and that's what we're doing.

So, we've seen, in Bridgend, that actually, we've managed to reduce—only slightly—the number of people in residential care, but the number of people we're supporting at home rises significantly every year. So, the budget will increase. What I think we need is a discussion about how we're going to pay for that. So, the resident will pay some of that—the citizen—but that is capped, in terms of home care, at £80. But, in residential care, we know that cap is rising. But, if that person has a health need, it is completely free—completely free. If you have a social care need, then you have to pay, and you could lose all your life savings paying for that social care. We do need to think of a way of funding these services, because—. You expected me to mention austerity, so, in England, how have councils dealt with these problems? We know what's happened in Northamptonshire. So, Northamptonshire has literally gone bankrupt. I'll simply make the point that Northamptonshire is larger than any authority in Wales, by the way. So, it's not just about the size of the authority, but it is a shire, but it's a county shire, so it has responsibility for social services. It won't be the last; it's the first, and there are more to come in England. So, it isn't crying wolf when we say the pressures that we face are very significant, and we anticipate in the future authorities struggling to meet those costs. So, we need, together, to come up with a solution for that that makes it sustainable, and not just this year, but for the next five to 10 years.

09:45

You won't—. Of course, in terms of the committee, I'm sure, and, in terms of your individual experiences, you'll have heard this before, but I think it bears saying in support of both what Huw and Dave have said, of course: it's the impact on other local authority services. Social care has the benefit of being a statutory service, and I say 'thank God' for it, because, you know, other services—. So, in some parts of England, for instance, library services have been wiped out. So, local authorities, in my view, have been very, very successful in balancing budgets, and, for the large part across Wales, social care has been protected within authorities. But, of course, that doesn't come at zero cost. So, if I take Cardiff, for instance, we are making enormous cuts in-year in relation to budgets, but, especially in relation to social care budgets, we are having to find—. And some may say, 'Well, good, you are looking at innovative ways to support good practice', so, in support of what Huw's said, what we're seeing in Cardiff, for instance, is people are actually going into care homes perhaps just for the final year of life, and I think that's actually a measure of success in terms of delivering social care.

One of the things that the responses you've heard so far haven't touched on—. We've got to talk about, you know—. There has been some conversation in relation to workforce costs, but these are enormous. It's our ageing workforce, particularly in relation to domiciliary care workers. Huw's already mentioned their terms and conditions and their salary rewards, and I know the important work that Social Care Wales are doing, for instance, in terms of really wishing to professionalise the sector.

And there's also—. For me, it's the reliance on the unpaid, the voluntary carers that we must not—. Because this is a whole system, and it's clear the whole system is creaking at the seams, and—. Yes.

Okay. We'll explore some of those issues now, I think, with Mike Hedges.

Can I just start with two comments, very briefly? The first one is that Northamptonshire's problem, like all shire counties, is it hasn't got the non-statutory services to squeeze. That's why they've done what they've done in merging it with the district councils, and expect to see a massive reduction in leisure facilities in the former district areas. The other thing I would say, and I think you might agree, is: wouldn't the health boards do very well if they could learn from local authorities in dealing with pressures? But the question I've got—

I think Mike Hedges usually has these comments at the start of his questions, so—. We'll leave them for the record for now.

But what we've seen happen—and this is a 20-year period, at least—is the move from the local authority providing services to the private and independent sector. Is that continuing, and can it keep on continuing?

I mean, it can keep on continuing. I think one of the great issues that we have in Wales at the moment is the fragility of that independent sector market, regardless of what type of service—whether it's residential, nursing, domiciliary care; it doesn't matter. Councillor David mentioned at the start of the meeting some of the welcome initiatives that we've seen around things like national minimum wage, pension, national insurance contributions. All of those things are extremely important in making the social care workforce an attractive place to come and for people to stay. But, as we said, that hasn't come without a cost. As a consequence of that, authorities have done their best, assisted by some moneys from Welsh Government in terms of things like the social care workforce grant, which has been passed over to the independent sector in full, but that, still, if we're very honest, leaves a deficit. If that deficit simply can't be met, those providers become very, very fragile.

One of the ways authorities are responding to that fragility is actually, in some instances, by beginning to insource again. Because the level of exposure to the independent sector is so great and the risk attached to that is so significant, many authorities are beginning to take care back. In my own authority, we've got a balance at the moment of 30 per cent in-house services, 70 per cent external. That isn't an unfamiliar situation to be in, but the sustainability of that market is a major concern for us.

09:50

I think I should move on to recruitment and retention, which is a huge problem. Leaving aside that people get paid more in supermarkets, which is often so now, but, what they can do, of course, is get paid more working in hospitals, for example. Are you seeing a loss of skilled and experienced staff to other parts of the public sector? I know that everybody talks about, 'I can get paid more stacking shelves in supermarket x', but is the tendency for people to move from social care into the health service because they can get paid more in the health service?

Well, I think the short answer is 'yes'. And what I've heard directly from care providers is that people move in and out with some regularity, which, in terms of the churn, is difficult in terms of managing it. So, for me, it is about looking at the parliamentary review and I welcome this whole-system approach that is definitely required.

I think, David, you mentioned the fragility of the independent sector, and we've had evidence from the independent sector, from Care Forum Wales, who talked about that fragility. They talked about the fact that the return on capital for investment is just not so attractive, particularly for equity finance. We know there are closures—you must've experienced them in all of your authorities—and we won't go into all the issues about the pressures on the independent sector, but is it your experience that this fragility is causing difficulties in terms of planning and social care management?

I don't think there's any doubt about that. I think particularly the residential care market in Wales has got a particular peculiarity to it in the sense that many of those homes are locally owned by private individuals. Many of those individuals, like the rest of us, are getting older, and it comes to the point of, actually, are you going to be able to pass on that initiative via a sale, or are you going to close that home down and sell it for flats? That has certainly happened in my own borough quite a lot. So, that is a concern.

I think the bigger concern at the moment probably relates to the domiciliary care market. I think there are very few authorities in Wales that haven't had packages of care handed back. I certainly had a very significant issue in my own authority—80-odd packages of care, 1,000 hours a week that had to be re-provisioned, because what providers are now doing is costing existing packages of care and, quite frankly, if those packages of care are not providing a return, then they're handing those packages back to local authorities. We have no other route other than to recommission those packages of care, some of which you can do with other private agencies, some of which you have to bring back in-house. But it does feel like we're in a little bit of a vicious circle, really because of a costs spiral—a very welcome costs spiral in terms of people being paid appropriately—but there really hasn't been enough money in the system to do that properly.

Sorry, Chair, I think it's also important to reflect on the fact that, yes, there are going to be significant increases in cost because of the increase in the minimum wage, but that isn't going to make the sector any more attractive to employees, because the minimum wage is going up across the board, isn't it? So, the costs are going up, but it doesn't make the sector any more attractive.

The other point I wanted to make is that I quite often hear people saying that if you do things regionally with better commissioning and smarter procurement, you will make savings. Well, the fragility of the private sector, and with people telling you that they're giving care packages back, it's quite clear evidence that, actually, we've got very strong commissioning arrangements. We're probably driving them too hard, aren't we, to get best value? So, the answer isn't, 'Well, if you get together as a region and you commission your homecare that way and you commission your residential care that way, there are savings to be made'. There aren't savings to be made, not significant savings, because we know that people are handing care packages back. If anything, we probably need to be investing more. Whichever way you do it, you're going to have to invest more if you want to improve recruitment and retention in the sector. Whether it's in-house or out of house, there's going to be a higher cost over the medium to long term, because what we're also seeing, as well, is that a lot of people that work in the health and social care sectors are people from the European Union, and a lot of that workforce has obviously dried up, in the sense that they're not coming. We're concerned that what will happen is that some of those people that leave the health service will be replaced by people from social care, and we know that terms and conditions are better in the NHS. Not only is the pay better, but it's also a more secure form of employment as well.

09:55

Very briefly, on regional working, surely, the worry is that that would actually make matters worse because people would cherry-pick which part of the region to work in and you may well find some parts of a region totally denuded of any care.

I think the geographical aspect of it is an interesting one. We're aware of those issues and problems that, certainly, the larger rural areas face, but even in individual authorities—. My day job is director at Caerphilly. It's much easier to get independent sector provision into the south of the borough than it is in the north. So, yes, that does play out and, as you say, if you move on a regional/national basis, then the potential is those problems get even more marked, really.

Nick, did you want to come in? Sorry, Jane, it's your question at the moment. I'll bring in Nick after.

