National Assembly for Wales

Good morning. Bore da. Thank you. My engagement with older people, as you know, has always sat at the heart of my work. In fact, on day one, I began my engagement roadshow with older people, and with hindsight, it's one of the smartest and best things I could've done. I was very clear that I wanted to stay rooted in what mattered to them. So, I used that engagement to do two things: first was to establish my priorities as commissioner—as you know, I published those, and those are what I've been working through, and to, every year—but also, to make sure that I could stay close to what mattered to older people. I've always said, one should aim high but keep your feet rooted on the ground.

So, over the last six years, we've travelled, I think, 100,000 miles, we've met 28,000 older people, we've met with a thousand groups, and we talk about life—the issues that matter to them. So, they're fairly open conversations, discussions. I have to say that the people talk to me about a huge breadth of issues; issues such as treatment in care, in hospitals, in residential care settings. And I would say that some of those concerns have grown in terms of what people speak to me about, but in no small part that's also because I talk about those publicly as well. It's been very clear when I do talk about issues, particularly through the media, that drives more traffic towards me, both through engagement and through my casework as well. Financial issues, things like an incorrect charge in the fees, non granting of financial entitlements, issues to do with paying for care, issues to do with discharge, adaptations, housing issues, evictions, waiting times, domestic abuse, and so the list goes on.

It's very hard for me to ascertain whether there's been a significant shift through just that engagement and my casework in terms of what people share with me because these are very personal individualised issues. As I said, very often, what I talk about will drive people towards me, but there are, I think, some common themes that underpin everything that I see. So, I think the best way I can answer your question is to share those common themes with you, and there's one underpinning observation that I have in relation to that.

So, these are the things that come up both through my engagement roadshow, my casework and my engagement with an extensive range of intermediaries, particularly the third sector. So, the things that I would say—and I talk about these in my published casebook, because, as you know, periodically I publish a casebook with some examples of people's challenges. The first thing is that policies and procedures can be complex, challenging, not clear or transparent. Now, very often we will support people to go through the complaints process. That's the right starting point, but it can be for many almost impossible to navigate their way through, as one gentleman said, 'It felt like I had a blindfold on going through a maze.' Inflexible processes, a lack of integrated working—they create barriers to securing the outcomes that people want, the resolution that they need.

This has been so stark: issues that can, and should be, resolved quickly seem to go on for an unacceptably long period of time—they just go on and on and on. A lot of what I deal with—it shouldn't take me, as a commissioner, to break that log jam, but it does. Communication is often ineffective and consultation feels meaningless. People don't feel they're equal partners. Public bodies and decision makers often don't understand the impact of the decisions that they make on individuals. The issues that matter to older people are too easily marginalised. Now, I talk about the little things that make life big, but sometimes it's the big things that make life big. For example, a couple have been married 50 years, both need support from a care home and are put in different care homes—completely, completely unacceptable. There's little understanding of the Human Rights Act 1998—there's huge support for the human rights Act, despite the duties it places on public bodies—and often there are misunderstandings as to what constitutes criminal abuse or neglect. So, those, if you like, are the big themes that run through all of the issues that people raise with me. 

But underpinning all of that, I think, is something quite stark and it's about the significant power in balance. So, when people find themselves in challenging circumstances and they're not able to secure the support that they need, they find themselves in the position of being a vulnerable individual versus the power and the might of the state. And it's very, very difficult sometimes for them to challenge that power and that might, and the sense, very often, that the state, embodied through public services, thinks that it is right. Now, there is some really important learning in that for us in terms of how we take forward things like co-production and things like prudent healthcare in Wales, because we talk through those concepts about wanting to share power with people. If you really want to share power with people, we have to address some of these fundamental issues, and it's one of the reasons I talk so much about independent advocacy.

I've spoken many times—and I'm publishing an advocacy report later this week—about giving people the power they need, not just to speak up, but to be listened to and for what they say to be acted upon. So, there is this fundamental imbalance between the might of the state and the power of the individual. Certainly, through my casework, that's what I do: I address and redress that power imbalance, because for the first time, often in a very long time, older people will find somebody who has some power that they can bring alongside them to challenge the decision making.

So, the issues are as broad as the day is long. It's very hard for me to extrapolate from my work whether some issues have grown bigger or some issues have gotten smaller. I would say some things are getting better across Wales, some things are getting worse. But these are the root causes, I think, of a lot of what people share with me, and are certainly a lot of what people come to me with in terms of asking for help. 

And we'll probably investigate some of those individual aspects now. Okay, thank you. Diolch. 

Diolch, Cadeirydd. Good morning, Sarah. 

Morning. 

Nice to see you again. Your latest report, 'Rethinking Respite for People Affected by Dementia', was published in April this year. And I'd like to ask you: could you tell the committee about the information required to publish this report—how you collated it and so on? 

Well, just to to back slightly to put into context how the report came about— because, as you know, one of the challenges for me is what I focus on, and for the reason we just spoke about there are so many issues—last year, I published a report 'Dementia: more than just memory loss', looking into the experiences of people living with dementia, as you know. The commission is for all older people but particularly for those who are most vulnerable and most voiceless. One of the issues that they raised with me—so, these are people living with dementia and their carers—was the issue of respite. And they felt so strongly that we weren't getting it right that I promised I would do a further piece of work, and that's the work that I published recently.

Again, the approach I took, in a sense, was fairly simple, I asked people—I asked carers, but also, importantly, I asked people living with dementia as well, because I wanted to focus on the relationship between them. I asked a wide range of other organisations, intermediaries, sister organisations who work in this field, but also we looked very carefully at the academic research that there was as well. And what we did was we pulled all that together, but, as you might expect, I gave pole position to carers and people living with dementia, and you will see that their voices again are littered through the report.

What the report found—well, the clue in a sense is in the title—was that we need to fundamentally rethink respite: that too often it is seen as a break from 'the burden' of caring. Too often it's seen as something that we use when people are in crisis and too often it's difficult for people to access. But we need to see it more as a therapeutic intervention. We need to see it as a way that keeps families together. We need to see it as a way to help people retain the skills they have and regain new skills, because people living with dementia can retain and develop the skills far more than they're supported to, at the moment. We need to see it as a way to support carers, develop the skills that they need, to build their own and their family resilience for the challenges that they will face. We need to focus as much on the needs of people living with dementia as we do with the carer as well. And we need to build respite in a much more flexible way into a pathway. 

