National Assembly for Wales

Welcome, everyone, to this meeting of the Local Government and Housing Committee. The first item on our agenda today is introductions, apologies, substitutions and declarations of interest. We've received one apology from committee member Lesley Griffiths. The meeting is being held in hybrid format. Public items of this meeting are being broadcast live on Senedd.tv and a Record of Proceedings will be published as usual. The meeting is bilingual and simultaneous translation is available. Are there any declarations of interest from committee members? There are not.

We will move on to item 2, which is our fourth evidence session on the committee's work on the role of local authorities in supporting hospital discharges. I'm very pleased to welcome here, joining us in person this morning, Faye Patton, policy and project manager for Care & Repair Cymru, Alicja Zalesinska, chief executive of Tai Pawb, and, joining us virtually, Johanna Davies, head of health and social care for the Wales Council for Voluntary Action. 

Thank you all very much for joining us today. Perhaps I might begin with one or two general questions, before we turn to other committee members. Firstly, on partnership working and housing priority, are housing issues and the suitability of a person's home environment currently given enough consideration and priority as part of the discharge process? What is the current situation as compared to what should happen, and how can this affect discharge delays? Who would like to offer an initial view?

In terms of the current situation, in theory, patients are put onto a pathway through discharge to recover and assess. In a Care & Repair context, we would get involve in pathway 1, which is supported home first, but increasingly also pathway 3, which is for more complex cases. So, we might get a referral for someone who is on end-of-life care, and it's about making the home suitable if that person's chosen to die at home, for example. 

Whether housing issues and the suitability of a person's home environment are given enough consideration, I think, can be a mixed picture. I think more than the suitability of the home in the round, there's often an emphasis on the kinds of referrals we get, which is about that person's mobility at home—so, the person, but not thinking about perhaps the home environment as a whole. I can imagine that that can be quite hard for someone in a hospital environment—a clinician—to start thinking about a person's home, when actually they just want that person to leave hospital.

There is that omission in the Welsh Government hospital discharge guidance, where it does mention housing adaptations, it mentions homelessness, but it doesn't mention housing condition. There is increasingly a policy emphasis on care closer to home. If that's the direction of travel, then we do really need to also be thinking about the home that that care is going to take place in. I think that that is something that we definitely see. Also, not just thinking about the home from the perspective of hospital discharge but also as a preventative tool as well, so stopping someone going into hospital in the first place when it is because of accessibility issues or housing condition-related issues.

I just have one more point, if that's okay, around current pressures on disabled facilities grants as well. In some cases, local authorities are getting waiting lists three to six months into the financial year, and to me that shows that local authorities are perhaps not allocating sufficient capital funds to be able to cope with demand of DFGs, even though obviously they're mandatory. So for me that would say that there is a bit of a lack of strategic thinking between health and, in this context, housing in local authorities when it comes to hospital discharge, because we will get a lot of referrals that are for almost interim measures, so small adaptations, when actually that person needs a DFG, but they know that there's a really long waiting time for that. So that would be my second point on that, if that's okay.

Siân.

Your very first words were, 'In theory, these are the pathways'. 

In having a pathway, putting someone on one, there is an emphasis on perhaps moving people through those pathways, and then it becomes a case of, maybe, whose responsibility that is. So we will get referrals that are perhaps inappropriate for us because someone maybe wants to move that patient down a pathway. I think sometimes the patient, who should be at the heart of that decision, can be forgotten because there's an emphasis on moving a problem, basically. So in theory, yes, I think it's a really good idea. I think sometimes the implementation forgets the person at the centre of that. 

So it's not that they're not put on a pathway. You're not saying that, in theory, everybody should be on the pathway. Are there examples where that stage, even, doesn't happen, there isn't a pathway immediately available?

I think it's hard for us to know. Because we're third sector, we're not always privy to those conversations. In some examples, we sit in discharge planning meetings where we know that someone is on a pathway, but often we can just get a call to the office and we don't know for sure what pathway that person is on.

Peter. 

I recognise your concerns about DFGs. There's never enough capital going into them, they're never allocated enough. In your experience, is there a lack of access, or is the fact that they've perhaps allocated most of their DFGs a fundamental factor in slowing up discharges of care? And in your opinion, then, would it be better if there were at least a ring-fenced pot of DFG capital, so that it can be allocated to accelerate discharges of care?

Yes, that is something that we have advocated for in the past, because obviously, DFGs are mandatory. So someone who has been deemed as needing one, essential for independent living, should be able to get that and they shouldn't be waiting years for that. We are seeing works that are taking 1,000 days plus to do. People are waiting such a long time for something that a health professional has deemed absolutely necessary for them to live independently.

Would it stop certain people who would be ready to leave hospital, though? Does it often chuck another week in or something like that, because you're having to fight for the DFG?

The process takes longer than that. So, what would happen is that interim measures would be put in place, we would be referred to, and we would put in handrails or grab rails, lower-level adaptations as an interim measure.

I think homelessness is important to consider, especially that we're awaiting new legislation. Cymorth Cymru's 'Health Matters' report found that 65 per cent of the homeless patients that they engaged with were not asked about suitable housing on discharge, and 11 per cent were discharged onto the street. We all know that discharge into homelessness increases readmission risk and highlights the need for longer strategic planning around health and housing, and joint work there as well.

And it's a missed opportunity as well sometimes to prevent homelessness. We absolutely support the ending homelessness White Paper, which proposes a new duty on public services, including health and social care, around identifying and referring those at risk to local authorities early, trying to sustain housing and co-operating. However, obviously, that needs to be resourced, so I think there's a big risk there that it could drive further delays if it's not appropriately resourced, if we don't sort out other parts of the system, like DFGs, other adapatations, supply of housing, accessible housing as well. 

There has been a focus on trying to find out as much as possible around good joint working practices between homelessness and housing, and health and social care. There's a task and finish group that has been established under the ending homelessness board. So, I think whatever good practice they're looking at, it's worth highlighting and replicating with that legislation. 

And then the other matter that we looked quite closely at, and have looked at over the years, is accessible housing allocation as well, and that looked at together with adaptations. What we found in extensive research that we did in Gwent, engaging with over 200 people—disabled people, health, housing, social care professionals—was that early referrals are much needed, better and clearer pathways and who's in charge of those pathways and where the person's voice sits within that.

As you would probably expect, housing professionals often stress the need for heightened awareness amongst health staff of assessments as early as possible, on admission preferably, of home environments and housing needs and clearer pathways. Health professionals often stress to us that there's a need for more responsive housing services, housing options perhaps being at capacity. We're dealing with a housing crisis and a homelessness crisis as well. 

So, it's complicated. We also hear that housing systems are complicated, adapations systems are complicated and difficult to navigate as well, and there are certainly ways in which it can be improved. We saw some good joint working practices like Care & Repair's Hospital to a Healthier Home lighthouse project, which operated in Gwent some time ago; I'm not sure if it's still there. But just the fact, I think, that both sides here identifying pressures means that we need more capacity to help the situation. I think both sides there recognised that.   

I agree with my colleagues' comments this morning, but wanted to add that investing in prevention and community-based approaches will lead to better hospital discharge outcomes for people ultimately. We need to push prevention further upstream to support people with suitable housing options, as Alicja mentioned, promoting health literacy and providing support to live well, such as care and repair services. Helping people to live well in their homes will actually mean fewer people reaching crisis point and needing emergency support, and then we can focus on planned support and waiting lists, and supporting people out of hospital in a more planned and strategic way. Diolch.   

Thank you, Johanna. Obviously there are difficulties with getting partnership working between health, social care, housing and the third sector in the position we'd like it to be. In addition to what you said already, is there anything in particular you'd like to highlight to the committee in terms of what should happen to achieve better integration, better partnership working? Are there any specific developments? Johanna.

I think, from the WCVA's perspective, the legislation, guidance and infrastructure already exists to deliver integrated care to communities. But I think that integration agenda largely sits with our regional partnership boards, and each RPB has implemented their ways of working and their own versions of integration across Wales. Now, that's really positive, to be able to respond to local demands, but it does mean somewhat of a postcode lottery in terms of progress and integration, and, consequently, how the public sector then works with the voluntary sector on that integration space.

So, the voluntary sector has been delivering commissioned hospital discharge support for over 20 years, yet this expert knowledge and experience is not fully utilised by local authorities and health boards in the planning and partnership space. So, there are some excellent models. I'm sure many of you committee members will know the Pembrokeshire Intermediate Voluntary Organisations Team, PIVOT, model, in Pembrokeshire. It's a good example of co-ordinated voluntary sector support and partnership with the public sector. We'd like to see more strategic working in that way. So, we want early and continuous dialogue with voluntary sector partners, in all areas of the health and social care planning space, not just around hospital to home, but hospital to home would be a good place to start, I think. Thank you. Diolch.