I just wanted to pick up on the issue about domiciliary care particularly, because, also, the trend is, and we support it, for more care in the home, and you said, Susan, it is often the last year or so, or months or weeks of life in a care home, and yet if it's outsourced you are very dependent on those providers, aren't you? I think it is a real issue for us to look at in terms of costs, because, also, the private sector may—. Perhaps we haven't talked to the independent sector enough about this in terms of—they've chosen to develop the domiciliary care sector, but it actually appears to be very fragile, although they haven't got the kind of estate costs that the residential homes have got. So, I think it's a very important area. Sorry, Chair, you were going to say something.

No, I think Nick was also interested here, so, an opportunity for him—

Mike actually asked what I was going to, and you pretty much answered it as well. It was just that point—you made a fascinating point there about how it's against the conventional wisdom, isn't it? We constantly, automatically think that if you go down the route of the larger authorities, or even if you leave that aside and you have the greater collaboration and regional working that has been the agenda for long time, that that will at least go some way to solving the problem and create these savings. But from what you're saying, it almost puts the problems on a bigger platform.

Absolutely, because the costs are that person delivering the care, and we've worked really hard with the sector, and that isn't going to change, is it? You can bring three authorities together and you just treble the number of older people that you need to support at home. You might make a saving on that in one less director, but in the grand scheme of things that is not going to stop the demographic pressures that an authority faces. In another sense, what you are doing—as you said, the bigger you make that market, the more risks you'll have, and this has always been my fear with regional working. I think we have a lot of benefits from regional working, but, say you had a national market for Wales, then you'll have big private providers in England licking their lips. So, just be careful what you wish for, because we've got the Welsh National Procurement Service, and I've heard some Assembly Members talking about the value of that in terms of supply teachers. So, just be careful when you ask for an all-Wales solution because ultimately this is a very individual service, isn't it, for individual care?

10:00

You've also got the problem there that if the provider doing what you said earlier then returns the package—

And what I wanted to come in and say is that what we mustn't forget, and I'm sure you're not forgetting, is the person who is actually experiencing receiving that care in their home. I know all the improvement factors that are going in, and there is some really, really good practice, best practice across Wales, in terms of moving away from the time and task and really concentrating on providing the good welfare checks, the good experiential checks for the individuals who are receiving the care. But that will cost money, and one of the things I want to say, of course, is that the private sector is very canny. They will always find the routes to maximise their profits, because that is why they exist.

Obviously that's a really important point, but it's interesting how there is also this move back to some taking back in-house services, and some not-for-profit services, and we perhaps need to look more at that opportunity. I think it was Susan who said earlier on that the whole system is creaking at the seams. You also say that you describe the financial position of local authorities as unsustainable in terms of the whole picture. We need to look at this in a Welsh context, obviously, in terms of what we can do with the parliamentary review, with our discussion and with how we can respond. Is there anything more you want to say at this point in terms of what the consequences are for the social care sector?

Can I just make one comment? My colleagues will have heard me say this before, but the one thing I have been deeply impressed by in my four plus years as a local councillor and cabinet member for Cardiff is the ability of local authorities in terms of fiscal discipline. I had considerable years—and I'll declare an interest in terms of being an independent member on Cardiff and Vale health board, but my plea to the whole system would be, 'Exert that fiscal discipline as a whole', because we mustn't forget there are huge amounts of money in this system. Absolutely, from my perspective, we need to ensure parity across the system in relation to social care, local authorities and health, because we need a balance there.

Just to add to that, I think, again, you've only got to look across the Severn to see what has happened where the cuts have been. So, we have experienced cuts in Wales, make no bones about that, but they haven't been as deep as they've been in England, and that's simply a matter of fact. If you look at delayed transfers of care, they're much, much higher across the Severn. There are two reasons for that. First of all, there are people unnecessarily being admitted to hospital at great expense to the taxpayer because they're not getting care at home from social care, or, when they are ready to leave hospital, when they're medically fit to leave hospital, they're unable to leave hospital because there are not the care packages in place. Now, I'm not saying there isn't some of that in Wales, but it is far lower in Wales than it is in England, and what we need to be very careful of is that if we don't continue to invest, and invest more in social care in Wales, we will simply end up in the same position as they are in in England currently. Because they are the same people that we are supporting: the most vulnerable people. We are supporting them through the social care system. People with dementia or Parkinson's—they will be getting care from us, and they'll be getting care from us first, before they're getting care from the NHS, and we don't want them to be on trolleys. Nobody wants to be in hospital; they want to be at home. If they're getting cared for at home, they're getting cared for by the social services department of their local authority.

I'm proud of the innovation and, for example, in Monmouthshire there are really good schemes. There are really good schemes across Wales, but what we need is that investment in some of those preventative measures. So, telecare is a wonderful development. We've got over 2,000 people in Bridgend, and we're keeping them safe at home through telecare. So, instead of putting them, as we would have 20 years ago, in a residential care home, at home it provides security to the families, but it also provides comfort to the individual, they get help when they need it, and it keeps them independent. That's happened across Wales, but we need some significant investment in that, so that's why we're calling for a primary prevention fund across Wales, so we can develop more of those services, because we've got to develop them at pace. Otherwise, we will end up in a crisis—make no bones about that—and it will cost the taxpayer more, and it will be worse for the citizen if we don't develop that.

That prevention fund, obviously we'd want to work with the NHS partners and with the voluntary sector on that, because we are also firmly of the belief that only by working together will we find the solutions, and we think there's an opportunity there. So, there will be more money coming to the NHS—there's always more money coming into the NHS. We would argue that if we work together across the public sector, then we can build at pace and at scale some of those interventions that will keep people at home for longer and independent.   

10:05

Chair, can I just bring in—? Because I think, again, I don't want for us to forget important groups, and those are self-funders, because you will have heard, of course, the well-established argument that, actually, self-funders are currently subsidising local authority resident citizens. And I think that is something that we really, perhaps, don't concentrate on, but according to LaingBuisson, people who pay for their own care homes are subsidising local-authority-funded residents by more than £100 a week. It is significant. There is not parity within the system.   

Thank you for that. I think we'll move on with Nick Ramsay with some questions as well. 

You're happy. We've potentially—. We have covered whatever you need as we've gone through this. That's fine. I'll return to Jane, if you've still got some. 

Yes. We've talked quite a bit and you have about the importance of—. I'm glad you see that this inquiry is going to be helpful and you're part of it, and that we need this discussion and the parliamentary review provides a real vehicle of opportunity. You do, in your written evidence, say that there's a need for the Welsh Government to turn its ambition of social services as a sector of national strategic importance into a reality. Can you just say a bit more about what you mean by that? I mean, it's not just about funding—that's absolutely critical, clearly—but it's how we can use the parliamentary review, for example, and of course you've already made quite a few comments on how we can increase that strategic position of social care. I think we've all felt through our lives in different ways—as councillors, Assembly Members, ministerially—that it has been so difficult to raise that profile and importance of social care, and we want to. 

I think that is the critical issue, and thinking how important it is to population, we're a little bit of a cinderella service. Everyone understands the NHS and the value of the NHS. It's a universal service. Everyone's got a GP, and everyone's got access to that system. I think there is a misconception that, actually, there is a much smaller group of people that benefit from social care. That may be true in the numbers of people that actually directly receive that care, but in terms of the impact of social care on the broader family and broader communities, actually, the numbers are far, far greater. I don't think there's that understanding within, as you say, the broader population in Wales. I think the Welsh Government piece of work around 'Prosperity for All' is very significant in helping social care move up that ladder of awareness, but we've still got some way to go. There's little doubt that the parliamentary review has the opportunity to help, but we have to be on the front foot as a sector, and politically, in viewing the social care sector as being just as important as the national health service, and we are not there at the moment. 

10:10

Any other things you would want to say about what contribution you can make to influencing Welsh Government on this point?

I suppose, building on what Dave said, and I'm sure Susan will come in, it's just around that. So, it is around status. So, I think, for example, registration of domiciliary care workers, et cetera, investing in training. There is significant investment through the SCWDP grant, the social care Wales development—and what's the last 'P' bit? [Laughter.

But, anyway, it's investing in training—

Yes, the workforce of Wales. But I think we've got to give them that status in the scheme. And part of that is about pay, because they do see that—. We do live in a society where people feel that a big part of their value and their status is determined by their pay, and when they are paid less than, quite often, colleagues who can be doing the same job, they can be looking after the same people and get paid less for it. 

And I think there's been a very recent example, hasn't there? And this isn't a criticism, but we've seen the recent announcement around the NHS pay award, which is different than the local government pay award. So, at a time where we want to bring our workforces together, we want to work in a seamless way, we want people to feel equally valued, we want to stop fishing in the same pool, we've actually accelerated the differentials there already, and we've got people on different pay situations. 