And the way I think about it is—just to give you a slight different example—is in relation to hydration. So, we know that if you become dehydrated, clinically it can be really dangerous for you and very difficult, if you are already someone frail, to get you back on your feet. So, the advice, of course, is drink water on a regular basis. Well, it's the same with respite: too many people have to wait until they get to that critical stage, whereas we should be looking at innovative, community, local flexible approaches to keep people sustained and resilient and keep families together. One of the most stark findings for me was the extent to which people living with dementia and their carers are pushed into default roles. One lady spoke very eloquently—a lady called Pat—and she said, 'I am my husband's carer, but above all, I want to stay his wife, and I want support that enables me to stay his wife whilst I care for him.'

So, there are many examples of good practice, and we bring in some international good practice and UK ones and some Welsh ones as well, but they're too few and far between, and we have to fundamentally rethink this. Why should we rethink it? Well, too many of our carers are on their knees, they're absolutely struggling day in, day out, at huge cost to themselves, but also at a cost to people living with dementia and also a cost to the state as well. I gave evidence recently to the Finance Committee and I spoke about where I would be investing. I'd absolutely be investing in these kinds of services, because we are spending a lot of money to deliver poor outcomes at the moment. We could spend less to deliver better outcomes if we listened to what people tell us. 

Thank you for that comprehensive answer. It is good to see that the information that you put into your report was compiled by an all-round approach and the real-life experiences of people. So, it's not surprising, the hands-on approach that you use, Sarah, knowing you, as I do. So, thank you. 

Your legacy report outlines a number of reviews and reports that you have worked on in relation to driving up the quality of health and social care. So, what has been the outcome of these reviews and reports and are there any outstanding issues that you can tell us about, please? 

You're absolutely right: driving up the quality of and access to health and social care was one of my key five priorities. I say it was my key priority, but it was an older people's priority, and that's how it became mine. So, a number of my pieces of work have focused on those, and there have been many, but perhaps if I focus on my care home report and my GP report, and then if there are others that people want to ask me about, I'd be very happy to—. 

So, in terms of my care home report, it's probably the piece of work that I'm best known for. It certainly has been the biggest and the longest running piece of work that I've had. I don't think, when I began it, that I could actually imagine how big a piece of work it was going to become, but it is a huge issue. As you know, when I published my initial care home report I called for fundamental change: fundamental change in how we perceive care homes and the people who live in them; the standards we set and how we monitor them; and the range of support provided, and, just as importantly, how we provide that support. And I've always said it's not just what we do, it's how we do what we do—that value-based approach. But, fundamentally, I was calling for change in the duty of care that we owe. When I published the report, there were requirements for action from a wide range of public bodies, and I spent a long time tracking that change, having made it very clear that I would come back and look at progress. So, I published my follow-up report, and in that I gave credit, because I tried to be measured to many of the changes that were taking place, and there has been much progress driven by that report and also the work of many others, since it was published. We’ve got new legislation, we've got new guidance and training requirements, and we've got new value-based—and these are really important—and rights-based inspection frameworks and a wide range of local initiatives, and I was delighted to see so many providers responding so strongly to my call for us to do better. But, as I said, I was concerned, and I spoke about this in my follow-up review, that there were a number of areas where I did not get a sense check that progress was good enough, so I decided to look more formally at those.

So, I picked 15 areas to focus on and they range from things such as antipsychotics—and I was so grateful for your support and your inquiry as well; I've been trying so hard to give this issue the profile that it deserved for a long time—continence and falls, those everyday issues that are happening now, up to much more strategic issues such as workforce planning. And I was right to focus on those 15 areas because, again, not taking away from the good practice that there is, progress, by and large, was too weak across many public bodies in those areas. What was stark was how difficult people found it to evidence to me the outcomes and the impact of what they were doing. They were very good at telling me about process, strategies, policies and plans, and whilst those are important, I was very clear that that was not what I was interested in. I wanted to know that people weren't falling, I wanted to know that their continence was being properly managed, I wanted to know that we did have enough staff with the right skills, and if we didn't that we had a good plan in relation to that.

So, I was very clear and I spoke publicly, and I was delighted that we were able to launch that from a care home in Merthyr. It gave a voice to a group that often have none. I wrote out to all of those bodies with very, very detailed analysis. I said to them, 'I want you to take to you corporate boards and I want you to feed back to me after that.' Those responses are now starting to come in and I'm starting to look at those again, and I will write back to them, just to wrap up on that. What I have said to people is, 'Look, it is for you now to deliver and drive this change. However, do not think that I or my office will take our eyes off this issue.' So, I am sure there will be a further stage of scrutiny. And, of course, as that scrutiny goes on, it gets more targeted—more ‘bighty’. The first time, you advise people; the second time, you caution them; the third time, you call them out publicly.

Indeed, and we've met many times in Merthyr, haven't we? 

Yes, we have.

The tea dance—do you remember the tea dance?

I do.

Anyway, it was just on that point about the care homes, and that some have responded well and some are making really good progress, and some you're having a bit more of a problem with and you're waiting for that to come back. I understand all of that, but what is it that you could point to, do you think, that has been the main barrier to progress in some of these fundamental areas? Is it a question of leadership, is it a question of staffing, money, training, regulation, politics—what do you think has stopped some of these organisations moving forward at the pace that you'd like to see?

That's kind of a root-cause analysis question, isn't it?

Yes, how long have we got? [Laughter.]

I can give you a fairly short answer. I think there's a longer answer, which is very complex, and there's a wide range of issues all crystallising together, which makes the challenge difficult. However, having said that, it was clear, through my initial work and my follow-up work, that some people were able to get it right within the current system and within their current resource envelopes as well. So, my challenge is quite simple: if some can get it right, actually, why can't everybody get it right?