Johanna, have you got any views as to how that might be achieved, that more structural, more consistent approach? Is it a matter of Welsh Government guidance, or—?

As I mentioned, the guidance exists in terms of partnership working. I think it's about implementation. In our consultation response, we suggested utilising the funding code of practice for the third sector, and also utilising early and continuous dialogue around that planning—so, allocating resource together in partnership, identifying the need, discussing it, what services are needed to meet those needs and achieve good outcomes, and then finding out who should deliver that then, and allocating the resource accordingly. But, all too often, it's decided by local authorities and health boards, and, then, whatever's left then goes to the sector. It's not quite the integrated, strategic approach that we would like to see to achieve the outcomes for people.

Is there anything about the regional partnership boards then, Johanna? Because, as you say, they're perhaps responding to their own local circumstances, but, if some are not properly involved in the third sector, then is that something Welsh Government might address?

I think that some more support, maybe, around the section 16 forums. Some of them are working really well in terms of engaging with the sector, but then that's not the same across all of Wales. There is varying practice. We want to know more about that in WCVA. So, we're doing a piece of work to try and bring the third sector representatives who are on those RPBs together, so we can start to understand what support they need to be able to engage appropriately in those spaces, and make a useful and representative contribution in that RPB space for integration.

Okay, Johanna. Thanks very much. Any of our other witnesses want to add anything on that?

Shall I—? I think I'd agree with Johanna that an integrated approach to discharge needs to be preceded, really, accompanied, by an integrated approach to prevention. That's a key way, really, to address the late discharge of care. In our engagement with disabled and older people with accessible housing needs and health needs, we heard time and time again, and hear time and time again, about the impact of inaccessible homes on their mental and physical health. I think we quite often focus on the physical health, but—. I just wanted to read one excerpt from our research, where we interviewed an occupational therapist and a disabled applicant. The OT told us, 'One woman moved, after waiting for 18 months, to an accessible adapted home. She had access to a toilet, living room. The youngest child had stopped being suicidal, another stopped self-harming. She said that moving had a massive impact on all the family.' And then there's the disabled applicant for housing: 'I'm left feeling afraid and down. I'm housebound, and I can't get in or out of my house. I sleep in a chair downstairs. I can't use the stairs.' I think we can only imagine the impact and the effect that these sorts of situations have on people. And it's not all about discharge; it is about going, like Johanna said, upstream, really. The housing role in there, I think we need to get better at assessing housing needs of disabled and older people into the future, both in terms of development and supply—homes ready to be adapted, homes that are already adapted and accessible—how allocation and the knowledge that we have about current housing stock, or don't have, often interplays with spend on adaptations, because they're very much connected, and how all of that is considered strategically alongside health and social care needs by fora like RPBs. The whole system kind of works together.

We do have the homelessness legislation coming in. We don't know what the duties will look like. Obviously, we've seen the White Paper, which is proposing no discharge into homelessness. All of this, I think, needs to be considered in the round, and planned for appropriately, to prevent admissions in the first place as well.

Okay. Thanks very much. Did you have anything to add, Faye?

Yes. I think, back to the original question, an integrated approach absolutely is needed, and, sometimes, housing in that is forgotten. So, for example, we hear a lot about package of care delays. Sometimes that can also be because of a housing issue. So, we get calls at, like, 3.00 p.m. wanting same-day discharge, because the package of care is in place, it's ready to go ahead, and then someone realises, 'Oh, actually, the carer isn't going to be able to access the property', because there's literally no key safe for them to do so. The same with moving furniture downstairs, if someone is going to have domiciliary care downstairs in their property, but also housing issues where it might be health and safety issues, where it's unsafe for the package of care to go ahead from the care worker's point of view—so, if there are hoarding or clutter issues; we have people discharged where perhaps there's no water in the property, things like that, where we kind of have to scoop in last minute and problem solve this plethora of issues, whereas if we thought about this a little bit earlier on in the process it wouldn't be this last-minute scramble, basically, to pick up all of these issues.

Does that lead to delays then, Faye?

I think Care & Repair are very good at problem solving quickly, and that's essentially what the Hospital to a Healthier Home service is. So, we have the capital of the rapid response adaptation programme, for example; Hospital to a Healthier Home provides the revenue to be able to do that problem solving, through our casework. Because we have that revenue, we can strategically triage our resources to be able to make sure that we can do things very quickly, so that discharges aren't delayed. It would be a lot easier for us if we got those referrals several days before, when it's clear that that person's going to go home soon, so that it isn't such a last-minute scramble.

But I do think there are some really good examples of partnership working as well, and I mean partnership in the very literal sense of Care & Repair, third sector, sat in the same room as discharge co-ordinators, as occupational therapists and so forth, where you can just turn around and ask a question. I think that's a model that, perhaps, was more prevalent, or used to be more prevalent, but we still do have some really good pockets of good practice of that. And we get a lot of calls that aren't necessarily referrals; it's just an OT phoning up and saying, 'Can I pick your brains about something?' So, that kind of mutual exchange of expertise that we have is a really good example of partnership working. So, it is there. I think, perhaps, it's just not always consistent where you are.

Okay, Faye. Laura. Laura Anne Jones.

Diolch, Chair. Thank you. When I was out with Care & Repair recently on my patch, being introduced earlier, when a patient is being admitted, was something that came across quite strongly, because that would solve a plethora of issues, really, to have that time to prepare. As you said, also they're very good at reacting, and I witnessed that as well.

When focusing specifically on the roles and responsibilities of local authorities in hospital discharge, you've already mentioned a lot of things like the lack of strategic thinking, lack of funding, short-term funding, no integrated strategic approach, and all those things that you've already mentioned. Is there anything else that, in your view, are key issues that need to be addressed to improve the process and reduce those delays, being more proactive than reactive? Cheers. Thank you.

If I can add, perhaps, a risk that, again, is there, and I think is going to get bigger if we don't address it, around homelessness legislation—. We absolutely support the White Paper on homelessness. One key risk that we identified, and we see and hear about, really, is that a lot of housing, quite rightly, is being allocated to homeless people. There's absolutely a need for it. However, I think, in some areas, that has an impact on those that might be at very high housing need, priority need; some people might be delayed discharge of care. So, I think that needs to be looked at.

In most local authorities, I'd say that, if there is an accessible home or adapted home, the priority is given to a disabled person, but, because of the dire situation that we're in with temporary housing, with homelessness, I think that if we don't develop enough accessible homes and we don't sort out the adaptation systems, there is a risk that those waiting lists and the waiting times as well—including delayed discharge of care, but also thinking about prevention of admission for disabled people—are going to get longer. That is obviously not to say that we shouldn't introduce the legislation, but we need to build and improve the adaptation systems as soon as possible, really—which is easily said, I know.

Thank you. Yes, on adaptations, actually, if I may, Chair, just quickly—? One thing I noticed and became very aware of when I was out with Care & Repair, again, was the adaptations, and one of the major problems was that—I don't know if you think this adds to the problem of delays of discharge—you talked about DFGs needing to be done, but, in the meantime, as a short-term fix, those lower-level adaptations that needed to be made, finding the contractors to do that is a problem that I was made aware of, specifically quality ones that were tested and able to go into these homes. Was that something that you—? Because of the complex process around getting involved putting off contractors, was that a problem that you would recognise is adding to this delay problem?

So, Care & Repair employ handypeople to be able to fit the small adaptations. So, from that point of view, we can do that quite quickly. But you're talking, obviously, about DFGs and larger contractors. That is an issue, I would say, across Wales, that kind of takes you into, maybe, discussions about an ageing workforce, discussions about skills gaps. But also, because sometimes those contracts can be quite small, and we have seen, perhaps, over COVID, where, you know, works weren't going on in people's homes, it meant that, after that, contractors could pick more lucrative private works as opposed to DFG works, and I think that is still something that we are seeing. So, yes, there is a lack of contractors and it is impacting. Not just hospital discharge, but the DFG process, I would say, across Wales, is impacted, and that's where you're seeing those really big waits and delays, in addition to lack of resource.

Yes. And in terms of prevention as well—

Yes. Absolutely.

—if those adaptations aren't being made. My final question on this bit is that—. You said there are examples—one of you said that there are examples—of best practice and pockets of best practice. How do we get better at sharing that and what are the differences between the local authorities? Are there massive gaps in how they approach this and get involved, or is it pretty similar across the board across Wales? Thanks.

Do you want to—?