I wonder whether it is time, if you like, for almost a national conversation about the role of social care, because, as colleagues have said, everyone understands the NHS, everyone supports the NHS, and I think that's part of the sort of tension in the systems, returning to my phrase, in terms of fiscal discipline. And local authorities will have an enormous role in terms of that national conversation to really explain. And it's not just, as Dave said, that lots of people are either receiving social care services, or are touched by that receipt for friends or family members; it's much, much, much broader than that—that we all have an understanding of the essential contribution that it makes. 

So, moving on to, well, national conversations, we had a huge conversation as we took through the Social Services and Well-being (Wales) Act 2014, and that was very much a partnership approach and we got the Act through. How has the Act changed the services that you commission, and the cost of providing those services?

Shall I start because I was actually in the Cardiff scrutiny last night and we were talking? Because, for us, of course, now, because of the impact on the social care budgets, we are looking more innovatively across the council in terms of our preventative offer. So, working very, very closely in terms of our independent living service offer, and there will be lots of teams who will go into visit people. Because it's not about waiting for someone to be in crisis and they might actually receive or need to receive social care. And what we're seeing, actually—. Huw's mentioned telecare; Cardiff also has that telecare offer, and we are seeing savings. So, we are seeing a saving to the ambulance service, because we are avoiding ambulance call-outs of 11 per cent. 

So, in terms of that preventative offer, what we are seeing is a diminution from about five years ago in terms of people who would come through a system who would automatically perhaps feel entitled to some service, but what we're seeing now is that it's probably about one in four people, when they go through our systems, require social care in terms of eligibility for that service, and actually because they will have the most complex needs, and that is where social workers need to spend their time. But we are building up a suite of other services in that preventative way that will get in sooner.

10:15

There is an issue that's come up in stakeholders' questions about eligibility criteria. It would be helpful to have a view across local authorities, but the view is that the eligibility criteria have tightened each year. In a sense, you're explaining a way of understanding other routes in terms of access to appropriate care, such as telecare, but are fewer people being eligible now found to be eligible for statemented social care, and how are the eligibility criteria being used across local authorities? I don't know if the WLGA or ADSS can comment.

I haven't seen any significant movement as far as eligibility criteria are concerned. I can certainly understand why perhaps that perception is out there because, I think, as a consequence of the Social Services and Well-being (Wales) Act 2014, we're having very different conversations with people. As a consequence of those different conversations, there are different outcomes, so there may well be members of the community who could perhaps point to someone who lives a couple of doors away who, two years ago, would've gone straight into mainstream social care services, where there are alternative solutions and services identified for that individual. So, I think what we're seeing is the pace and the face of social care changing and the perception of that, from different people, could well be, 'Well, actually, you've tightened your belts and you've tightened your eligibility criteria.' I just think it's a reflection of the fact that we are working and thinking very differently now than we were four or five years ago.

I think it is a positive response because it's really clear that the 'What matters' conversations are taking place and they are leading to good outcomes—more positive outcomes for people.

And they are difficult conversations because, often, people's expectations when they begin that conversation is the, 'I will have', 'You will give me', 'You will provide', and so those conversations take people down different routes, and that can take time. You often have several conversations with an individual before you get where you need to be. That is slightly more time-consuming than when, perhaps, it was a little more straightforward, when it was, 'No problem, we'll arrange for you to have 12 hours of domiciliary care a week.'

I think it's really important, particularly around older people, to stress that, sometimes, it's the families who assume that what their frail, fragile grandmother or mother and father—whoever it is—need is for people to come in and look after them, because that's the instinct isn't it? Whereas what we're saying all over Wales now is, 'No, no, we need to help you get mum or dad back on their feet', and that's hard, isn't it? Because they have perhaps spent time in hospital and they do look frail and fragile, but our reablement service would say, 'No, no, you're having six weeks of really intensive support', and then you're back on your feet and you may have a befriending scheme and you may visit a local dementia cafe, or it might be an aid and adaptation to make it a little bit easier in the long term. So, there are all of these alternatives. We're still helping and supporting people, but to keep them independent; they're not accessing the traditional, conventional care package. But that's about their welfare and well-being, as much as it's about savings—it does save as well, but it's primarily about what's better for them in the long term.

And it is about those voice and choice conversations.

I think it's outside the remit of this committee, unfortunately, but the conversation about primary care, secondary care and social care and how they all fit together is something that we desperately need, because what we've seen is a drift of money into secondary care, and primary care and social care losing out. I can talk about the financial side of it, but I know you'll be telling me off.

The other thing that I find that happens in Swansea East, and I know it's common, is that people don't quite understand what they have to pay for and what they don't, and why they have to pay and why they don't. And that's not just in social care. People don't understand why they have to pay doctors—general practitioners—for certain things. They don't understand why Mrs Jones down the road is in a nursing home and she's being fully funded by the health service, but their parent, who to them is equally as frail, has to pay. Do you find that people don't quite understand who pays and who doesn't and why they pay and that people sometimes feel aggrieved at having to pay when they see 'other people' are getting it for nothing?

10:20

Absolutely. We bump into that on a regular basis. As far as the mainstream social care services are concerned, there are some very prescriptive charging policies, and there is an element of means testing. So, people understandably pay different amounts. I think things like continuing healthcare bring another level of complexity that, quite frankly, not only do citizens struggle with but professionals struggle with as well.

That was the point I was trying to make. People understand that the rich person down the road is having to pay and the poor person here is not. What they can't understand is people who live on the same street, live in the same houses, and look as if they've got the same sort of relative income. Some people have got to sell their houses in order to pay for it, and others, because it's decided it's a health need not a social care need, all of a sudden are funded. They don't understand that, in my opinion. Do you get that problem as well?

Absolutely. And of course, in terms of the social services and well-being Act and the information, advice and assistance, I think we have to, as local authorities, get smarter in terms of communicating to our citizens what the charges are and what they're going to be, just to give people the information so they can make well-informed choices.

And I think—sorry, Chair—the increase in the cap has made a difference. That has been welcomed by people, because you're right, it's heartbreaking at times; you see people who have actually quite modest incomes, they've built up their life savings, a nest egg, they want to leave it to the next generation, but because of their health and social care needs they require residential care, and quite quickly that money can go, can't it? You're talking £600 a week, quite often. So, quite quickly, you can burn through a lifetime of savings.

So, I think that increase in the limit by Welsh Government is to be welcomed and has been welcomed, but fundamentally there's still that inequality that I talked about earlier. It doesn't matter how much—. I know you've quite often got to wait for it, but it doesn't matter how much the cost is of your health treatment, it will be funded completely. It could cost the state hundreds of thousands of pounds. But the minute it's defined as social care, then you can lose everything over it, can't you?

Can I just ask—? You've mentioned the cap a couple of times now. In your opinion, have you been fully funded by the Welsh Government for that?

Fully funded for—?

The cap. Well, we're still working through that, if you like, because the cap is being raised on an annual basis. We're still identifying the pressures. Is that fair to say, Dave?

It is, absolutely.

We'll come back to you on that. You might be surprised to hear that, in the past, some of these new initiatives haven't quite come with the money that is needed—

And that can be problematic. So, when the cap on domiciliary care costs first came in, what happened was that a lot of self-funders just came out of the system. Because a lot of social care—there's a spectrum there, but a lot of social care happens on a very informal basis, doesn't it? We know the most informal basis is that there are hundreds of thousands of carers in Wales who care for their own family members, but there are a lot of people who were paying for domiciliary care and we just didn't know about them. Once they knew about the cap, they were coming to social services. I think in the Vale of Glamorgan the budget went up by about £0.25 million in one year because people were just saying, 'I'm here, there's a cap, I want you to pay for my costs.' So, we're working through that. I've got better information about the residential care sector because, by definition, they're in institutions, aren't they? We've got a relationship with all those institutions, because we have people who are on funded placements alongside those people who pay for their own places. But we'll come back to you.

10:25

A lot of people have to resort to mixed care—some family and some paid, perhaps through the community. So, that itself causes confusion. Would you also not agree that this lump of money coming into the Welsh block grant is to cover that, there's no additional money in the Welsh block grant, so, if they weren't giving you the money for that, it would still be coming into the Welsh block grant for local government? It's not as if they've taken it off another service in order to give it to local government. So, although we can always produce a list that shows that additional money has been provided for something, isn't the danger that the additional money provided for something is because something else in local government has been reduced?

Yes. [Laughter.] I don't think you're even being cynical there. 

That's a past and present local government conversation, I think. [Laughter.] We're almost out of time, so I would like to get one last question in before we do conclude, and it's one to look to the future, because you've discussed very well the pressures that are there at the moment. There are discussions; some of this is blue-sky thinking, but there are discussions around what might happen in the sector over the next 5 to 10 years—whether we'll have the social care levy. There's quite a big discussion now around automation and whether some aspects of social care could be automated. I'm not quite sure how that deals with the personal relationships, but it's certainly something that's been discussed. Within the local government context—I know they're two very different things—are you having a discussion around what might come in in terms of automation and robotics and that element? And, on the fiscal side, the social care levy as a particular proposal, or any other proposals you might be aware of—you know, is that something that's being discussed actively at a local government level?