So, having said that, I think there are some root-cause issues, and I spoke about this recently with the Finance Committee. One is to do with market fragility, and that was one of the big issues that I raised in the care home review: market fragility, market stability and the approaches that we take to commissioning, and particularly the importance of developing long-term sustainable commissioning, which enables us to build quality into the heart of that process and enables providers to invest. Many providers are small organisations and they need the stability that comes from that.

We have some good practice in Wales, but in one part of Wales, we have, what was described by a daughter as the 'eBaying' of her grandmother—reverse tendering, three lowest quotes—that is not a way to build a sustainable sector. That's why I focus so strongly on the importance of a national plan to address market stability and our provider base. I have concerns—and I hope they’re not founded—that we're not going to get that as strong as we need it to be. You might decide as a committee that that's something that you want to stay focused on.

The second issue we have, or the second underpinning issue, is one of workforce. I've spoken in very strong terms about how, I think, ineffective our workforce planning has been. Why do I say that? Well, we don't have enough specialist nurses that we need. We've got huge issues across health and social care in terms of career pathways progression for people. This is a position, in a sense, that we knew would come, but that we didn't plan effectively for. So, that, I think, is the second issue.

The third one—and people will have different views on this—is that it's not all about money, and I was very clear on that, and some are getting it right, but there does come a fundamental point when you get what you pay for. I hold the view—people don't have to agree with this view—that we need to put more money into the social care sector. There is clearly a debate about how we do that. I have views on that. There are different methods, but the one thing I am very clear about, though, is that however we do it it must be hypothecated, it must be protected and it must be clearly aligned to outcomes and longer-term planning as well. It must be seen as an investment tool.

So, I think there are a range of local issues. You're absolutely right: leadership, culture, a focus particularly on understanding outcomes and impacts. But I think there are some big, systemic drivers as well. I understand that those are difficult and those are complex, but I still come back to this point: that it's still not as hard as it is living in a care home that is not as good as it should be.

Diolch. I wanted to ask you about another report—your safeguarding in hospital in Wales report. I know that you asked the Government to respond to your recommendations in that report. Could you tell us whether they have and what are the key points that you want the Government to act on?

I'll just say that I'm conscious that I didn't talk about the GP report. If people want to come back and ask me about the other ones, please do. 

There are plenty of other questions to come.

I'm sure there will be. Six years is a long time, isn't it? 

Yes, thank you—safeguarding and hospitals. So, I undertook a piece of work looking at this. Now, I just want to be very clear in terms of what I was looking at, because safeguarding in hospitals is a very, very broad topic. So, it was really a specific analysis of section 7 and section 10 of the Social Services and Well-being (Wales) Act 2014, which focuses on those safeguarding duties and places those upon hospitals. And so, those were important duties within the Act. I welcomed them, but what I wanted to know is: to what extent is that starting to roll out in practice? It was really a review of policy and practice at this still fairly early stage.

So, I focused on things such as the changes made by health boards to the composition and organisation of their safeguarding teams—it sounds very technical, but it's actually fairly important; changes to safeguarding policies and procedures—how were they changing how they acted on a practical basis; the training that staff have; the extent to which there was more ownership of safeguarding, more identification of safeguarding issues; the arrangements they had for learning from individual cases and practice, and so on. So, it was a very targeted review, linked back to the duties in the Act, or, as I call it, the promises made within the Act.

I have to say that all of the health boards, as well as the Velindre trust, participated, because it wasn't a statutory review. It was optional to some degree, but they genuinely participated openly and positively to the review, and they were able to identify a broad range of initiatives that they were taking. There was some very good work within that, but there were significant issues that I thought were weakening their approach, or which were undermining their ability to deliver. I talk about those in detail with the report and I've shared those with chairs, chief executives, the chair of the national safeguarding board and, as you say, the Cabinet Secretary.

Some of the issues where I was concerned were: there were issues in relation to the adoption of training of staff. Just to say a certain number of staff are trained does not equate to having the skills and knowledge that you need to effectively safeguard. There were issues in terms of joint working and also issues in the capture and use of data. Now, it's not all about numbers, and you know I've said that many times, but sometimes numbers do matter, as long as you focus on the right things. But I guess my overall observation and my concern was that health boards are still waiting for an updated version of the safeguarding guidance—the guidance that will follow, if you like, and sit behind those duties in the Act. It is two years on since the Act was implemented—I think they were due to come in this April. In the absence of those, what I saw very clearly was health boards trying to operate within the current guidance or develop their own guidance, but that's not what we need—what we need, urgently, is that clarification, so—

The guidelines were due to come in—

As I understand it, they were due to come in in April 2018. So, I've written to the Cabinet Secretary. I've just had a response and I'm still analysing that response. I'm going to be writing back to him, and at that stage, I'm very happy to share the report—well, the report's on my website—but I'm happy to share his response to me and my further response to him.

So, are there some unanswered questions that you've put in?

I am sure that I will be seeking clarification on a number of issues in relation to the letter from the Cabinet Secretary, particularly—. My questions are always simple questions: 'When is the guidance going to come out?'

But you haven't had an answer to that.

No, not yet. But, as I said, I've just had the response; I'm still analysing it. I don't like to give off-the-cuff answers. I'll be very happy, in the next week or two, to share all of that with you.

Because, obviously, April, we've only just passed—

Exactly.

So it's not as if six months have passed.

Yes, but what is really clear is that health boards need that guidance issued. It's good that the new duty came in. I've seen a lot of real leadership effort and focus amongst them, but the guidance will answer the question around how do we do it and what does 'good' look like. So, we need that guidance. But, as I said, I'm very happy to share all of that with you. There's a lot that i'm trying to wrap up. I should say that I'd also hoped that the new commissioner would be in a position to start so that I could discuss that with them as well to give them continuity, as I hand over, but as I understand it, there will be a bit of a time lag in relation to that, so now I'll pull it all together—

So, there won't be an overlap, will there?

As I understand it, no. But if you want to ask me later about what I'm doing to ensure continuity, I'm very happy to answer that question.

We may well come to that. Julie.