Okay. Yes. I mean, I'm always going to sit here and say that Hospital to a Healthier Home is an example of good practice, because I think that it is. I think that it's a service that's been developed over time that is based on trust and is based on relationships, and I think that's where good practice comes in, where we've been able to show that an OT or hospital staff in a busy environment can refer to us, and the work gets done and, in effect, we're able to solve a problem for them that would otherwise delay the discharge process.

In terms of what happens in each local authority, I couldn't tell you, by times 22, what happens specifically in each area, but Hospital to a Healthier Home is a service that is across five local health boards, so we do have that partnership working. But there are only 17 caseworkers, so your volume and your scale—we're talking about, maybe, one caseworker for a health board, compared to however many hospital staff teams, et cetera, that are referring into it. So, I think that you could scale a model that is working well to ensure that you do have, across Wales, good examples of good partnership, because, capacity-wise, it can get a little bit tricky for Hospital to a Healthier Home.

I think, from a practical perspective, sometimes legislation can be a driver of more focus on good practice, and a driver for trying to replicate what others are doing. I did mention the housing and health task-and-finish group, which is a group under the ending homelessness board, which is actively looking at good practice in homelessness and health, working together. I have no doubt that these examples that are being collated and looked at as part of that, and the innovation, are going to be shared, and there's going to be more interest in it if we introduce the legislation. There's a lot of good stuff out there, isn't there? 'How do we share it?', I think, is a good question.

Just to widen that out to the voluntary sector as a whole, the voluntary sector often provides a safety net in those transitions into and out of hospital care, and, actually, is a vital support in terms of providing information, advice, the practical support that we've heard about, and also about advocating for people's rights, in terms of the decisions that are made at that point of discharge as well. There are often some tensions between health boards and local authorities around how to manage that capacity and demand, because everybody's under so much pressure. But I think the issue for me is not about the role, specifically, of the local authorities, the health board or the voluntary sector individually—it's actually about what do people need, leaving hospital, to help them live well at home. If we start with that question, then the support services and who should deliver them will also be decided as part of that service design. So, I think, from our perspective, and the voluntary sector's perspective, I think the way to improve hospital discharge is through partnership working and to utilise the co-productive methods that are developing across Wales. I think it's to lean into those tools. Diolch.

Thanks, Johanna. Thanks, Laura. Lee, did—

I've just got the one question about volunteers. You've answered it already, pretty much, on the volunteers side of things, but you've mentioned PIVOT and the safety net and the positive impact that volunteers can have. How can we better integrate those into hospital discharge pathways? Thank you, Chair.

First I want to highlight that, before embarking on involving volunteers, public sector bodies really should ensure that they adhere to our charter for volunteering and workplace relationships that we've developed the TUC. That's to make sure that volunteers are properly integrated, and their involvement is not inappropriate and as a replacement for staff, essentially. In Wales, volunteers are providing lots of support to people coming home from hospital, settling back in, helping people get home safely, community transport examples, errands, companionship. The list goes on, really. Those are being led and co-ordinated by organisations like the British Red Cross, Age Cymru, and the Royal Voluntary Service. And those volunteers also act independently in emergency responses. They might go for a check-in, and then realise they haven't got enough food in the cupboard. So, they might go and do a quick shop. So, the outcome potentials are huge, really, for utilising volunteers.

There was a Helpforce England report that we cited in our consultation response that basically emphasises a lot of the asks that we have made as WCVA, which is about supporting the development of the voluntary and community sector infrastructure, so that it can enhance its capacity, and to engage with the NHS around volunteering activities in the community. It’s about sharing best practice—we’ve heard a lot about that already—and fostering meaningful partnerships in the integrated spaces, and involving the voluntary sector in the design and delivery, with support for people before and after their hospital stays. So, it’s pushing that prevention further upstream again, in preparing for admission to hospital as well, and what we might come on to in the next couple of questions is to provide consistent and long-term funding.

There is a loyal and committed volunteer force in health and care, but, actually, we’ve seen a real decline in numbers volunteering. So, 56 per cent of organisations we surveyed last November said that they don’t have enough volunteers to support their activities. That's why we need to work with Third Sector Support Wales, and Helpforce Cymru, who are the experts in volunteering practice in Wales, to ensure that public bodies adopt a strategic approach to creating volunteering opportunities that don’t impact on an already pressurised volunteering sector.

Diolch, Johanna. Lee, did you want to come in? 

Yes, thank you. I wanted to follow up on a comment the chief executive of Tai Pawb made. She said that the sharing of good practice was often a stimulus for a change in practice, and I just want to question the extent to which that is true. It should be true, I'd like it to be true, I’m not sure what the evidence of it actually being true is, though. Good practice simply existing does not seem to be enough to encourage others to change their practice. So, I wonder if she and the other panellists have any thoughts on what more we could do to hardwire good practice once it appears, to spread and scale it.

Perhaps I wasn’t clear enough. I think legislation can be a good driver, or plans to legislate can be a good driver of good practice. The new homelessness duties, like I mentioned, I think we all know that they will need resourcing. Not discharging into homelessness will need the system to work together. It needs resource, but it requires better joint working as well. So, if legislation like that is introduced, I have no doubt that people—. People are already—. Just the fact that there’s a task and finish group established on health and homelessness, working together, I think, for me, is evidence that there’s interest in replicating good practice and innovation, to help deliver on that legislation, and to help meet people’s housing rights. I think that’s all I meant. I don’t think the existence of good practice is evidence in itself. I hope that helps. 

Okay, well that’s a different point, then, isn’t it? Do you have any thoughts on what more we might do to make sure good practice is taken up by others?

We talked about the third sector. I think there’s a key role for the third sector there to promote the good practice that they see. We’ve got umbrella bodies, we’ve got Community Housing Cymru, we’ve got the Chartered Institute of Housing, we’ve got ourselves—we promote good practice around equality. So, that needs resourcing. And I think that, maybe, there is a role as well there for regional partnership boards. I don’t know to what extent good practice around housing, and the role of housing and adaptations, in improving health is currently part of that role, but I think there’s a role there as well.

Can I just press you on that? Because all you’ve really said is, ‘Give us more money’. How do we hardwire it to the current working practices—the good practice that has been shown to be effective?

More money is always welcome. I do think that legislation is—

There is no more money. The question is how do we spend the money we've got better.

I suppose it’s how you spend your time, and to what extent resources are spent on promoting good practice. Workforce and volunteering was mentioned at one point. We’re in the middle of the TAI conference, hosted by CIH. I heard yesterday from them that perhaps there are conversations about establishing a development academy to aid the supply of housing. I think that shows a key role of the third sector. This is not only promoting good practice, but driving good practice around development. I think that is a great idea, and perhaps something that could be looked at in the adaptations space, or anything to do with housing.

Are there any current communities of practice to share things that work?

I can take that. In terms of home first communities of practice, relating to the six goals for urgent and emergency care, there is the home first community of practice, which has been quite helpful. I've presented about Hospital to a Healthier Home there. There's no revenue funding for Hospital to a Healthier Home in Powys, for example. Having that community of practice has meant that we've been able to have some—. They haven't gone anywhere, in fairness, but we have had conversations and pick-up, so that there's more awareness of that service, which gives you a bit of an in. So, there are communities of practice, and I think there's a lot of work going into those to try and share good practice across Wales.

But you just said it's not going anywhere.

Well, we haven't had revenue funding for Hospital to a Healthier Home in Powys, but it's opened a conversation starting. It's long term. It's very difficult to get funding for revenue from the RPB or from the health boards, but a lot of the time it involves finding the right person in that space to be able to take that conversation forward. So, having a community of practice where you do have those individuals can be quite helpful to help start that process.

But with respect, you've both given me examples of things where you think if we had more money we could do more things. My question is this: with the money we have, how can we spend it better by rolling out things that have proven to be more effective in some part of Wales? I haven't really heard an answer to that.

I would say that adhering to the code of practice for funding the third sector would be a good place to start. That's soon to be refreshed or is being refreshed. I mentioned earlier that the route to better integration and better outcomes for people is through partnership working, and I think the longer term contracts would provide stability for the voluntary sector and would present some cost savings for the public sector in terms of the administrating of those contracts and things. So, I think it's about utilising where we can make savings and how we then reinvest those into spaces that need that uplift in funding.

But with respect, none of that is about spreading good practice. 

We at WCVA have networks that can share that best practice as well. We're looking to establish a network of regional partnership board third sector representatives in order to help to provide that feedback loop to the Welsh Government, but also to connect and spread practice throughout the voluntary sector across Wales as well. So, I think it's about sharing, being in partnership and acting on, maybe, those, and we haven't quite got that right. You're right. I think it's a work in progress.