Well, I'm sure that Susan will come in. I have to say that I think that I know it's being talked about—automation—but there are 2,500 people having telecare in Bridgend; I think it's already there, if you like. That's a form of automation, isn't it? We can talk about it; we're already doing it, actually, very effectively and successfully in local government. Do we need to come up with some imaginative solutions around funding? Absolutely, because we are not crying wolf here: the pressures are acute. So, we've made cuts of over £1 billion—over £1 billion of cuts we've made in local government. In the last four years, we've made more than 470 people redundant in Bridgend County Borough Council. There is a limit to how many more savings we can make if we want to maintain the basic decent services, essential services that our citizens expect and that you, as members of the National Assembly for Wales, expect from us. 

So, we are certainly up for a discussion around a levy, a contribution—whatever you want to call it—that is now available to the National Assembly for Wales, to the Welsh Government, through new tax-raising powers. If people want local authorities to look after their families, look after their elderly relatives, look after looked-after children, then the costs are rising significantly and we need to find a way to meet those costs. If they're not going to come from Welsh Government through the revenue support grant, council tax is already rising significantly year on year and there's no sign of that changing, and we can't, I don't think, have higher council tax increases—I don't think that the population will tolerate that—then we need to find a third way, unless the revenue support grant goes up significantly.

Just in terms of automation, Cardiff is part of a sort of innovation project looking at Alexa—you know, the talk box or whatever—. So, it's become very, very interesting and I think that we will see more of these things develop, but remembering always, of course, the individual end user and the sensitivities. And in relation to your final question, I think it is—and in terms of Professor Holtham's work—. To me, it goes to the point of the national conversation so that everyone understands the need.

Okay. I think we'll put the conversation to bed there. We're very grateful to you. Thank you for coming back again. I appreciate your time in doing that. Diolch yn fawr. 

Can the committee take a short break? I think we'll reconvene at 10:40. 

10:30

Gohiriwyd y cyfarfod rhwng 10:30 a 10:41.

The meeting adjourned between 10:30 and 10:41.

10:40
4. Cost gofalu am boblogaeth sy'n heneiddio: Sesiwn dystiolaeth 6 (Comisiynydd Pobl Hyn Cymru)
4. Cost of caring for an ageing population: Evidence session 6 (Older People's Commissioner for Wales)

Galwaf y Pwyllgor Cyllid yn ôl i drefn, felly, a chroesawu Sarah Rochira, Comisiynydd Pobl Hŷn Cymru i gyfarfod y pwyllgor. Jest i ddechrau, hoffwn eich croesawu chi, ond hefyd diolch yn fawr i chi am y wybodaeth ysgrifenedig rydych chi wedi'i pharatoi ar gyfer y pwyllgor yn ogystal, ac wrth gwrs am ddod i mewn a rhoi amser i ni y bore yma. A ydych chi'n hapus i ni ddechrau gyda'r cwestiynau? A ydy hynny'n iawn?

I call the Finance Committee back to order, therefore, and I welcome Sarah Rochira, the Older People's Commissioner for Wales to the committee meeting. Just to start, I'd like to welcoming you and also thank you for the written information that you've prepared for the committee as well, and also for coming in this morning. Are you content for us to start with questions?

Ocê. Wel, os caf i gychwyn jest drwy ddweud, yn codi o'r dystiolaeth ysgrifenedig rydych chi wedi'i rhoi i ni, eich bod chi'n disgrifio sut mae anghenion corfforol ac emosiynol pobl hŷn wedi cynyddu yn sylweddol dros y blynyddoedd diwethaf, a chymhlethdodau anghenion hefyd. A allwch chi ymhelaethu ar hynny a rhoi, efallai, rhai enghreifftiau i ni o sut rydych chi'n gweld hyn fel comisiynydd pobl hŷn yn y gwaith a'r ymatebion a'r trafodaethau rydych chi'n eu cael gyda phobl hŷn yng Nghymru?

Okay. If I could just start off, arising from the written evidence that you've submitted, you describe how the physical and emotional needs of older people have increased over recent years, and the complexities of their needs as well. Could you expand on that and, perhaps, give us some examples of how you see this as the older people's commissioner in the work and the discussions and responses that you've received from older people in Wales?

Okay. Thank you. This is one of the areas I spoke about first in my evidence, because I wanted to remind us all about the human and individual face that sits behind these big strategic, macro-level discussions that we have. And it doesn't take away from the need to have those discussions, but it's reminding us all about the impact of social care. After my care home review was published, we coined a phrase in Wales about social care and we called it a sector of strategic national importance, and I think that's the right place to start. There's a danger that we see costs associated with social care as if it was a burden upon the state. So, I think the best way to answer your question is to reframe how I think we should think about social care and then show you the impact on individuals as part of that.

So, social care services and support are clearly critical to older people. If you strip back often the complex language we use, it keeps them safe, the 40,000 older people who are the victims of domestic abuse. For many of them, it's gone on for decades—social care support is a critical lifeline out for them. It enables them to regain and maintain their independence, for example, after a fall. It enables them to keep doing the things that matter to them, that give their life meaning. It enables them to take their medication. So, for some, that means it keeps them alive. And it enables them to maintain their personal care. And really, I think what we're talking about then is their dignity and respect as they grow older. It is, for many, a lifeline service. It's also vital to carers. Now, we are, in no small part, a nation of carers. I talk in my evidence about them being the backbone on which our public services stand, though many carers are still on their knees. Without the support they get form social care and social care services, they would go under, and they would not be able to do what they want to do, which is care for those that they love.

But social services and social care support are also critical to our wider public purse, for example in reducing costs to the NHS and unnecessary admissions to hospitals, and we know our hospitals are struggling to cope with demand. Also, it's about minimising costs to individuals, for example by avoiding going into residential care unnecessarily, or certainly deferring that as well. I share those examples so that we begin the debate by seeing social care, social services—however we want to define it—as an investment in the human capital of our society. Social care support and social services are crucial to delivering on our wider well-being agenda, which I've welcomed, here in Wales. They're crucial to delivering on the equality agenda as well. More than that, they are also, because they are that sector of strategic national importance, crucial to the wider health of the economy as well. So, they're lifelines to many, but they're vital to our wider economy and our communities, and our broader public services as well. So, I would, of course, argue they're a key area for investment. 

10:45

Thank you for that. I think it's also interesting and relevant to point out that, generally, within the Assembly the social care sector is now seen as part of the foundational economy, and it's seen as something that is very much tied in to the way that the economy has to work in Wales, and investment and skills in that. But one of the things that you mentioned there, and in your evidence, is voluntary or unpaid carers and how important they are. Of course, many of them are also older people. I think you give quite—they're not surprising, because we know that it's happening, but they're certainly revealing figures about the number of carers over 80 that we could have by 2030, for example. The growth in that area is enormous.

So, when we talk about social care, investment and the economic side, if you like, you also have this huge pool of voluntary people, many of them older people. How do you see, from the evidence that you are able to discern, that aspect developing? Is that something that we should automatically assume continues? Should it be a sector that we try to professionalise, in a sense, or are we, rather, needing to tailor our investments and our spending in a way that supports that voluntary pool of carers? What's the best way forward, as you discern it?  

Okay, to take your—. I think there were three questions wrapped up in there. The first question was: should we assume it continues? I think that would be an extremely dangerous assumption. You saw from my evidence—these are UK figures, but you can extrapolate easily for Wales—that of 6 million people in the UK caring for an older relative, 2 million are themselves older than 65, with more than 400,000 being over 80 years of age. I travel all of the time. I met a lady just last week—she was 76, caring for a 96-year-old. She told me how she spends more on petrol than she does on food for herself. There is a question as to how long she can continue.

Many of the carers I've met are on their knees—they are struggling day in, day out, at huge cost to their physical and emotional health, and their overall well-being, to do what they want to do. Also, just in terms of sheer numbers, the demographic profiling has indicated that this is the year in which the level of demand we have for unpaid care outstrips the number of unpaid carers that we have. So, the state, in no small part, has been carried by unpaid carers for many, many years, if not decades. We cannot assume that that will continue.

On the second point, in terms of whether we should professionalise it, well, I think it depends what you mean by 'professionalise it'. Unpaid carers don't necessarily want to be professionals. Many of them, whilst they're happy to provide the care and support, also don't want to be categorised as carers. One lady particularly—Pat—told me, 'I care for my husband, but, above all, I want to be his wife still. What I want is support to help me care, without undermining my role as his wife.' Having said that, I think there is a lot we can do to support them, for example in terms of training and skills to care for people, which we might see, maybe, healthcare workers providing, or social care workers providing. I think there's much more we can do to upskill our carers across Wales. The Royal College of Nursing has done a really good piece of work looking at that.