Right. I was going to go on to ask about the impact that the declaration on the rights of older people has had in Wales. One of the things I wanted to raise—. I've had a couple of events, actually—some of them you may have been to, or someone from your office—in Whitchurch about working with older people. Out of one of them came the issue that older people wanted the opportunity to enjoy themselves and to have a good time and to have exercise. Rubicon Dance started a class and that's still running, and I saw them in a show fairly recently. I just wondered—obviously, what we've talked a lot about is safeguarding and some of the things to do with older people that we see as problems, whereas I wondered whether you could say something about the opportunities that older people need to fulfil themselves and whether, in your time as commissioner, you've been able to identify any of those and take them forward. I'm putting that loosely under the declaration of rights for older people. 

I well remember the event with Rubicon—

You were there, I think, weren't you? 

I was indeed. Perhaps if I could frame that in the context of 'Prosperity for All', which of course is the Welsh Government's guiding approach in terms of how it's going to take forward its work. I broadly welcome 'Prosperity for All', particularly the move away from the silo-based approach and a stronger focus on outcomes, and, in no small part, the outcomes are actually very relevant to older people, and I was grateful to Welsh Government for involving me in an early stage of that. What I have said to Welsh Government is that 'Prosperity for All' needs to reflect, in its breadth, the issues that matter to older people, because—and I've worked hard to challenge this notion—there still is too much of a notion that it's all about health and social care when it comes to older people, but it's not. We've made, I think, some progress in pushing it outside of the health and social care portfolios over the last six years.

So, if you think about opportunities for learning and employment, for example, and not just learning for employment, but life skills and learning new skills as you grow older. Four or five years ago, or when I began, people just used to ask me why I was talking about these issues. I worked very closely with other committees, had an inquiry into that issue. I worked very closely with people like Julie James, and as a result of that, we got the age bar lifted on apprenticeships, we had the 'no best before date' campaign with employers across wales—a small beginning, but actually a positive beginning in recognising that older people want to stay in the workforce, that our economy needs older people to stay in the workforce and, more than that, people need support to develop new skills for life as well. But I think it is still one of the big challenges for Government in terms of how we make sure that older people sit full square and equally in these non-health and social care portfolios, because you are absolutely right; it is so much more than just being safe. It is about still being an active participant and contributor in life.

As one gentleman said to me, 'I’ve retired from work, not life'. So, I think there is still a long way to go, but for me, 'Prosperity for All' is now what I'm looking at in terms of making sure that these issues are picked up. I've had some very detailed conversations with Government about what sorts of issues I want to see picked up across those portfolios, and also my expectation that there is an updating to the strategy for older people, and that is one of the key things it must do. It must reflect the breadth of that. But also, it must build in this model about support to older people, enabling them to do things for themselves, and staying as active contributors to society. I’ve spoken many times: older people are worth £1 billion. Well, that was six years ago. I suspect, if we looked now, that figure would be significantly more, contributing in so many ways. One of the things, actually, I'm proudest of over the last six years is having challenged this narrative that age is all about frailty and decline, and it's what we need to do for our older people who are just such a burden. It's so wrong. It's ageist, discriminatory—wrong in every way. They're a huge asset who have a right—and this goes back to your point about rights—to be active participants in their local communities and in our wider civic society.

And you have called, haven’t you, for legislation—for the Welsh Government to introduce legislation to promote the rights of older people.

I have. So, in terms of 'Prosperity for All', there are three things I want to see focused on: yes, health and social care, but outside of that portfolio. I want to see an approach that is really an asset-based approach, continuing to challenge the ageism that is endemic through society, and rights as well. I called, just before the last election, I think, for stronger rights for older people, a piece of legislation, a bill of rights. I've been discussing that with the Welsh Government since. I was hopeful that we would be able to bring forward legislation. The Welsh Government’s view is that, for a range of reasons, not least of all because of the impact of Brexit, in terms of legislative timetables, and also the need to review where rights more generally sit post Brexit, legislation is not going to be possible in this term of office. I’m pleased that they haven’t ruled it out totally, but I have discussed with them a range of things that I think they can do in the interim that will start to further make real, in a practical way, rights for older people.

So, I'll just share some examples with you in terms of things like the declaration of rights. I’ve seen that used in local hospitals, I’ve seen that used in care homes, I've met with a health board that has a whole charter built around that, and much else besides, but I think there’s more the Welsh Government can do. If it can't bring forward legislation until the next Parliament, then I would hope it would be able to do so on a cross-party basis of support. There are things that I think they can do, and I would hope—I should put this quite carefully—that the Welsh Government will be in a position to make an announcement before I finish about some of the practical things it could do to really push forward rights for older people. You are either for rights for older people or you are against. If you are for them, tell people what you can do in the short term that is practical and will make a difference.

I think it’s a blow that Brexit is holding us back on that as well. Thank you very much.

Thank you, Chair. You were involved in the scrutiny process of some ground-breaking legislation, like the health and social care Act and the future generations Act. Do you think these Acts are achieving their intended aims, or the promises made, as you've said, for older people? And what changes do you think have been brought about since these Acts have been enacted?

Goodness, that’s a huge question. It’s probably almost an evidence session in its own right, so I’ll try and be fairly focused. I think there are three pieces of legislation to pick up on. So, you've got the social services and well-being Act, you've got the regulation and inspection of social care Act, and they're, really, sister—I think, at one stage, they were going to be one piece of legislation, weren't they, until they were split. And then you’ve got the well-being of future generations Act. So, to take the social services Act and RISCA—well, a huge ambition. I welcomed it, I gave evidence in the last Parliament to the Health and Social Care Committee, and we were hugely aligned in what we were looking for. Again, I was really grateful for your support in relation to that. We were pushing hard for similar things.