We'll have to move on at this point. Siân Gwenllian. 

Diolch. Hospital to a Healthier Home is different from what we provide already, because we have hospital-based caseworkers, so it is a proper partnership in that sense, in that we are physically in the hospital, working with hospital teams, MDTs, discharge co-ordinators and occupational therapists to identify patients who are clinically optimised or on their way to being clinically optimised, but who can't go home because there is a housing or environmental reason. If we didn't have those Hospital to a Healthier Home caseworkers in the hospital in those spaces, those referrals, perhaps, wouldn't come to us at all, or people would be discharged, potentially, without having the kind of adaptations or interventions that they need.

I think, and it perhaps goes back to Lee's point—sorry, the Member's point—that it's about using what we have slightly better. So, Hospital to a Healthier Home and the revenue of that is a way of strategically using what we have to make sure that it meets the right people at the right time to facilitate improvements on patient flow, system flow. So, for example—and it is a well-used service—over the last five years that it's been operating, we've had over 27,000 referrals; that's just for 17 caseworkers. So, that case load is quite large per caseworker. And through that, we've completed over 38,000 home adaptations or home improvements for older people to help them go home more quickly from hospital.

So, we talk about adaptations, but also there's a lot of home improvement work that we do as well through this service, which draws in lots of different agents and actors, so that those caseworkers are able to—and this is how it is different from our normal wrap service—draw in those different agents. So, for example, I received a case study yesterday that was of a gentleman who had been discharged from hospital and it involved us, ourselves, almost in a project-management role, really, because there are so many different agents that come in to make a safe hospital discharge. So, you had ourselves as the caseworker liaising with our technical officers, liaising with a social worker in the community to create a joint visit; you had hospital occupational therapists, you had community OTs; we had the contractors completing the work. So, there is this whole plethora of people who need bringing together to problem solve, to have practical solutions. And so, it's different in the sense that it's a really effective way of using the resource that we have to solve a problem and this problem is delayed hospital discharge, essentially.

In terms of the barriers, this has operated since 2019, and it's not about having more money, because obviously, the service is funded, but it's about the way that we get that funding each year. So, often, it comes incredibly late in the day and you have—. As I mentioned earlier, the service works because we've built trust over time with those relationships. So, you risk losing very good staff who have built those relationships, who have built that trust over time, because, basically, they fear that they won't have a job come 1 April. I know it's 3 April now, and we still have one health board where they've kind of said on e-mail that it's going to continue, but it's not formally agreed, so it comes so late in the day. 

We have had some success. We went through a competitive tender commissioning process in one health board for three-year funding and we won that, if you will. But the amount of paperwork that went into doing that, the amount of resource and capacity that it took for us, as a larger organisation, to do that, for a service that is a proven concept—that tender was there because Hospital to a Healthier Home was operating in that health board. We think perhaps a trusted partnership between statutory organisations and the third sector would perhaps be a more progressive model of delivery for services that have proven concepts and that have been there for a number of years. I can only imagine how difficult that would be, that amount of paperwork, and the time it took, for a smaller organisation as well. We do have capacity to be able to do that. I can imagine that that would stifle smaller organisations in that space.

I think, yes, that is a massive blockage, because it does take up a lot of time and capacity, and the uncertainty, it does mean that you do lose really good staff, and the kind of staff that we have that deliver Hospital to a Healthier Home is specialist. It requires someone who is incredibly reactive, who has very good relationships with hospital staff, who has spent so much time developing them. So, I think the fact that the funding comes so late in the day is a big barrier to us. I mean, it just lacks efficiency, really. Having a closer look at a more efficient allocation of funding for a proven service, I think, would be very beneficial.

But the fact that it has happened with one health board, and that you have had a three-year—

Yes, yes.

—contract shows that it is possible, but there are lots of problems, as you say, in getting to that stage, so if some of those problems could be removed, then the three-year contracts could become more of a reality across, and therefore, you could spread out the service.

Absolutely. That has come about because of so much chasing on our side, so I think more proactiveness from health boards to engage in that process with us would be really helpful as well.

Okay.

Johanna wants to come in, Siân.

So, to emphasise Faye's point, the voluntary sector is included in a lot of frameworks and expected to deliver, to meet a desired outcome, but there is actually no guidance or collaboration with the sector to actually decide what that role is, what do we need to deliver, what needs are we going to meet, what outcomes are we going to achieve, so we've got to get into that kind of space, and the discharge to recover and assess model is a really prime example of that. And the Hospital to a Healthier Home service is a really good example of where a national charity with a local delivery infrastructure can have some great practice that spreads across Wales, but then I think there are ways that we can do that with locally based voluntary sector organisations as well. And I think we can do that by adopting collaborative commissioning approaches that adhere to the national principles for commissioning social care, and also the code of practice for funding the third sector, and I think there's a way that we can deliver a pan-Wales service level, but with a patchwork of services that are all working to achieve the same outcomes. So, I think that's the vision, I suppose, from WCVA and the voluntary sector in how we can work with the health and care system to tackle these challenges and support people well.

In terms of our engagement with Welsh Government, we engage via the third sector support partnership council. Voluntary sector organisations engage and inform the Minister of issues, particular pressure points, for example, and identify ways that we can overcome those. We've had some really positive discussions of late, but I feel like there's more that we can do as WCVA to bring the voluntary sector partners together to tackle some of these real issues, and hospital to home is a space where we want to do that. We can provide feedback to regional partnership boards, local authorities, health boards, in terms of how we work better together if we are more connected as well. So, I think we are leaning into partnership with each other, which is what we're good at and known for, and how we can use that to make a contribution towards the integration agenda.

Okay. We'd better move on. Peter.

Thank you. And specifically for you, Alicja, perhaps to start with, because I know you identified in some of your research the need for more accessible step-down provision, and you concluded that the Welsh Government needed to review and invest in a variety of step-down temporary accommodation. I just wondered if you could tell us a bit more about that and what you are advocating.

I think these were recommendations for the partnerships that exist between local authorities and health and social care. Some of it perhaps answers Lee Waters' question, the Member's question on resources as well. Obviously, there's much evidence that it's better for someone's mental health, and physical health often, as well, to be cared for at home or closer to home, and investment in community settings is key, away from traditional secondary care centres is better for people. So, in our research, when we engaged with health, social care and housing professionals, there was big support for step-down, step-up accommodation, but accommodation that is flexible and meets people's needs.

We looked back then, I remember, at research conducted by Gwent RPB into the demand and capacity for step-down accommodation, which found that three local authorities used in-house facilities, or in-house facilities were used. In one authority, beds, let's say, were commissioned across four facilities, and they spot purchased beds as well if needed, and one simply commissioned beds from private care home providers. But, interestingly, the report highlighted that, although the demand, according to the report, outstripped capacity, some local authorities experienced voids in step-down capacity that they already had, especially if it was what was called a block capacity, so it was underutilised at certain points. That's probably because it wasn't right for people's needs, and it wasn't flexible enough. Patient choice plays a big role there as well.

We mentioned in the report a project or programme of good practice called Cariad, which was a joint service between health, housing and social care, including two RSLs, Linc Cymru and United Welsh back then. What we found was it was really valued by health professionals, and the thing that they quoted time and again was that it was flexible, because it was a mixture of residential care, sheltered housing, extra-care schemes, so various different types of accommodation and care, from high to low support, and in different places as well. So, that shows that, sometimes, looking in more detail, I suppose, at what works, how money is spent and what the needs of the people are can help use public money better.

Can you describe a little bit about temporary accessible housing facilities? I'm quite interested in seeing what sort of models did they look like. I'm trying to envisage what that could be. Have you any examples of that?

In this example that I mentioned, when that was needed, it was commissioned or provided by two local housing associations that had a range of facilities available, so either a place in an extra-care scheme, or sheltered housing scheme, or residential care, or it could be just an accessible home that was available with some joint working with care providers, if it was really low support—

So, we weren't talking of caravans and things like that at all. No, that's all right. Thanks on that one. And more of a general question, then, and I think we've covered it a lot, we've heard a lot about legislation and how legislation could be improved, and I just wondered if there is anything wider that colleagues might have around the Welsh Government's strategic approach, holistically, to hospital discharge, and is there something else they ought to be doing.