And, then, should we do more for our carers? Well, the short answer is 'yes, absolutely', if we want, as a state, to keep benefitting from what they do day in, day out. Despite the Measures that we've had—we've had the carers' Measure in Wales, which was passported into the Social Services and Well-being (Wales) Act 2014—I still meet many carers who don't know that they're entitled to support and haven't had an assessment. Some of the home visits I've done, when I've met with carers, older people who are carers, have almost been beyond belief in terms of what they're struggling to cope with almost entirely on their own.

So, I've said in my evidence, you know, and I'm very clear, people don't have to agree with me, but have a view: I think we need to put more money into the system, and I have a view about how we should do that, and I have to talk about that in more detail later. But I'm also very clear on the areas that we should invest in, so it's not about using money to do more of the same, and of the five or six critical areas I would invest in, unpaid carers would absolutely be one of them. The return is phenomenal: £9 billion [correction £8 billion] I think they're worth to the Welsh economy. If we invested in them more, maybe we could make that return on investment of £18 billion. 

10:50

I think that's the key point, that when I used the word 'professionalise', I was using it in the wider sense of the word—skills, training, support—not necessarily becoming paid carers, in that sense, because the evidence that we've had in the committee is that so much care is actually provided in a mixed way, so even people who are having domiciliary care from a local authority will also have informal or family care, and we need to make sure that that whole system is sustainable and that we're not exploiting any part of that system, and particularly, from what you've just said, the voluntary carers as part of that. So, just to explain what I was trying to get at there. And I think that's my comment rather than my question to you, so I'll invite Jane to take it up there. 

Well, this is going on on the same theme because you also, quite rightly, in your evidence, say that carers do reduce demand on services and that they play that vital role, and therefore it's crucial that we do invest in carers. So, I think you've already given us very good evidence, and again this morning, about why you think carers are so crucial to the system and why they do reduce demand for other services. Perhaps you could—unless you want to add anything—say a bit more about how we could, from a costs-of-caring perspective, invest in carers more effectively. 

It's a question that probably deserves a longer answer than I could give here, but a piece of work that I'm shortly about to publish is about rethinking respite care, and this came on the back of a report that I published last year in relation to people living with dementia. One of the big issues they raised—people living with dementia and their carers—was about the need to rethink how we provide respite, which tends to be focused on some time apart to relieve people of the—and I put this in commas—'burden' of caring. What they said is we need to see respite as a therapeutic intervention that helps us maintain our skills, regain our skills, and maintain the relationships that we want to have. It could be so much more, and it could be so much more at a less cost than we pay now because the way we tend to provide respite is residential care, so maybe two weeks away every six months or whatever, which is expensive and not liked by many people. So, I think respite care is absolutely one of the areas that we could focus on.

My report comes out in, I think, two weeks' time. I'll be sending it to the Cabinet Secretary because he has asked to look at it as part of the work on the dementia strategy, but, actually, the issues in it run much broader than just dementia: these are the voices of carers across Wales and people who receive care and support saying that we need to rethink respite, deliver more flexible models across Wales that are more tailored to what they want and are more focused on maintaining skills and the relationship that they want to keep. Because carers shouldn't have to default to being a carer and to lose being a wife, or a mother or a daughter, because if they do, then they're excluded from the well-being agenda in Wales, and we're fuelling an inequality. So, I think respite is a really good example of something we could do differently. We could probably save money, and we could get better outcomes as well. 

Well, that's useful. I don't think respite has been mentioned much in our inquiry. And also in terms of, perhaps—. We'll look forward to your report. Perhaps 'respite' isn't the right word; it's one thing that emerges from that kind of arrangement, but 'respite' sounds a bit, sort of, desperate, rather than being—.

You're absolutely right. If I could change the word, I would, but it's in such common parlance that—

—it's probably not worth trying to do it. But it is called 'Rethinking Respite'. It's a fundamental reframe of the purpose and the impact, and underpinning that sits a different business case and a different narrative, and that's very much in line with parliamentary review, very much in line with the social services and well-being Act. Think about it fundamentally differently, because you can't just keep pedalling harder.

10:55

Also, of course, that will be very useful evidence for this committee, but is there anything else you want to say or add about your homecare review, which, of course, was back in 2014—anything that you would want to share with the committee in relation to the purposes of our inquiry?

There is probably much that I would want to add, but, again, time is limited. As you know, I undertook a follow-up review. Again, I was measured in that. There was progress that I gave credit for, but there were clearly still areas where more needed to be done. There are many overlaps between the review and the committee's inquiry, but perhaps the one that I would pick up on is the issue about longer term planning. So, it was one of the big issues. We need to properly plan for how many staff we need and where. We need to properly plan for how many places we need. We need to properly plan for how many people are going to need domiciliary care across Wales. I spoke about the lack of effective workforce planning and the lack of effective long-term forward planning. I still see little evidence that we're getting that right. I have report after report land on my desk, but I've asked the question: in 15 years' time, how many residential care beds will we need, how many nursing care beds will we need and what levels of staff will we need, particularly those with specialist skills? The answer that usually comes there is none. So, I think that that's the big link.

I said this in my evidence. None of the issues that we're facing now should be a surprise, because, if we'd started 20 years ago, we'd be ahead of the curve. Now I would say that, in Wales, we probably started earlier than they did in England, but we didn't start early enough, and if we don't want to keep repeating these cycles, we need to get much, much better at our forward planning. And you have to build scenarios into that, but at least you can start to take early action. If we'd taken some of the action that we're going to have to take now back in the early noughties, when we were in a much better financial position, we'd have headed off some of the challenges now, not just for public bodies, but for individuals as well. So, I think: long-term planning, strategic planning, needs assessment.

Thank you. One of the sectors that's so engaged in care and social care generally is the third sector. Have you got any views you want to share with us in terms of the third sector's role in providing care services and how the sector's changed and also been affected by austerity and challenge, but also how the third sector has changed in relation to other providers and informal care?

Yes, I'm very happy to do so. I spoke a moment to go about—. I'm very clear that I think we need to put more money into the system, but then the big question, of course, is what you do with the money. So, I have my shortlist, I guess, of areas for investment. I'm not saying they're perfect, but based on my experience these are the areas where I think we can get more return and make the big differences. So, carers was one of them and the third sector is another one of those.

The third sector, it seems to me, is very good at being out at the front line, very fleet of foot, very innovative, very creative, very responsive to individuals as well. It's very good at working at the secondary prevention level, which is often where they're commissioned, but also incredibly effective at that primary prevention level in terms of stopping things happening. This is where I think the levels of investment are lower than they should be in the third sector. You only have to look at some of the examples that were given in the evidence. I think the Royal National Institute of Blind People sent in an example of a spend of £900,000 per annum on a service and it saved £3.4 million in health and social care costs. For any business, that's a really good return. Look at the evidence from Care and Repair: for every £1 spent, £7.50 is saved.

They are, if you like, the front line of defence that we have for preventing much of the inevitable frailty and loss of independence that can come with older age. We talk about them being a key sector, but I don't think they are equal players because you have health and social care—the big beasts—with the power, with the infrastructure behind them, and then you have the third sector, who are always going hand to mouth. So, I would want to see them brought in from that model to being full and proper equal partners with health and social care.

I think it's also important, when we think about the third sector and their role in prevention, that we think about prevention on a much wider basis because we know, for example, that healthcare only accounts for about 10 per cent of the population's health. It's why I talk about buses—the concessionary bus pass is a lifeline for people. It's why I talk about public toilets: public toilets are good for individuals' health. It reduces demand on wider public services, and they're good for the economy as well. So, they absolutely would be one of my five areas to really, really invest in because they go to the heart of the primary prevention agenda in a way that no other body can, because they're flexible, they're quick on their feet, and they're inherently bound up with what the individual wants. They go to the places the state can't in a way that the state never will be able to.

11:00

Thank you. Moving on from the third sector to the independent sector, I think you—. And we've just been taking evidence from the Welsh Local Government Association and ADSS and we talked about the fragility of the domiciliary and residential care markets. So, key risks to those markets that you identify would be useful to hear.