There's much that I've welcomed. And these are really important structural things, and one shouldn't take away from the importance of them: things like workforce regulations, registration, removal from registers—registration not until, I think, 2020 and 2022, but we all pushed hard for that and it was, I recall, a hard push at the time and required some persuading—overarching duties within the Act, particularly in relation to advocacy, rights to assessment, strengthened safeguarding, population assessment, and particularly the national outcomes framework, which I still talk about more than anything else, because, in a sense, the job will be done when people answer 'yes' to the questions in there. It's one of the few really personalised outcome performance metrics we have. But I do have concerns around that. We cannot simply say, 'Well, we passed legislation so it's going to be fine.' We've placed a range of duties on a range of bodies at a time when they're facing huge financial constraint and other challenges.

So, maybe if I just share four areas with you, these are the ones that, if I was to continue as commissioner, I would be keeping a very close eye on. Independent advocacy: I publish my advocacy report on Friday; it is very clear from that that the intent of the legislation is not hitting the ground, that too many vulnerable people are being excluded from that. I won't say too much now, but, if you want to ask me more about that, I'm very happy to. 

Issues in relation to eligibility: I've been very taken with evidence from Age Alliance Wales in relation to this. If you ever have the opportunity to take evidence from them, I would. They've been tracking the Act. They have real concerns that people are being pushed out of the state sector onto them and that the levels of acuity and need that people have are too high. So, what the state basically says behind the Act, when you cut away from it all, is the state should only do what the state should do—the kind of more high-end, complex stuff. That's fine. What they will tell you is that high-end complex stuff is being pushed out to them and, even worse, they're not resourced to be able to deal with that. So, I have real concerns about that.

I have real concerns in relation to carers and their assessment. Again, I'm very taken with the work that Carers Wales have done in terms of 'track the Act'. So, if you think about it, in Wales, there are 370,000 carers. A third are older people; 24,000 are over the age of 75. So, there is a huge pool of need, and what the Act says is, 'Well, if you are a carer, you have a right to an assessment and, more than that, you have a right to support as well.' So, I don't have a problem with the intent, but then you look at the numbers. This was my point earlier: sometimes, numbers are quite telling; you have to be careful how you interpret them, but—. If you look at the numbers, I think for last year—and these are Welsh Government's own figures—6,200 carers had an assessment; of those, 1,200 [correction: 1,800] went on to get an offer of support. Now, notwithstanding the fact that you need to be careful how you interpret figures, that seems to me to be very, very low and begs the question as to whether carers are getting the assessments that they need.

And then the fourth area I would focus on, well, it links back to my work about the safeguarding duties placed upon health boards and the extent to which those are being delivered and worked through. So, I'm feeding into the evaluation scoping that's going on by Welsh Government. In terms of the change that it's making, do I see things that are changing already across Wales? Yes, I do see things that are changing, but I also see challenges that are huge upon public bodies. So, it is still a work in progress, but my message has always been clear, and it doesn't take away from the intent, the ambition, of the strategy: a work in progress is not the same as getting the job done. The job is done when those national outcomes framework outcomes—'I belong', 'I am happy', 'I am safe'—are made real for everyone.

Then, just very briefly, moving on to the Regulation and Inspection of Social Care (Wales) Act 2016, that sister legislation, well, again, a lot that we all welcomed and that we all—. And, again, it was a hard push. We pushed for things like fit-and-proper-person tests—that was a huge issue for me, based on my casework—increased accountability for responsible individuals, you know, at the top of the organisation, clear duties, robust procedures, offences linked to the role, and quality reports that they have to provide; the issues I spoke about in relation to workforce training and registration, but also the section 27 regulations that we have coming in, which mandate new standards, service provider annual returns, more openness and transparency—and I pushed hard for that: how do you know as an individual whether the care home you're going to is good care home; it's a decision you often have to make at short notice, and, once you're there, it's jolly hard to move, if not nigh on impossible—new approaches to monitoring, and much else besides.

But, in a sense, the critique is exactly the same as with the social services and well-being Act. Do I have areas of concern? Yes, I do: the national plan that we spoke about earlier. That national plan is so crucial to addressing some of the big issues—issues in relation to integrated approach to the regulation and inspection of healthcare within nursing homes.

The previous committee in the last Parliament—. We pushed so hard on this and it has still not been addressed. We were told it would be addressed in what was going to be the NHS equality Bill. It has still not been addressed and this was one of the big issues I raised in my follow-up review. Now, I know Healthcare Inspectorate Wales and Care Inspectorate Wales have done pilot work in north Wales, and that's been a good piece of pilot work, but that looked at something else—that looked at access to primary care. And that was an issue I raised and I wanted it looked at. That is not the same as having a systemic integrated approach to answer the question, 'How good is the quality of nursing care?' In the absence of that, we have health boards doing a lot of local work, but that is not the same as a properly embedded approach across Wales. And then again, those big issues around things like longer term planning, as well. So, the same critique, really: ambition, yes, intent, yes—the test is always the extent to which it crystallises out on the ground, how quickly that happens, and, in the absence of that, where does risk sit.

Very quickly on the Well-being of Future Generations (Wales) Act 2015, I was a very strong proponent and advocate of the Act from very early on, and I know it had somewhat of a turbulent passage, early on, as it developed, but I'll explain why I was. The first of my published priorities—what older people told me they wanted me to focus on—was embedding the well-being of older people in the heart of public service. What they were saying was, 'We've lost the plot—strategies, policies, plans, assessments galore. They're important, but it's about the quality of our lives'—the things you spoke about, Julie; you know, the extent to which we have lives that feel, in the broad scheme of things, good lives. And, of course, what that Act did was put well-being at the heart of public service. So, I strongly supported that.

I've worked closely with Welsh Government in developing the national indicators. They're not perfect, but they're a good start. I'd expect to see them, over time—. But I've also started my own piece of work looking at the granularity behind that, because there's a danger that we look at headline figures that say—I'll just make one up, now—that 85 per cent of people are satisfied with A, B and C, but what I really want to know is: what about the other 15 per cent? Why are they not satisfied? Are there certain characteristics—are they all older people, are they people from black and minority ethnic backgrounds, for example? Are there certain characteristics that mean that, actually, our equality agenda is not being addressed properly as we take forward these issues?