One example that we had, it's a practical example that was raised with us when we were doing all this work was—. Back then I think it was called the 'integrated care fund', the funding; it's called 'regional integration fund' now, isn't it? There are obviously guidance and priorities attached to that, and there are various priority groups within that, like care leavers or children and so on. I remember speaking to one local authority that identified, and it was a person who worked in housing options, but very much involved in adaptations—. They looked at their data and the needs that they identified—. At that point, from memory, they had a lot of veterans with physically accessible housing needs. However, it was a big need at a very specific point in time, but the guidance didn't identify that group as a priority group so they couldn't go for that funding. So, there was a call for perhaps more flexibility around local needs, and, obviously, all the groups that had been identified in that guidance back then—and I'm not sure whether it's changed now—are groups that, nationally, are very much in need of that support. However, locally, and at certain points in time as well, that can vary. So, flexibility was called for back then.

Okay. I think Johanna wanted to come in as well, Peter.

Yes, I could see.

Johanna.

I mentioned earlier that the tools exist for us to work in partnership together, but I suppose the things that Welsh Government have put in place, those mechanisms, should be utilised better, I think. But there's no feedback or accountability, particularly for regional partnership boards, around how they've developed their section 16 forums. And there's 20 per cent expectation for regional integration funding to go to the voluntary sector, but reports from the voluntary sector say that that can be as much as 30 per cent in some areas, which is great, and then as low as 8 per cent in other areas. But it's not clear to me how those calculations and how those amounts have been arrived at. Also, what is the reason for that and how do we support the public sector to get their funding allocation based in communities a bit better? Because it's not necessarily, for me, about the amount, it's more about are we allocating sufficient resource to do the community-based, person-centred support that needs to happen to achieve good outcomes for people, and the voluntary sector is the tool that can be used to improve those outcomes for people.

Okay. I'm afraid that's probably all we have time for for this session, but thank you all very much for coming in to give evidence to the committee. You will be sent a transcript to check for factual accuracy. Diolch yn fawr.

Okay, we will move rapidly on with our next panel, then.

It's our fifth evidence session now, then, with Care Forum Wales. I'm very pleased to welcome Melanie Minty, policy adviser for Care Forum Wales and Sanjiv Joshi, treasurer. Thank you, both, for coming in to give evidence to committee this morning.

Perhaps I might begin with a couple of initial questions before we turn to other committee members. Firstly, on social care capacity and workforce, we regularly hear, of course, about a lack of capacity in social care services and shortages in the workforce. Could you tell us about the current situation from your perspectives? What's the scale of the problem, as it were? Where are the main pressure points and how is that impacting on hospital discharge delays?

I think it's a variable picture across Wales. Certainly, the feedback from our members is that they are experiencing delays in discharges from hospitals coming to them because of delays in assessments, so there aren't enough social workers. In terms of the sector itself, social care workers—there is, in some areas, a very heavy reliance on overseas workers, which is becoming increasingly problematic for a number of reasons, but it's becoming more and more complicated to actually recruit from overseas and meet all of the legal obligations. It's also, I think, more than social care staff—it's very difficult to judge it in isolation. It's such a holistic picture, and I think a lot of the issues are from our community services, like general practitioners, not having access to wraparound services, but also the clinical staff. One of the common issues we hear is people finding it difficult to get through to ward staff when they're trying to arrange to go in and do an assessment. So, the whole system, I think, is rather creaky.

I think the social care sector—Sanjiv will correct me if I'm wrong—has probably stabilised a little bit since COVID. It's not as dire as it was, but the pressures are still there, and with the national insurance contributions, of course, coming in now—the extension—that's going to make it very, very difficult. I think we'll see that an unintended consequence will be that employers are forced to suppress pay increases that they had planned, and some will be making redundancies, so that is going to have an impact, obviously.

Bore da. I'd just like to add that although Mel has given you an overall picture, there are some changes that need to be recognised. Post pandemic, we were on our knees. There were two factors—Brexit as well as the impact of the pandemic—that meant that the workforce depleted quite severely. In a sense, overseas recruitment has been a saviour. We're now seeing problems, when we recruit so heavily from overseas, on assimilation and maintaining the quality of services. These are problems that can be overcome, but what we were facing was a cliff edge, as far as our workforce was concerned, at the end of the pandemic. So, from that perspective, it has changed.

Also, there have been a couple of initiatives that have assisted in stabilising the sector. For example, recognising and valuing our care workers with the Welsh Government initiative of a real living wage—that went a long way. There were a couple of boosts that our staff got with bonuses at the end of the pandemic. All of those were very well received, much appreciated, and assisted us in what was otherwise a very, very difficult, challenging time. So, we've got to recognise that there were improvements.

What we're now seeing is the impact of those particular initiatives not being carried through. We needed to build on them. For example, the real living wage—the first year, when it was announced and was implemented, providers had to give an undertaking to commissioners that we were paying the real living wage. Since then, that's become aspirational, as commissioners have not had the funds, or so we're told, to follow through and maintain those real living wages. So, we have, now, if you like, new problems arising out of well-intended, good initiatives, which aren't consistent and continuous.

Okay, thank you very much. Is there anything in addition to what you've already said that you'd like to bring to the committee's attention in terms of key measures to improve recruitment, and obviously to retain staff, to have a more sustainable workforce? We’ve heard as a committee about shortages of social workers and domiciliary care workers in particular. Is that your experience?

Yes, unfortunately, we couldn’t get a domiciliary care provider to come with us today, but I know that there are a variety of issues. Recruitment is always particularly difficult in rural areas. The nature of the work, of course, is very stressful and people are out working on their own.

The real living wage, as Sanjiv said, isn’t reaching the sector, necessarily, but the real living wage is really a drop in the ocean. We can’t compete with the statutory sector on terms and conditions, so we have to concentrate on trying to make the work as fulfilling and interesting as possible. That’s not always easy with the way the work is commissioned. A lot of work is spot purchased. There is a reluctance, which I understand, by the statutory sector not to block-book something that they might not need, and that would be a waste of public funds, in their opinion, but it means that providers can’t actually offer guaranteed hours, in many cases, especially in domiciliary care.

We’ve also got a rather perverse situation now where there have been bidding wars in certain areas, which means that more people are coming into the market, the work is spreading thinner, and there’s not enough work to go around all the agencies that we’ve got out there, and that’s particularly difficult for international workers, when you need to guarantee their hours.

What I think we would like to see is a much greater emphasis on commissioning for outcomes, rather than transactional commissioning. It’s better for the individual, but it’s also better for the care workers, because they’ve got more time, they’re not being measured on how quickly they travel between clients, and they can spend time with that client and actually make sure that they’re meeting their outcomes and not just giving them their medication or washing up their breakfast things. I think that fulfilment is key for us.

Okay, Melanie.

Perhaps I can just add, on the capacity side, and Mel’s described it, we have capacity, it’s not that we don’t have capacity, but the whole commissioning structure of spot purchases means that we’ve got to adapt and change for the needs as they arise, which is very difficult when we are working in a sector where you’re trying to provide a service on a longer term basis, which means you need a stable workforce, you need a motivated workforce, you need to provide career paths et cetera. It’s very difficult when the overall environment you’re working in is one where you’re spot purchasing, or where commissioning is on the spot. It becomes a transactional-type arrangement, which doesn’t work well with having continuity and consistency in our services.

Yes, thank you very much. Peter.

Yes, I just wanted to—. Something you said, and what we’ve just talked about—you’ve got enough capacity. In fact, there are more people coming to the market and there’s not enough work to go around. I’m trying to correlate that with the messages I’ve heard from local authorities that they have hundreds of hours of unmet need each week. I remember one chief executive telling me, 'Peter, you can give me as much money as you want, that won’t cure the problem, we can’t get the people.' So, I don’t know what—. Has this change happened recently?

Yes.

In theory, then, there'll always be elements of unmet need because you can't set up contracts quick enough and things like that, but that shouldn't be a big problem now, should it?

I think it’s very variable. I think that’s happening in certain areas depending on how the council contracts and whether they run a bidding process or they use favoured providers, as it were. There will still, I think, be some problems. Historically, west Wales has always been more difficult because of tourism—young people want to work in the tourism industry in the summer and then come in in the winter, so you’ve got constant churn. So, it’s very variable, I would say. There are still recruitment issues in some places, not just in social care workers, but in nurses working in social care. That's a particular issue for us.

Can I explain the point we're making here? When we say there is capacity available, it's not permanent. It also changes according to the processes of commissioning. So for example, when we talk about a bidding process, imagine you have a domiciliary care provider who's been providing those services for 20-odd years but is being now undercut by a newcomer. At some point that's going to put in jeopardy the business that they've been running for 20 years. So that capacity may disappear, and therefore you end up with capacity and shortage at different points because of the process and the way it's being procured.

I think Peter will come back in a minute, but just before Peter does, with the elderly mentally infirm beds, is there a particular problem there in terms of shortage?