There are so many and, in a sense—. I spoke about those very clearly in the care home review. I guess if I had to try to crystal it down in a short period of time I think I would say often a lack of long-term investment in those sectors. It's really hard. Most of our independent providers are small and medium-sized organisations. If you run your own business, the big issue doesn't tend to be profit; it tends to cash flow. It's really, really hard if you're short on your cash flow. Now, in some parts of Wales, they have really good models where they are long-term investing through their commissioning process. In other parts, you have a reverse tendering model where Mrs Jones is, basically—. An older person described it as 'eBaying of my grandmother': this is Mrs Jones' three lowest bids for her. How can you build a long-term sustainable relationship with your providers if that is how you are operating? It runs contrary to the interests of the individual, and it certainly runs contrary to building into our nation a quality-based long-term sustainable relationship between commissioners and providers. So, I would absolutely have that as one of them. And we do have some good practice in Wales, which, of course, begs the perennial question, 'Why is our good practice not our standard practice?'

I think the second thing I would focus on would be the issue of funding—just how much money there is in the system. This is partly why I come back and say, 'We have to bite the bullet at some stage'. People don't have to agree with my view, but have a view on this topic. Local authorities are squeezed increasingly—not of their doing. That squeeze pushes onto providers. The squeeze then pushes onto older people, who pay extensive amounts of money for their social care already. I was clear in the care home review: it's not all about money, but there does come a point where it is about money. I don't default to say that the state should easily ask people for money, because this is money people earn, they work hard for. I don't default to that in any shape or form, but there does come a point where you get what you pay for, and I think we need that big national debate that says to people, 'What sort of quality of care do you want? Because we're not sure we can provide that any more, with what we're paying in, and if you want it to be better then we need to have a big grown-up debate about how we do that, not just in the short term, but where that takes us in the longer term as well'. So, the second area I would have would be just the amount of money there is to go around.

I guess the third area I would build in, I think, would be—. There are so many I could choose from. I think I'd probably go to the point about the standards that we have. Now, these are a challenge, but they are a challenge for the best of reasons. So, one of the cost pressures that we have within the system is because we're driving up quality in a whole range of ways, but that does push cost pressures through the system, and we can't shy away from those. Then, around all of that, you have things going on that are outside of our gift. So, you have things like national insurance increases, for example, that come relatively out of the blue for people and hit small and medium-sized businesses really, really hard.

So, commission for quality, long-term investment, actually recognising that there does come a point where you get what you pay for, and what price a decent older age for the people that raised us? And then—rightly so—a whole range of drivers that come in relation to pushing up quality. The challenge, of course, is that they've all come at the same time, and they've all come at a time of austerity, and therein lies the rub.

And, of course, the other key area is staff recruitment, the workforce, and how—. There is evidence of a shortage of staff and recruitment and retention issues. We've discussed that quite a bit already with the independent sector and just with providers and with local government now. So, how do you—? What are your views in terms of the workforce issues—the shortage of staff working in this sector?

11:05

Well, one of my third areas for investment is actually around the workforce, and how can it not be? Systems matter, structures matter—governance and accountability, commissioning models all matter. But, when you pull all of that back, wherever I have found great care—and I speak all the time about the great care I find—I find great people; it's a really simple metric. But, to be great, do you know what, we need to invest more. And this was one of the big, big messages coming out from the care home review: we need to invest in our social care workforce.

My view is that we need a proper integrated national workforce plan, and that's more than we have at the moment. There are, as you say, these specific shortages, but it's not just about addressing those shortages; we need new skill bases, particularly ones that overlap between health and social care. We need new career paths—particularly career paths that can help people move from social care into health. When I joined the NHS 30 years ago, you could do that; you really can't do that very easily now. But we also need to focus on the skills and competencies of current staff. So, we've got short-term issues. So, it's estimated there'll be a shortage of 500,000 social care workers by 2030 across the UK. In parts of Wales, heads of adult services will say to me, 'You cannot get carers for love nor money'—a gentleman who was a delayed discharge from a hospital three times died in hospital because there wasn't enough dom care support staff, the lack of specialist nursing staff in our nursing homes, and so the list goes on. So, there are critical issues right now, but it's not just about having more of the same staff. The reality is that, in 1948, we set up a social care and a healthcare system that saw that as being two uniquely different things. The reality from our older people now is that the line is hugely blurred. One day you might have nursing care needs, the next week, you might not have them, yet people still bounce around across those.

So, absolutely, I would focus on a proper integrated national workforce plan, and, within that, I have to comment on the effectiveness of our workforce planning. 25 years ago, when I worked as a director of primary care, I filled in a workforce return, and we produced them probably every month, and I worked out from that that in 25 years' time—about now—something like two thirds of our GPs were going to retire. Do you know what? We still don't have enough GPs, we still don't have enough specialist nurses, despite an industry and decades of workforce planning. I've said this in my evidence, it has to beg the question: actually, how good were we at it? So, it's that needs assessment, the longer-term population planning, but the proper integrated workforce plan that bridges the health and social care divide is a key area for investment. The more we put in that, the better outcomes we get and the more wasted money we save ourselves.

Good morning. How does the cost for self-funders compare with the rates paid by local authorities for the same levels of care and support? You mentioned this in the document you provided us with. Could you elaborate a little on that?

If you look at the evidence from—I think it's the Competition and Markets Authority that recently undertook a review into the residential care market. This is one of the issues they raise: they talk about what is, in effect, cross-subsidisation. The cost of residential care can almost be higher than you could believe. So, you could easily pay £1,000 a week for residential care. The evidence is really clear: many self-funders pay more than local authority rates. Local authorities are partly in a position to push down their rates because, obviously, they're purchasing more care—many of them may develop more longer-term relationships with individuals, but there is undoubtedly a degree of cross-subsidisation going on.

It's also important to recognise that, until recently, and until the Social Services and Well-being (Wales) Act 2014, many self-funders struggle to know what to do, because what they didn't get was the advisory support of the state as well. So, you might be in a hospital and someone says, 'Perhaps we'll agree with your mum that she goes to a care home.' Well, which home? Where? For what purpose? How do I decide where the best place to be is?

So, there is cross-subsidisation going on. I think it's part of something much wider that we need to recognise, which is that older people are paying quite extensively for their care already. We talk about the cost pressures on our public services, but the cost pressures are really high on older people as well. I've got a figure—excuse me one second.

11:10

So, if you took the cost of that self-funding out then the problem on the other sector would be even greater than it is now.

Absolutely it would. And even greater on older people as well. I've got some figures on the financial pressures on the system, but on older people as well. So, one in 10—this is one in 10 of us here, just to kind of personalise it—will pay £100,000 over our lives, with no way to insure ourselves at the moment. I met a lady, she was selling her mother's clothes to pay for her dom care, because it wasn't considered to be health related—well, it was, after she appealed, six months after her mother's death.

Older people pay extensively already, and that's not to take away from the caps—they're important caps that we have in Wales. But what happens is you get cost shunting; you get cost shunting from the public sector to the independent providers. Some of the best independent providers say, 'We're not prepared to deliver services at that level, because we cannot deliver a good quality'. You get older people asked to pay top-up fees. And I think that's what we've had over the last five years is costs shunted through the system, but there comes a point when the system just pops, because you can't shunt those costs any further. So, this is where it starts to get—obviously, it becomes really quite complex.

And you said about the increase in the costs of residential care exceeding the growth of incomes over the last five years, so that's having a big effect.

It has a huge effect. I'm out and about, as I said, with older people all the time, and they have views on issues. If you raise the topic of paying for care, the room will erupt. If you raise the issue of continuing healthcare, the room will erupt as well, with a real, real sense of, I think, injustice, because, of course, what older people were told decades ago was, 'Pay your subs, your tax, your national insurance, and, when your time comes, the state will care for you', but somewhere along the line, the rules changed and the state said, 'Unless we categorise it as social care, and, by the way, the vast majority of what we used to call healthcare, we now categorise as social care' and you saw those huge transitions in budgets from NHS, which was free, to means-tested and entitlement-based social care. Older people pay a huge, huge amount. Even with the increased cap—and I've welcomed the increased cap in Wales—people will still pay a huge amount. The lady who was selling her mother's clothes to pay for dom care despite the cap here in Wales—older people are feeling the pinch significantly and it has a huge impact on them. So, it's not just the impact on public services and the budgets there, we have to recognise the impact on individuals as well, who are already vulnerable and are already struggling because of some of the things that come with older age.

Our last witnesses were saying that if it's classified as being within the health sector then it's pretty much all taken care of, but as soon as it passes into the social care side of care, then, suddenly, that burden falls rather remarkably heavily on the older person.

It absolutely does. And we've seen a huge transition in the way that we categorise costs. So, we talk now about the extensive financial pressures on our social care system, but, when you dig behind them and find out where those financial pressures are coming from, there's a really interesting narrative, which is different to the popular narrative we have. So, the popular narrative is that the financial pressures that the system faces are because we're a nation of older people, because we're all growing old and we've all got more needs and there's more of us and we use them, but, actually, that's not the case.