I strongly welcomed the focus on public services boards. They answered this big critique. Older people have a very accurate critique of public services, one of which is: why don't people talk to each other? Welcoming all of that, as I did, my biggest concern, in a sense, was that older people would be left behind and I wrote to the Minister at the time and said, 'Look, well-being of future generations—can I just point out that there are almost a million of us who might not be considered the future generation? We're the current generation; we need not to be excluded or left behind'. So, I met with every single public services board and we had really good conversations about how not to exclude and leave older people behind. I then issued them with formal guidance, using my powers in terms of the issues that I wanted them to focus on. I provided them with feedback on their needs assessments and we're currently in the process of reviewing the well-being plans that they will publish.

What I want is quite simple. I want visibility for older people, I want understanding of the issues that matter to them and, more than that, I understand that we need to fundamentally change the way we think—and this has been the big message, I think, from the future generations commissioner—but I want to see tangible change. The number of people who fall needs to reduce as a result of the work of those PSBs, the number of people who are victims of domestic abuse needs to go down as a result of the work of those PSBs, and so the list goes on. So, so much of it is still work in progress, or, as I like to call it, promises made to those who have a right for those promises to be kept. And, certainly, if I was going to continue as commissioner, I would probably be strengthening my scrutiny to see that those promises were kept.

But also I would say—. And it's right and proper that you ask me about these issues, but, in a sense, the only person who can really answer that is Welsh Government, because these were their promises—they made them. They—between you, I, the next commissioner and others—need to be held to account and evidence the impact. Is that—? I'm sorry, there was so much there.

I really appreciate that. I understand that it's such a big area to cover, but you did so very well there. Can you tell us a bit more about the Ageing Well in Wales programme and its achievements? And what do you think is needed to continue the work that's already begun?

Thank you.

Ageing Well in Wales has grown in a way, I think, that I could never have imagined when we launched it four years ago. But it's important that I just say a little bit about what it is and what it's not. It was deliberately set up as a movement. It's a broad church. There's no organisation too big or too small that can't be part of it. It deliberately built in a place for individuals and community organisations to be part of it. There's no joining fee, there's no exam. All people have to do is make a commitment to do something around one of the five key priority areas.

So, it was designed to energise action. It doesn't take away from the legislation or the strategies, but why wait? We have so much good practice. We might not have much money, but we've got fantastic people in Wales. I wanted to energise that. I wanted to legitimise it and validate it. I was very taken early on, when I was thinking about how we put it together—I was contacted by a group from a small village outside Brecon, and they said, 'We'd like to be a dementia-supportive community, village. May we?' I thought how interesting it was they were asking permission. I said, 'Well, of course you can. What support would you need to do that?' So, it's really been to put some energy and some drive around the stuff we can get on and do, and bring more people in while we wait for these big strategic changes. We now have 70 strategic national partners, every local authority, we've got 1,600 network members, and—what's the phrase—it just keeps growing like Topsy, and that's wonderful.

There are so many examples of fantastic things that are happening. I'll just share some with you. At Government level—. Because it works really at three levels: at national level, at intermediate level—so, health boards and local authorities—and then right down in the grass roots, where we live our lives. At Government level—well, I spoke earlier about the work on apprenticeships. That was one of the five priorities, opportunities for learning and employment, and the no best-before date. But loneliness and isolation was one of the five priorities as well, and between us I think we've worked really effectively. But Ageing Well in Wales has been a way to bring partners' voices together, to push that up the political agenda. Ageing Well in Wales has been a way to coalesce and bring together and give profile to those voices, and, with my support and your support, actually, we've backed them up to do that.

At a local authority level, every single local authority has an Ageing Well in Wales plan, and do you know what? That pre-dated the focus on well-being that we now see in the Act. We've got work going on across health boards—so, we've got, for example, the Ffrind i Mi work. Fantastic work. It's not their core business to do that, but it was a fantastic response to the challenge in Ageing Well, which was: do something because you can, because you're in public service and you have a leadership role. In Llanelli, I visited their dementia-supportive market. Fantastic work going on. Brilliant intergenerational work in Powys that I visited between schools and care homes, focused around dementia. In Anglesey, some brilliant intergenerational work. We've got age-friendly culture networks across Wales. We've got a range of leaflets—they're what I like to call the top tips on growing older, the things it's quite useful to know before you get there. They fly off the shelves. They developed on what people ask us for. Forty-five thousand publications have gone out across Wales, and I'm really proud of the work that we've done. The five areas that we have in there have a status that they didn't have before, but, more than that, we've energised a whole range of work going on. We've also, at the same time, managed to get recognition in Europe as being one of the exemplar countries, and Ageing Well in Wales has been what we've used to coalesce that position.

I just want to—. So, I'm really proud of that. My role was to bring people together, was to energise, was to give permission, was to give support, and I'm proud of that. I'm proud of what our partners have done across Wales, because so many people responded to the challenge. I'll just share with you—. I should say that there is—. I could talk about this forever, but one of the things I'm going to do next week—as you know, next week I formally publish my legacy report—is I'm publishing a stock-take, if you like, a progress report for the Ageing Well in Wales programme. Because there's so much I want to share with people. So, that gives so many examples of practical examples of things that are going on across Wales, but one of the quotes that we put in—. We asked people to tell us what they thought. It's always dangerous to ask older people what they think, I can tell you, because they're not shy. If they like what they see they will tell you, and, if they don't like what they see, believe me, they will tell you that as well. But one of the things that the chair of the National Pensioners Convention said was, 'Ageing Well in Wales has made a huge difference to the older people's agenda in Wales. It has helped to raise awareness of key issues. At all times it has involved older people as equal partners, and given us an opportunity to voice our concerns, our priorities and, really importantly, our solutions.' And then perhaps my favourite line of all: 'Ageing Well in Wales is about action', because that is what it was always intended to be about. 

So, to come on to the final part of your question, what's needed to continue and take it forward? Well, I think the commissioner's office—and this is partly, I guess, what my office was created for—has a unique role. There are not many people, I guess, who could have drawn everybody together and said, 'Do you know what? Here's the challenge for us all'. So, I would hope that the next commissioner will continue to see Ageing Well in Wales as a key part of their work, because it's not a statutory duty; it's something we chose to do. The commissioner's office puts the bulk of the investment in terms of co-ordinating it into the programme. 