That's my perception, certainly what we're told by commissioners. You need more care hours when the people you're looking after need more support. I think it's perhaps some of the older residential homes that don't provide nursing haven't kept pace and don't provide that service, but it's also again down to funding. There is, I think, one area in Wales that doesn't actually pay a higher rate for EMI than they do for standard residential care, and that's replicated throughout the funded nursing system as well. It reduces incentive, not because you can't make the profit, but because you can't break even if you're not being paid to provide the hours of care that you need. There are some areas where, possibly for historic reasons, I don't know, it has become particularly bad and there isn't enough EMI. 

I would say the way the funding works is at the heart of these issues. There is capacity, but in the wrong places, if you like. Where it's needed, if the funding isn't right, you're not going to have the capacity. As a care provider, I run an organisation where we have 14 care homes across south Wales and mid Wales, and when we set up any provision, it's a long-term plan and we work on a business plan with certain levels of funding. If the commissioning priorities change and the funding streams are in some way distorted, we can't work to those plans, we can't offer those services. If we then repurpose for other services, that's capacity lost where the need is. So in a sense, from my perspective and from most providers' perspective, it comes down to funding.

We've been running care homes in Wales now for 23 years, and we see over that period how decisions made on funding, on direction of what care is required, what the priorities are, impact the needs and what we can provide five years, 10 years later. There were some funding issues seven or eight years ago on recognising the additional resources needed for dementia, and I think that's played out when providers have looked at what provision they want to provide. They, if you like, despite the demand being high in those areas, have moved away because it's not viable for them to run businesses for that purpose.

I see. Sanjiv, thank you very much. Peter.

I wouldn't mind just exploring RPB funding. I know you've been quite critical of regional partnership boards allocating funding, particularly for the creation of more step-down and reablement services. You say funding is largely going in-house, and that many supposedly new models of care appear to be just extensions of existing statutory services. So I just wondered, can you tell us a little bit more about your views on this and the changes you want to see in the way that the RBPs commission? 

I think part of the issue is a confusion between the not-for-profit agenda for children's care and the rebalancing agenda of having a reserve of in-house provision in case a monopoly provider goes out of business. What we're seeing is an increasing number of local authorities are receiving funding particularly from the accommodation with care grants to build care homes. Some are supposedly new models but, to me, they seem to be just like a very expensive niche care home that probably will be very expensive and never recover its costs. 

For instance—I wouldn't normally name—in Carmarthenshire they are building a home for £19.5 million, where there is capacity throughout the county, and people have got spaces in their care homes. At the same tame, none of the regional partnership board funding in the majority of partnership boards will actually reach the sector because it's all earmarked for rebalancing, for new models of care or for preventative measures. Regulated care services are not just private providers, but third sector who are providing regulated services. It's kind of left out on a limb. I can't see any particular evidence from the boards that I sit on that it's being engaged in any of these new models of care. 

That's really interesting. That's quite helpful. Thanks for that. Moving on, just a point about joint working. I just wondered how effective joint working practices between partners, particularly health and social services, are on hospital discharge. Are there things that could or should be done differently? 

Yes, definitely. The funding is probably the key issue again. We do see delays caused by disputes over funding, but we also see local authorities being forced, more or less, to accept clinical decisions where the person's needs are definitely underassessed. So, in some areas where this happens a lot, providers are beginning to stop taking people from hospital, so that has a big impact. And, of course, it has an impact on local authority budgets as well and on the rights of the individual, because there are people in care homes who should be receiving continuing healthcare and shouldn't be paying for their care at all, from what I've heard from people. 

So, it's partly funding, and I don't think integrated funding is working as it was expected to. Most regions have put up some sort of system, but they're all different. For some of them, it'll be integrated in name only, and there's still very much a debate over who pays for what. I think the relationships will be different as well. My perception from sitting on different partnership boards in different areas is that some health boards and local authorities—. Particularly with the financial situation at the moment, there's a lot more tension between them.  

It's almost like that different partners don't understand or don't want to understand the other partner's situation, so you can't arrive at a holistic understanding of what's needed. 

Yes. 

Yes, and we struggle to understand why we have a delayed transfer of care issue as providers. If we stepped back, really, there are three major stakeholders here and, in a sense, by framing it about how local authorities work with health boards is perhaps missing that there is a third stakeholder here, which is the provider. For the system to work, these three have to work together and find solutions. We struggle with how the system is, if you like, developed and imposed, and it's probably the reason why it doesn't work as efficiently as it should.

From our perspective, we're sitting outside those discussions. All parties want to avoid delayed transfers of care. In the NHS, you have clinicians saying how patients get deconditioned; once they're clinically optimised, they need to be out, for the best for the patient. We have providers who want to take the elderly admissions; that's our business model, that's what we want to do—we want to deliver care in our homes. And we have the local authorities, who want to discharge.

It all comes down to protecting budgets and how they're set up. If you look at the holistic, as you put it, it's costing £500 a day to have a resident in hospital, when the solution in the care homes is at about £200 a day. So, you would have thought that, somewhere, we would be able sit round a table and solve this, and have the resources applied in a way that they don't work against each other.

We've heard it several times when we've taken evidence: is there enough sharing of data and information across, certainly, health and social care? I wonder how you fit into that. Do people ask you for data, or can you access the data you need when you have got to provide something?

As far as data, I think the local authorities and the health boards have all the data they need. Most care homes provide weekly updates on how many empty beds they have, and I think the capacity in the domiciliary care sector is similarly reported. We report in. What we don't see is the needs, et cetera, the assessment process of when we need to assess—. The system doesn't work efficiently. To give you examples: we've been sitting through, trying to work with the different parties to resolve some of them. The sorts of issues that come up are that the homes did not come to assess, there have been delays in assessing. But the counter to that is, sometimes, the same assessment is sent out to five different providers. So, when this happens repeatedly, four providers miss out, then there isn't really the urgency to go in and assess. These are simple examples, but these are things that can be sorted out, because, ultimately, there's only one assessment and one bed that the person needs to move to. Therefore, there is no reason why that can't be resolved.

I think there's a wider issue as well. If they could have some sight of the assessment, it would help care homes in making a more informed decision. It's much easier, if you've got a balanced view of someone, rather than a snapshot of visiting them in a hospital bed, to understand whether you can meet their needs, as well as the fact that we quite often hear about patients being discharged into care homes and arriving without their medication, without all their records, without a recently agreed do-not-resuscitate plan—all that sort of thing. I know, in England—and I think possibly Scotland—providers, for some time, have had access to NHS e-mail, which we haven't got in Wales, because I think it's quite expensive, so it hasn't been prioritised. But I do think that would help.

If I may just go back to the previous question, about the integration of where social workers and hospitals could work better together, we were reading the response from the British Association of Social Workers about the need for social workers to be more respected in hospitals and to be more engaged, and I think that's absolutely right. Because if you discharge someone based just on a clinical diagnosis, then you lose everything that the social worker brings about the holistic care and their well-being, and they will know the care homes in the area a lot better and know what they can provide and what's suitable.

What we often find is people will come in with a clinical diagnosis, but they have social needs that can't be met—they might wander, for example, they might be more dangerous in their behaviours than people have been led to believe. But once they're in the care home, it's very difficult to get them reassessed. I've seen some awful threads of conversations on our WhatsApp group, with people desperately saying, 'I have someone who has started to become violent. It's not safe for other residents or for staff, but there are no hospital beds. Social services, it's out of hours, so there's no-one there. The police don't want to know. What do we do?' And in the end, they probably end up calling the GP and asking for sedation, which is not the response that you want. So, there are some quite serious impacts of not getting it right.

That was really helpful. Thank you. That's all from me, Chair. 

Okay. Thanks, Peter. Siân.

Sorry. I didn't entirely get it, but I think you were asking how much the lack of co-ordination between the two affects discharges. 

Social workers.

Social workers, sorry.

I was asking about the assessments—the social worker assessments—that need to happen. How much of a blockage is that in terms of the discharge?

I think it can—. I think, in some areas, it's probably worse than others. But, certainly, I've heard from one member, for example, that someone was in hospital for about six weeks because the social worker was off sick and there was no-one to provide cover for them. So, at that point, yes, it can become quite dire. It's getting access to people out of hours and getting access when people are on holiday, and there's no-one to backfill.

Does it help when there is a social worker based in the hospital?

I would imagine it would do. I think, if you can—. It's got to be more streamlined, and it's got to enable the two to integrate and to understand each other better, and to work together more co-operatively. All the pilots that people have done in the past about sitting people in together, it has helped. It's helped boost co-operation, because it has to, if you're sitting next to someone and you're getting to know them and understand them. So, I think it can only be a good thing.