If you just give me one second, I'll just share with you where I think the cost pressures do come from, because I think this is important to understand and I think it links back to your point about who is paying what and who's bearing the cost of issues.

Excuse me. It's got numbers in, so I have to find it because it's too hard to remember all the numbers.

Well, I didn't know what you were going to ask me, so I had to come prepared, but also these are complex issues, aren't they?

Oh, I'll do it from memory—I can do it from memory. The reality is, as I said, that we think that the financial pressure—

Yes. Give us an overview and if you've got any further figures then we'd be delighted to receive them, yes.

Yes, I'll give you a quick overview of it, because these are in addition to what I—. I don't want to make my evidence too long.

So, the reality is—. We see the pressures that we face are because we're a nation of older people, we're all living longer—it's a good thing, but we all need more care—and that's where the cost burden comes from. But it's not true. The reality is that the costs faced by our social care services—less than half of those were accounted for by older people. At any one time, only one in 10 older people are using social care services. The reality is also—and we know this from published research—that demographic change accounts for a very small proportion of cost pressures in health and social care. So, that begs the question: where did the big cost pressures come from? Because they do not come from being a nation of older people.

Well, I would argue there are three areas, and we touched on some of these earlier. The first is quality improvements in the system. Those drive up costs. The second is system changes. So, you look at computerisation, for example, and technology being used to enable people to talk to each other better. That does not come cheap; it comes at considerable cost. And then you have system inefficiencies. Think of the cost of appeals, for example, on the back of continuing healthcare and think of the duplication that takes place. Those three areas are the key areas that are driving costs up, and then underpinning all of that you have the shift that took place in, I think, the early 1980s where you saw a huge amount of care recategorised from the NHS to social care. I think the budget over a 20-year period went from—I'll send in exact figures—something like £20 million to £1.2 billion [correction: £10 million to £2.5 billion]. That was not because older people were using services; that was because we changed the way we counted the beans behind it.

11:15

That's fascinating, because we always talk about—wherever you look it's, 'The cost of an ageing population'. What you're saying is, although there is obviously a cost to an ageing population, actually that's one small proportion of a much bigger cost rise that's happened for other reasons.

This is an absolutely crucial point, because, in no small part, older people become demonised: 'Well, if we didn't have so many older people, we wouldn't face these costs.' You might expect me to say this as commissioner, but I am never going to support that narrative. Apart from being pernicious and derogatory, it is also untrue. Older people account for half of spending on social care, and that figure has been declining, yet we don't talk about those other groups as being responsible for the cost pressures.

One gentleman said to me, 'The problem is we're public enemy No. 1, aren't we? That's the way it works now. All the challenges we face are because we're a nation of older people.' But it's not true.

Sharing another example—and this is a pernicious narrative that we absolutely have to push back on, because if we don't, we'll never get to where the true costs are lying—a senior person in the NHS said to me, 'The problem is, Sarah,' she said, 'people coming through our door, they're so ill.' I'm not being funny, but you're the NHS; it's what you do. Excuse us for being older, but that's not where the cost base comes from. I'm happy to write you with more detail on that, but it's a really, really important starting point, I think. 

On the point you raised about the changes in the 1980s, I think some of us, certainly, are old enough to remember some of those. They were categorised, to put it in broad terms, as the closure of what were then called geriatric hospitals, which took place all over Wales, but, in fact, that was a shift. In effect, they were giving care, not meeting health needs. That was a shift out of the NHS into, as you say, the social care arena. So, we have to be aware of where the different costs have originated and what we've done. Of course, what it then plugs into is the wider question that this inquiry is certainly looking at of whether health and social care are and should be more integrated anyway, in the first place, so how we rediscover some of that initial vision, if you like. But, I think, if it's—

It's not been mentioned yet, but it's the 'B' word—Brexit. Is that likely to affect the provision of domiciliary and residential services?

I answer this question with some trepidation. At one level, there are others who are better placed to speak about that. There is much that we don't yet know about Brexit, but we do know that we already have shortages of key skills, so, for example, paid carers in the social care sector. I read a figure, and I think it said one in five paid carers are born outside of the United Kingdom. If we see a further downward pressure in the numbers of people, we'll see greater competition across sectors. The reality at the moment is you can get paid more to work in a supermarket than you can get paid to work in some care homes. It's wrong for all sorts of reasons. I think we should be concerned that it is going to have a negative impact. I can't know that because there are too many variables. But I do think that when, at a UK level, Government looks at what key skills we have, if it does not look at social care support as a key skill, it will undermine for generations our ability to provide care and support. It might not be seen as the most highly paid job in the world, but you try telling that to someone who's actually dependent upon them because they're the only person who visits them in their home and keeps them safe. Does that answer your question?

11:20

I think perhaps the most useful thing you've said on the record is that social care and social services are not interchangeable words, but far too many people believe they're interchangeable, and social services covers a whole range of other areas apart from elderly care. That's probably the most useful thing you've said today, and I can only urge you to keep on saying that because the vast majority of people I talk to think the two words are interchangeable, and they're not, as you said earlier.

The question I've got is: do people actually understand the principle of what they pay for and what they don't, and top-up fees, and why they have to pay top-up fees, and the huge effect it has on families, often not very well off themselves, having to find top-up fees for their parents because that's what they have to do? Have you noticed top-up fees have gone from £10 a week to an awful lot more relatively quickly? Do we actually understand why some people can get everything paid because it's called 'health' and other people can't get it paid because it's called 'social care'? Quite often there's not much difference in the problems being shown by them. Sometimes—you may think I'm wrong—it almost seems like an arbitrary decision on whether somebody who is frail, elderly and incapable of a whole range of things is considered to be in health need or in need of social care. What I would argue—I'm not sure I would have much support—is that anybody's who's incapable of looking after themselves must by definition have a health problem.

The short answer to, 'Do people understand the difference between health and social care?' and, to paraphrase, 'How it all works', is, 'No, of course they don't'. It couldn't be more complex at the moment if we tried to make it more complex. Continuing healthcare is a great example. I get why we brought in a continuing healthcare mechanism, but it's tortuously difficult for older people at a time of huge vulnerability to sit in the middle of two systems trying to bolt themselves together. So, I don't think they do, because it is inherently very complex, and it just gets more and more complex as we try—and that's why we can't just pedal harder, push harder. We just bolt bits together.

I think it's also difficult for people to understand because the rules keep changing, but what the state doesn't do is tell people that the rules have changed, like the shift from NHS care to social care. I remember the days of the long-term care of the elderly ward. I wouldn't want to go back. I look back with some horror at what we thought was acceptable. People assumed that it was free and it will continue to be free, but we changed the rules. Look at the WASPI women, for example, who were told at very short notice, 'By the way, you're going to have to work for longer'. It's not the principle of working for longer, it's the short notice, and we're not explaining to people what the new rules are.

One of the reasons I talk in my evidence about thinking we should move towards a hypothecated tax or levy—I'm not totally sure what the difference is if you pay for it—is about transparency and openness and clarity for people. That should be one of the hallmarks of a funding system and that should enable us to simplify a lot of what we do. It's also one of the reasons why I'm not a huge proponent of an overnight move lock, stock and barrel to an integrated health and social care system. I think it's too much to do in one bite. I think it would be really confusing. But I do think we can move incrementally towards that, and I think that's what the parliamentary review was saying as well.

So, the short answer is, 'Yes, I find it confusing and I'm the Older People's Commissioner for Wales.' I have to struggle sometimes to follow it. If you're an older person who's vulnerable, good luck with trying to work your way through it. I see that through my casework and people who come to me, and I'm sure you do through your casework and people who come to you as well.

Final question: I think perhaps we look at and we treat everything in little pockets. I have a serious concern about integrating health and social care. My view is that if we do that what you'll see is the hospital sector seeing another funding source to give to them, like they saw in primary care with the funding source to give to them. Sorry, I'm going to bore people with this who've heard it before, but people live in inadequate housing who aren't fed particularly well, who have difficulty in keeping their housing warm. Is it any surprise that we have problems with their health that ends up with them in social care? Surely we should be doing more about making people have better lives? If that's the case, then the social care needs will reduce and the health needs will reduce.

11:25

You touch on a number of really important issues there, so I'll just recap my views back on them. Health and social care, in and of themselves, are relatively small determinants of people's overall well-being. So, I've always welcomed the strong focus there's been in Wales on integration, and I think it has been strong in Wales, certainly on an operational, governance and more strategic level. But it's not just about health and social care; it's health, social care and housing, and the third sector being an equal partner as well, and recognising our wider community services as a key part of reducing demand on public services and improving better outcomes.  

The reality still is that whenever I walk in this building, everyone assumes I'm here to see the health and social services Minister, and I've spent six years trying to dispel that notion. These other issues—the ones that seem so far off radar—are the opportunities we're missing. These are the big drivers and determinants of costs in no small part in services. So, that's a really important point. 