I guess, in terms of taking it forward, what do I want to see? Well, still to continue to invest in that front line. Many of us around this table have been on visits; we've seen them together. I want to see a strong focus and commitment from local authorities to continue to build on their Ageing Well in Wales plans, particularly to make the Dublin declaration that they all signed up to a reality, and that's about age-friendly, age-supportive communities. And I want to see—this is important, because the programme doesn't stand alone; it links into established priorities—a lot of the issues supported by 'Prosperity for All' across Government. Government values, and I know they value the Ageing Well in Wales programme because they stand up and they talk about the Ageing Well in Wales programme a lot, and I'm very happy they're a partner to that. But I guess my next challenge to all partners is, 'See what we've done in just a few years. Actually, we could do even more.'  

I think they have been, Chair. From what I hear from what you're saying, there are huge amounts of frustration that more hasn't happened more quickly, but a huge amount of pride in what has been achieved. I'm thinking, around 'Ageing Well in Wales' that you were just talking about, would you say that that was one of the key areas that older people and older people's groups have said to you has been a major success? You've talked about the engagement with older people throughout your report. Have they noticed a change? Have they fed that back to you that they think that they have seen a change in your time, do you think? You can blow your own trumpet—that's okay.

Is this the moment? Thank you. [Laughter.] It's a difficult question. I'd probably want to give it more thought, but, since I don't have time, I'm not sure if you asked older people the question, 'Have you seen significant change over the last six years?', they could talk about that in the abstract. All they could do is talk about their own experiences. As I said, I know from talking to older people that some things are getting better, some things are getting worse out there for a wide range of reasons. And the things that are getting better, they're in no small part down to great support and services provided by great people across our public services, our third sector and many other sectors as well. 

Do I think there has been significant change and that a high element of that has been positive? Yes, I do, and we've spoken about many of those areas. Do I still think there is a huge amount more to do? Yes, I do think that as well. One of the things I do think we would benefit from having in Wales, and I've spoken to Welsh Government about this, is a longitudinal study, because I think that would give us the ability to answer that question over time of how things are specifically improving for older people as a group, because we're not a homogeneous group. We are, I think, one of the only parts of the UK that doesn't have that longitudinal study. That, I think, would give us the baseline and the benchmark that we need. We do have the well-being indicators and those are useful, but the granularity isn't sufficient behind those. 

So, I don't feel I'm in a position to answer on behalf of all older people, but what I would say, and I talk about this in my legacy report, is that I have concerns around the equality agenda. As we get better for some people at what we do, it's important that we get better for all people. And there are certain groups I have met who have been the most marginalised. I'll talk about people living with dementia a lot, I'll talk about carers a lot. To give you some other examples, people from the LGBT community, for example—older women from black and minority ethnic groups. They have been as disenfranchised as any groups that I have met, and we really need to bring the equality agenda to the heart of the improvements, because it has to get better for everybody. 

So, I think there are a number of things we can do. I think there's benefit in a longitudinal study that sits alongside those well-being indicators that specifically focuses on older people but needs to have some granularity. And I think we need to bring into the debate about what is improving the question of, 'But who is it improving for?' so that everybody moves forward together.

You said this is the moment to blow my own trumpet, if I might. And, actually, I don't want to blow my own trumpet, but I do just want to say a bit about the things that I'm proud of. I don't want to blow my own trumpet, because it was never about me. I'm a public servant; I told you that on day one—paid out of public money. My job was to deliver change for people. So, obviously, in writing the report, and thinking back, you do reflect on things. So, I was thinking about what I am proudest of. Well, I'm proudest of the change that we have delivered here, and sometimes it's been a hard push and we've worked together on those issues. And it's not perfect yet, but there are people who have better experiences in care homes because of what we did. There are people who have got better access to GPs because of what we did. There are people who don't fall down the stairs anymore because of the work I did earlier on in the disabled facilities grants. One local authority put a £1 million of capital into it. That made a real tangible difference to people. There are people who are not the victims of domestic abuse because they're now coming forward because of the work that we did. There are people who are still in employment because of what we did. And so the list goes on. And I talk about those, and I'm proud that, through my office, and with the partners that we worked with, we were able to make a difference. 

I'm also proud of the difference we made to individuals through the casework—people who found themselves in the most horrific and awful of circumstances, and I share some of the quotes from them. Some of the quotes stay with you: 'I haven't seen my dad smile in months, but he smiles again now.' The amount of work that goes into that, but that's the uber outcome for it. So, I'm proud of that. Would I liked to have been able to do more? Yes, I would. I have squeezed every penny as hard as I could squeeze it. People ask me do I have enough resources? Well, I never moan about having enough resources. If I had twice as much resources, I could do twice as much more, we could deliver twice as much change. So, I'm proud of that. 

The second thing I'm proud of is that I've given a voice to older people. I promised on day one to be their voice, and, in a sense, all I've done is that I've just asked them and I've lifted their voices up—

Would you say that the single biggest achievement of the commissioner is giving a voice to older people?

In a sense, it's such an unfair question to narrow it down to one issue. I've got three. One is delivering real change, and the second is giving a voice to older people, because it is all about them—their rights. You know we use this phrase 'older people' as a group apart; they're not. They are the people that built this country, they're the backbone of this country. Our debt of gratitude to them is enormous. It is about their right to have a voice. I'm immensely proud of having done that. And the third thing I'm proud of is, having challenged the notion—and I spoke about this earlier—that older people, 'Well, we have nothing left to contribute because we're at the end of our life. We still have so much to give, we are such a huge asset.' So much of my work has been challenging ageism and the pernicious assumptions that we make about older people in oh so many ways, and we have to all keep challenging those. We have to be proud to be a nation of older people. We have to recognise how much we owe to our older generations and how much they still have to contribute. 