Yes, I endorse that. In our experience, the social worker's role in the hospital setting is invaluable, and, in fact, when you bypass that, you cause bigger problems down the line. Again, that's picked up by the number of times discharges repeat admissions to hospital and so forth, and the number of times the patient or the resident has to move elsewhere, if it isn't the appropriate placement. I think what came across was there needs to be high value on the input of a social worker in the hospital. They need to be valued, and that would make a big change, and we think a very positive change, to the flow through the process. But also I think we've also got to protect the decision-making processes and not have, for example, funding or budgets imposed on those decisions. For example, as Mel said, if the social worker has identified the right setting, and funding is an issue, then that should not mean that the decision is forced onto the social worker to make an inappropriate placement.

But what happens is, when somebody arrives at the care home, there's another assessment that happens. Is there a need for the two assessments? Should the social worker assessment, and that interaction with the person, continue throughout that person's life, really?

Sure. Absolutely.

But it doesn't.

It should do in theory, shouldn't it?

Our assessment in the homes are based on the assessments that we receive, so we have to have that starting point. Clearly, over a period, those assessments get reviewed and the needs change and so on, because these are long-term placements, but it is key to have the right picture at the start, otherwise very valuable time is lost in delivering the right care.

And it is set out in the legislation as well that you have the initial assessment, and the provider has to do their own assessment to confirm that they have the correct level of staffing and qualifications to be able to meet that level of care.

Turning to the most complex people, who need care that is expensive, is that a particular—? I think you referred to that, about protecting budgets. Is that a particular area that we should be looking at, in terms of the discharge?

I think it is, particularly, in some ways—and this isn't Sanjiv's area so much—in younger adult care, because those can be very expensive packages, because you've got younger people who have more social needs. A lot of it tends to be 1:1 supervision, and that's where, quite often, there's a misunderstanding of what makes 1:1, what does that actually mean. And I've heard of commissioners going into homes and saying, 'You're spending too much on food.' Things like holidays are being drastically cut back for younger people. You do hear, in certain areas, that there will be disputes because a social worker will place someone in a care home, and the care home will say, 'Yes, we can meet their needs.' But then the commissioners within the local authority will say, 'Well, I didn't agree that, and I'm not paying that.' And then you're left with nobody wanting to pay the bill or to put someone somewhere else. So, I think that is particularly vexed. But it certainly plays out in older people’s care as well, because the funding doesn't follow the individual's needs and the attention that they need.

Can I add? I think the special packages and the higher cost packages are only amplifying the underlying problem that we have in long-term care. So, if you think about the basic packages for care homes, we have different categories: we have residential, EMI residential, nursing, and EMI nursing. If you look at the packages there, if you look at the fees—or what we like to call the individual’s entitlement, because that's the funding, the budget, that the local authorities provide—there is such a variance in fees. I think we have submitted the fee table to yourselves, but, just to give you an example, we have two neighbouring local authorities where the nursing fees per week, there's a difference of £180. That's £9,000 a year. It's not far from here, and I don't think—. It's public, so I can share that we're talking about Cardiff and Rhondda Cynon Taf. The difference in fees is around £9,000, yet we have—. So, imagine the pressure that puts on. And it's not driven by the needs. So, the needs would not be that different from a placement in Cardiff to a placement in RCT. But when you have those sorts of differences in budgets, you find that the placements become difficult, the packages become difficult. That then gets amplified into packages at higher levels. The basis, the value basis, of establishing the fees are not standard, not universal, not on an equitable basis.

Okay, Siân?

You have more questions on that, I think. Yes, thank you.

Okay. Lee Waters.

Thank you. Yes, just to follow up on that, then, you said earlier that one of the issues that the private sector had was the issue of viability as businesses. And, obviously, you’ve just told us there's great variation across Wales in the levels of fees that are agreed. So, is there a typical level of viability? Is there a typical level of profit that makes this a worthwhile market for the private sector to be in?

I think what we do is that we work on business plans—. I'll now talk from the care home perspective. We work on business plans set out over 20 years to provide a service to see what it is viable. Of course, we have to have profits, and we don't see 'profit' as a dirty word. But these are capital-intensive businesses. For example, the average capital employed in setting up a care home and running it, in the private sector at present, is now around £250,000 a bed. So, there has to be—

Just to be clear, I’m not using this as a pejorative at all; I’m just trying to understand, for the purposes of planning, what is the minimum viability level that the NHS should be assuming the private sector needs in order to be a part of this sector.

Right. 

Is there a percentage?

The fees are set per resident, and they’re set through a methodology. And this is where the problem is, that the methodology isn’t applied consistently throughout Wales; it’s driven by the local authorities. So, we look at—. Providers will provide their information, financial information. They’ll go through the vetting process, et cetera. And then a fee will be set based on that. But it’s not done consistently, and, at times, it’s sort of reverse engineering. It’s what the authority can afford in their budget, which then works back into our fees. That leads to those variances.

I understand that, but what I'm trying to establish is: what is it? Is it 20 per cent, 10 per cent, is it 1 per cent? What is the working assumption that the NHS should have of the level of viability that the sector needs? 

Okay. Sorry, if I can assist you, percentage of what? Are we talking about fees? Are we talking about capital employed, profit-based—?

Sorry, you said earlier that there’s a minimum level of viability needed in order for the private sector to operate. I’m just trying to establish what that minimum level of viability is.

Well, we try and work on an 11 per cent return on capital employed. 

Okay. 

That does change, depending on interest rates, depending on external factors, how available capital is. When capital is tight, that needs to be higher. When capital is more available—. It seems to be going up now from the 11 per cent. 

I understand. Thank you for answering the question. So, across Wales, you said, different local authorities and health boards are providing different levels of fees. Are there areas of Wales where that 11 per cent is not achievable?

Yes, that's the problem. 

Okay. 

And just to answer your question, the 11 per cent of what is also important. For example, we have some authorities using £80,000 as the base, others using £60,000. And if you look at comparisons—. For example, in Carmarthenshire, they use £80,000 as the base, but Carmarthenshire themselves are now building an in-house home at £330,000. So, it also matters what that 11 per cent is of, on the viability.

Okay. And I think you mention in your evidence that two boards, Cardiff and Vale, and Aneurin Bevan, are more effective than others at commissioning. What is it that they’re doing that the others should be learning from?

I think they recognise the costs better. What we would say is there are always going to be variances, but they engage better. Aneurin Bevan and Gwent local authorities have for years worked with providers on understanding their costs and working their fee methodologies around that. And similarly, Cardiff and Vale have very active engagement with providers. So, their understanding, and their fee-setting processes don’t get in the way of commissioning, whereas, with others, the tensions arise on those basic areas, and we don’t get past that to be able to have the conversations about what are the appropriate placements, what are the best outcomes for the residents.

So, does that mean that there’s no consistent approach across Wales?

Yes, very much so. We’ve been looking forward to the—excuse me—new national office coming up with a fee methodology so that we can apply consistency. Sorry. And that, I think, would include agreeing a consistent level of profit or return on investment. Sorry. It's not really—

Have some water. Take a break and have some water. 

Just while we're waiting, could I bring Laura in, because, Laura, you wanted to come in on this particular point, did you?

Yes. Thank you, Chair. I just wanted to say that what I've heard from visiting care homes is that the consistent methodology needs to be there, because it's different between neighbouring constituencies, and it's not really a suitable method. There is always going to be fluctuation in terms of costs that care homes face, but there have been significant costs recently—national insurance up, food up, energy up, the real living wage up et cetera—to the extent that some care homes have said they're on the brink of closing, particularly the ones that have just established themselves, not so much the long-established ones. Have local authorities reacted to that at all in terms of the percentage that they're putting forward to you? Because obviously they're struggling as well. I was just wondering about your thoughts on that, just to add to what Lee said.

Again, it's very variable, partly because there is no fee methodology, and partly because a lot of areas aren't engaging with the sector to understand those costs and those increases. Some are more transparent than others. For instance, Cardiff, whilst giving a really good increase this year, has been very honest in admitting that they know it's not going to meet all the changes, whereas other local authorities in the past have been known to make an offer and say, 'And this will cover all sorts of things' but you know it can't possibly, because it's such a low percentage. There's no accountability or explanation of how that fee is arrived at, often. But yes, I do think it's very inconsistent, and in some areas it actually feels as if the sector is being deliberately underfunded and that it will be compensated by people building their own in-house care homes.

I'll just bring Peter in briefly. 

Thank you, Chair. It's on that point, on viability issues. I'm anxious that perhaps there's an all-singing and dancing new public sector thing put in place and it's got multimillion pounds; actually, they should always be working on best value as well, and creating value for money. What would be their return on capital invested for their section? If they're only going to turn over a 1 per cent or 2 per cent value for money on that, where there is capacity in the system already, which could have delivered what they were trying to fill, all they're doing is eroding the opportunity of the private sector to fill the gap.