You touched in what you said on a point about—and this comes up quite a lot—this idea that older people have never had it so good. I saw in the evidence from Gerry Holtham that he talks about social insurance tax, that there's a differentiated payment on the basis of age, which seems to be predicated again on these myths—and they are myths—that older people have never had it so good, and that older people are all just fabulously wealthy. Well, try telling that to the one in six who lives in poverty, because in the UK we have one of the lowest pension rates in the UK [correction: EU], the two thirds who are chronically ill, the half who have a life-limiting disability, those who die every winter basically because they're old and it's cold, the carers on their knees, those who are asked to pay top-up fees for basic care, or whose who receive appallingly bad care and often die as a result of that. So, there is something about recognising where the pressures are and, actually, who is going to be in a position to deal with these. 

So, on the big debates, I can frame it in three ways, really, because it takes us on to the issues about, 'Well, if we haven't got enough money in the system, how do we put more money into the system?' Obviously, there've been something like—I wrote this down—12 White Papers and Green Papers, five independent commissions—Dilnot, which was supposed to go into the social care Act and didn't [correction: Dilnot, which went into the Care Act 2014, but never happened]—and another Green Paper this summer. And that's why my point in there was that I can't be the only one who's slightly sceptical at a UK level about whether we're ever going to get an answer to this question. So, maybe we have to look at it and give credit to the finance Minister for coming up with a proposal. 

But the way I look at it, very briefly, is that there are three ways we can do this. The first is that we just struggle on doing more of what we're doing. I don't think we can deliver our ambition in terms of what I think and across parties we think is right, not just for older people but other groups, by just continuing to struggle on. The issues are too systemic and too big. We can go to wholesale integration of health and social care, and you touched on that, Mike. There are pros and cons from it. The pros are more flexibility and more resilience. The con is that social care remains the junior partner and health continues to suck up resources— 

It's not just health in this; it's secondary care. Secondary care has already sucked the money out of primary care. 

But it's the same principle: you have that partner which is more powerful, and that which isn't. There are huge transactional costs and it's hugely disruptive at a time of huge turbulence already. Or what I think the way forward is, which is an incremental, step-by-step approach. I think this is what the parliamentary review was moving us towards, but, in the short term, you have to put more money into the system. I prefer the model of a hypothecated tax because I think it's open and it's transparent. If you say to the public, 'Give us more money', they're rightly going to say, 'Why? What are you going to do with it and how is it going to benefit me?' And, actually, that's where the debate has to start. The debate has to start with, 'What do you want your futures to be like?' and then we can move on to how we do it. 

So, there are all sorts of different models. They all have pros and cons. Not everybody has to agree with me, but the time has come to have a view in Wales and have the debate. So, I look forward to seeing the paper that the finance Minister has commissioned. I hope it will be a starting point, because, actually, what I don't want is what I get every election, which is a proposal from somebody landing at short notice, 'Do I want to do this or not?' I'd like to see a range of options, including that hypothecated tax, and I think there's strong public support for hypothecated tax for the NHS and social care, and I'd like to see it across generations. I do not want to argue, as the Older People's Commissioner for Wales, against more money going to older people—clearly—it's a core part of my job. But, actually, there are other groups—mental health services, services in relation to drug and alcohol and substance misuse—a whole range of other services that we need to focus on, or all we do is perpetuate a cycle of challenge and difficulty and perceived burden in older age. 

11:30

Can I just ask you, just for clarity, because we do need to wrap things up? When you talk about a hypothecated tax in the context of what you've said in the last five minutes, that suggests to me a UK tax—an income tax, in effect—that's hypothecated for health and social care, although Mike Hedges has made the argument already about how health might capture the most of that. But you've also talked about the social care levy that's been talked about in the Welsh context, and Gerry Holtham's work, which, of course, is looking more like a social insurance scheme, really, where you pay in and that's hypothecated—or ring-fenced would be a better description there, because that's then a fund that's held by Welsh Government but cannot be touched: it's only available for social care. Of course, that's how national insurance started but we never ended up in that place. 

So, can you be clear: which are you advocating? Or perhaps you're advocating both. And there was a suggestion in what you said that the UK Government isn't going to address this, and maybe we should just get on with what we are able to do here in Wales. Is that a fair summary?

The last part, absolutely. How long do we have to wait? At this rate, I'm going to be in my care home and we still won't have made a decision. More than one in three of you will be there with me because one in three of us will end our lives with a form of dementia. So, actually, we've all got a strong vested interest in speeding this debate along, and if they won't, then we need to do it here. And I pay credit to Welsh Government for bringing forward a debate—a difficult debate, but an essential one. 

I guess in terms of the models that we use—well, there are certain criteria about sustainability, about equity, about clarity, about ease of administration, which I use as a kind of a matrix for assessment. But, within that, the three bits I am focused on are: it must be hypothecated—that's the way that we get the public buy-in; when we ask them for more money, whether we call it a levy or a tax, it's still money out of their pockets; it must be protected—30, 40 years ago, we said to the current generation of older people, 'Give us your money and when your time comes, we'll be there', but we spent it on something else; and it must be long term as well—the next 30, 40, 50, 60 years. 

For me, a hypothecated tax is cleaner and easier. Now, I'm not an expert on Welsh Government competencies and powers. Maybe it is within their power, maybe it's not. On many levels, I like the approach of a social insurance scheme because it's hypothecated, protected longer term. The bit I have an issue with, very briefly, on Gerry Holtham's evidence—and I know it's just evidence to the committee so the finance Minister might come up with something completely different. I think I have issues there about equality. I think women will be disadvantaged by that. I think there are issues for those on low pay within that unless the state pays for them. And I have a real issue with the differentiation over age, because whatever we do we have to be able to sell to the public. It is, in a sense, not a decision of Government. It has to be endorsed by the public. And I don't know how this narrative goes. So, we say under that proposal to older people, 'Thanks for everything you've paid in, and it's been extensive. We told you that when your time came, it would be free. Sorry, it's not. You've got to pay in more. And despite using less than half of the total resources on social care, you're going to have to pay more on top of what you've already paid.' For the life of me, I cannot see where the political sell is in that. And that's not a party political issue, it's just I cannot see at what stage I would vote for that, unless—and this is an important point, and Gerry Holtham doesn't touch on it—you link it to the issue of capital.

Unless you link it to the issue of capital. 

And then it starts to become a much more incentivised scheme. And, actually, whatever model we move towards needs to incentivise prudent practice, healthy lifestyles and proper choices made by individuals. So, it's complex. There are many different models, but hypothecated, protected, and longer term, understood by, and acceptable to, the public. 

We will be taking direct evidence from Gerry Holtham when his further report has been—

A really interesting piece of work, and really good to see somebody come up with something tangible. 

Can I just say in response to that that any recent graduate who has had a student loan will already tell you about an 8 per cent tax they're paying on everything they earn over £25,000, which makes it likely for most of them to never have it fully repaid? So, I think the principle of asking for additional money if you package it correctly may well not be that difficult, and I'd much prefer the student loan to disappear and people to be asked to pay an extra 4 or 5 per cent into the fund, which will help them when they're older, rather than this pretend system of student loans.

11:35

One of the challenges is how we address the issue of equity and equity across generations as well. There is a hugely divisive narrative abroad that often pits generations against each other. I will never endorse that. I will never support that. Our greatest strength is our intergenerational solidarity. We need to find a way forward, but we need to find a way forward that's predicated on the facts rather than myth, and that's why I started off with the point that older people account for less than half of the costs in these services. So, it just begs the question—and I say to people across the political spectrum, 'Be prepared for the question'—'Since we account for half of it and we paid in all of our lives, why are we being the ones asked to pay more?'

That's a good point at which to conclude the evidence session, I think. So, diolch yn fawr iawn i chi.

Diolch yn fawr.

Thank you very much.

We will also share a transcript, so that if there are any misquotations or whatever, then you can correct those. But you've also kindly offered to send us further information on some of the points that you've raised. Thank you. Diolch yn fawr iawn.

5. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o weddill y cyfarfod a'r cyfarfod ar 25 Ebrill 2018
5. Motion under Standing Order 17.42 to resolve to exclude the public from the remainder of the meeting and the meeting on 25 April 2018

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod a'r cyfarfod ar 25 Ebrill yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting and the meeting on 25 April in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

A ydy'r pwyllgor yn hapus i fynd i sesiwn breifat nawr o dan Rheol Sefydlog 17.42? Rydych chi'n hapus. Diolch.

Is the committee now content to go into private session under Standing Order 17.42? You are happy. Thank you.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 11:36.

Motion agreed.

The public part of the meeting ended at 11:36.

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