And I would just finally say that I'm often challenged back by public bodies, and that's fine. I challenge them; I expect them to challenge me back. And they say, 'But, do you know what? We live in hard times. They're difficult issues.' Let's not patronise older people; they know what hard times look like and they know what difficult issues are. The harder the times, the more complex the issues, the more important it is we listen to them, we give their voices pole position, and, more than that—I go back to the point I made at the beginning—we cede to them real power. It is all about them. My work has all been about them. It's been at the heart of everything that I've done. It has been such—it has been a challenging job in many ways and I knew it always would be, but it has been such a privileged job. I have learnt so much and they've made me the kind of commissioner that I am, because I was lucky enough to be able to spend time with them, to listen to them and to lift their voices up.

We've rattled through a couple of points. If we can be self-indulgent, can we have your thoughts on what we've been doing as a committee during your time? We have looked at a number of issues particularly relevant to older people. I'm thinking of work on dementia, on antipsychotic medication in care homes, and so on. Any thoughts or advice for us?

Well, as you know, I say it as I find it—or apparently I say it as I find it; it's what I'm known for. I have hugely valued the relationship between myself, my office, and yourself as a committee. We have, in so many instances, been hugely aligned on what we're looking for, and our ability, I think, to dovetail our voices has been really powerful in pushing the change that we wanted. As I said earlier, sometimes it's been a hard push—both of us have had to be really tenacious and clear in what we were looking for. So, I've valued that, and I'm grateful to you for that support, because that support has in no small part led to some of the changes and improvements for older people, across Wales.

I think the reports that you produce are excellent reports—I really do. They get to the heart of the issue. And I've been particularly impressed with the way that you've grown in your confidence in bringing older people themselves in to give evidence to you. I think the work you do is crucial both in terms of raising issues and holding those who need to be held to account to account. And I wouldn't say that if I didn't think that was genuinely the case. I guess I would say my challenge probably for committee moving forward is the same challenge that I have, which is what to focus on, because there are so many issues now, so many promises being made.

The way I've always tried to approach it is, well, to focus on two areas. One—and we spoke about this—is holding to account. The promises that have been made—have they been kept? Where is not just the assurance, but the evidence of impact, and that's where people's voices become so powerful, because, ultimately, that's where it sits. But, also, I think you have such an important role in raising the profile of marginalised groups and giving them a voice as well.

I guess if I was, again, continuing in my role, there are maybe four or five areas that I would probably be coming to you, talking about, saying, 'These might be good areas to explore.' I'm very happy to share those. I'm not saying this is everything you might focus on, but, you know, the agenda is so broad. There are a couple of what I would call systemic, underpinning issues, and a couple of specific issues. Longer term planning I spoke about. Many of the issues that we face now are not because we're a nation of older people—absolutely not. That is just wrong. They are because we failed to plan properly, and we failed to get our longer term planning right in oh so many ways. There is a lot of change going on now. We have more needs assessments now than you can almost count—we've gone from none to many. We've just had the population needs assessment published—the first time we've had an assessment of what the needs of older people were. There's a question about how robust that is. If I was here, I'd certainly be asking how robust that was, and a range of other longer term planning, particularly the ongoing work in terms of workforce planning. So, that would be my first systemic issue.

The second systemic issue would be our investment in the third sector. I've spoken many times about how they are part of—I've spoken about it at the Finance Committee; they are the uber front line—the prevention against frailty and decline, which need not be inevitable, or can be deferred. Many of them go from hand to mouth—they are struggling. Many of them, in no small part, have become substitutes for what the state were five years ago, as the state retrenches back to that more high-end role. So, there's a huge question: much as we talk all the time about valuing the role of the third sector, what does that look like in practice? And I think they would have much to say. But not just the third sector; it's the extent to which we're supporting volunteering as well. Because what I think you've seen is a skill-mix shift all the way up. So, I think that's a really, really important area, and I've been very taken with the strength of the evidence from the third sector.

Then there are a couple of particular issues. This issue about integrated regulation and inspection: the one thing I've learned as commissioner is tenacity; you just need to keep going back on these topics and pushing people for answers on them. I still remain concerned that we do not have a way forward for an integrated approach. Issues in relation to the quality of commissioning, and this particularly goes back to care homes specifically: there is some great commissioning work, and I'm pleased that CIW are going to be focusing on commissioning, but we do not have a template for good commissioning. I want to see a more prescriptive approach in relation to that. Issues in relation to carer support: I spoke about those numbers—again, be careful with numbers, but I think they warrant further investigation. Our carers are the backbone—the backbone—on which our public services are built. They are worth £8 billion, and they are struggling. This year, demographically, the number of carers that we needed—unpaid carers—was less than the number of people who need care. We have expended that resource now; we are not doing enough. If our carers fall, our public services fall. It is a really simple equation.

And then the final issue, well, again, I touched on this earlier: you'll see that so much of my work is interrelated and is about eligibility for support—this big issue that's being raised in terms of whether people can actually get through into the new system or whether the eligibility bar is being set so high—so, a range of systemic issues and some particular issues. I think what I've always valued is our ability to have those conversations, and between us, we have doubled the capacity and doubled the effort, and I think, also, the sharing of our findings with each other, because, in no small part, my care home review, yes, was founded on the concerns that older people were raising with me, but it was something that the committee had picked up as well—just one of the recommendations on it, but actually our work chimed well. So, I'm grateful for your support. I think, when we work together, we're very strong and I think, between us, we have—to go back to your question, Dawn—pushed real change.

There are people who have better lives now because of what we do, but the job is done, not when some have better lives—and I talk about this at the end of my impact report—but when people are safe in their own homes, they're safe in hospitals and they're safe in care homes. The job is done when people don't die in the winter because they're old, they're cold and they're poor. The job is done when people stay in the workforce, and so I can go on. That's when we get to celebrate success. Everything else is process. Everything else is just what you do in public service. I'm very clear how we define success at a macro level, but when you strip all of that back and go back to the national outcomes framework, the job is done, by public services, by Government—national and local—and others, when people answer 'yes' to those simple questions: they're safe, they're happy, they think they belong, and—to finally come back to the point that you made, Julie—they have quality of life that they think is worth waking up to in the morning, and they feel valued and they are respected and esteemed members of our society.

Diolch yn fawr. Thank you.