You've summed it up. We can't understand. It sounds irrational. We know that in the public sector, for their internal accounting in the past, they would have a contribution of 8 per cent on their capital. I'm not sure whether that still applies. These are not publicly disclosed numbers, but certainly it's not value for money, and ultimately even if it was what we would call 'free money'—Welsh Government grants et cetera—there's a national debt, which is at 5 per cent or higher. Therefore, you've got to put some number on the cost of that capital. You've summed it up. We have the private sector delivering incredible value for money and being eroded by underfunding, and then we have the replacement—the public sector spending four or five times that amount. It doesn't make sense.

And in addition, it's not unusual for local authorities who have their own care homes to charge about £200 a week more to clients than they pay to the independent sector.

Can I just add? It kind of adds to all the questions that have been asked. As independent providers, ultimately the costs are very similar throughout Wales. If you think about how carers are now underpinned by the real living wage, and other costs—utilities, food, environment and property costs—are very similar, when we have these sorts of variances and underfunding, we would say the ones who have sat with us and looked at our costs are closer to the true cost, and that would be the likes of Cardiff—the local authorities at the top of the table. With the ones that aren't, providers have to respond because they need to survive. So, what we are seeing more is that we're now turning to third-party contributions—we're now having families contribute to have the residents in a home, which is highly inequitable. It's unfair on those residents that it's being subsidised, although it should be provided through the local authority funding, or, for that matter, through the NHS funding.

Okay. Lee.

Thank you. Melanie Minty was telling us earlier that she acknowledged that there was monopoly provision and that when that provision collapsed, there was obviously market failure and there was a role for the state. Just in terms of your debate, you're obviously saying that the state shouldn't be getting involved and we should be utilising the private sector first. Obviously there is a huge danger in overrelying on the private sector, because we've had corporations buying up large homes, driving down prices and standards in order to maximise profits, and then going under. So, there's a legitimate role for the state here, isn't there?

Yes, there is, but I don't think there are that many of that kind of care home out there anymore. And in an area, for instance, like Carmarthenshire, where this big new build is going on, the majority of care homes in the area are small and medium-sized enterprises, family run, and because they haven't got the reserves of the larger companies, they're going to probably go under first.

Just to show that it's a problem for all providers, third-sector care homes are commissioned in exactly the same way as the private sector providers, and most of our third-sector members have sold their care homes because they are not viable. So, whereas the private providers are doing what they can to move investments around and take loans out, the third sector can't do that in order to comply with the regulations on charities and most of them are leaving. Christie & Co did a report that showed that 40 care homes had closed since 2022.

Can I ask about the national framework for commissioning, which was published last summer? Has that started to have the effect that it was designed to have and are there lessons that can be learned already from that?

I would say that it hasn't made any difference at the moment—it's very much in its infancy. I think we're pinning our hopes on the national office. I think in the future, it will be very helpful, but there have been issues in being able to recruit people to the new office. We have a little frustration in that there are toolkits—we did a lot of work a couple of years ago with Professor John Bolton on the 'Let's agree to agree' toolkit. So, it's there, but not being followed in a lot of areas. So, it is frustratingly slow and I don't think it will come soon enough to avoid some of the immediate pressures that we're facing, but in the long term, it will be very valuable.

And just finally from me: are there things that we might recommend as a committee that would help?

Can I just come back to the point about large corporations and private equity et cetera being in the market? The reality is that, in Wales, they're probably less than 5 per cent of the market. The majority of the market, of our members, are small and medium enterprises. We've heard several times that this is a big concern, but I think it's an imaginary concern, and there are—

Well, with respect, it was your colleague Melanie Minty who used the term 'monopoly supply' earlier. Any monopoly provides a danger to provision, doesn't it, whether it's a private equity-owned monopoly or it's locally owned monopoly. A monopoly is a monopoly.

We would say that the dominant players and the monopsonies are the commissioners. If you think about placements, they probably control 80 to 90 per cent of the market. We are price takers—we can't set our prices. We are commissioned and our, if you like, referrals are admissions, which come primarily from the NHS and the local authorities.

Sure. I think you've made your point clearly that there needs to be a greater consistency and a greater openness about the viability that is required from the private sector, and that needs to be factored in if the NHS wants to use the private sector. That needs to be understood and that's the price of doing business. If it doesn't, as you rightly said, it needs to show the alternative provides value for money. I think that is clear evidence and helpful.

I want to just finish by asking this: you said the national commissioning framework is still in its infancy and hasn't lived up to its promise yet; are there things we might recommend that could help with that?

I'd like to see the Welsh Government hold commissioners more responsible and accountable for the fees that they're setting, rather than taking a step back and saying, 'Well, it's a local decision.' Yes, it is, but when you know that funding isn't going where it's supposed to—. I know there are a lot of arguments against it, but there are things like not ring-fencing the funding for real living wage, so that in some areas, it was not spent on real living wage, it was spent on libraries and so on. That's not helpful to the sector in making sure that the money is going where it's needed.

Thank you.

I think that's all we have time for, I'm afraid. Thank you both very much, Melanie and Sanjiv, for coming in to give evidence to committee today. You will be sent a transcript to check for factual accuracy. Diolch yn fawr. Thank you very much. We will break briefly until 11:20.

This is evidence session 6. I'm very pleased to welcome Rob Simkins, head of policy and public affairs for Carers Wales, joining us here in our committee room, and joining us virtually, Kate Cubbage, director of Carers Trust Wales. Thank you both very much for coming in to committee to give evidence today. Perhaps I might begin with a couple of initial questions, and then we will turn to other committee members with further questions. Actually, sorry, Peter Fox will begin and then we will hear from other committee members. 

Good morning to you both. I would like to start by touching on the role of local authorities. I'm just wondering if you can talk us through the specific role and responsibilities that local authorities have to support unpaid carers in the hospital discharge process. Can you describe what should happen in contrast to what currently often happens when the cared-for person is being discharged from hospital?

I can go first, if that's okay. In terms of local authorities' responsibility to unpaid carers throughout the discharge process, much of that is underpinned by the Social Services and Well-being (Wales) Act 2014, which outlines duties on local authorities in terms of support for unpaid carers, providing information and advice and support, carers' needs assessments and proactively going out and identifying unpaid carers and helping them to recognise that they are carers as well. So, that would probably be the main bit of legislation that underpins local authorities' responsibility in that respect.

In terms of what is currently happening and where we would probably like to be, practice differs and varies across the health boards, across local authorities, which I think is probably an issue in and of itself, there's not enough standardisation. But there are pockets of good practice and pockets of practice where things are just not working. That's placing massive amounts of pressure on unpaid carers, on who they care for, and it means that when people are discharged from hospital settings, often that discharge completely falls apart and they're readmitted. So, I think, yes, we're a long way from where we want to be and unpaid carers supported adequately by local authorities but also by health boards can play a key part in addressing some of those issues as well.

Thank you. Kate.

Absolutely. So, in terms of hospital discharge, unpaid carers remain an often unseen and undervalued partner in ensuring that patients are discharged from hospital to the community safely, efficiently and sustainably. I'd like to highlight that initiatives such as discharge to recover then assess have had real unintended consequences for unpaid carers and have resulted in patients with high care and support needs being discharged into the community before carers' needs assessments have been undertaken. This is both because of waiting lists for carers' needs assessments and because the choice to action local authority assessment for those with care needs at a later date has, in some cases, resulted in carers having to have their needs assessed along the same timeline. This is especially the case where a joint assessment has been requested, or even presumed as what the carer wants. So, we believe that there's an important opportunity for carers' needs to be assessed and that has to happen at the earliest opportunity.

As committee members will be aware, local carer organisations across the country, including network partners of Carers Trust, provide specialist hospital facilitator or hospital outreach worker services. These provide really vital support for carers who are caring for a person in hospital and as that cared-for person is discharged from hospital. But a challenge we face is that these are often funded on a year-on-year basis, either by the health board or through Welsh Government ring-fenced annual funding, or regional partnership boards, therefore local authorities by extension, via the regional integration fund. And speaking to the point that Rob has made around inconsistency and variation in approach, that lack of certainty around funding has made embedding services and staff retention really challenging, and these are key to pathways of getting carers to local authorities to have those assessments that they have a statutory right to.

Both forms of service that I've described should be referring carers into carers' needs assessments, but we know that that isn't really happening. So, if I refer to the Public Services Ombudsman for Wales's own-initiative investigation, 'Are we caring for our carers?', which was published just last year, it shows that just 2.8 per cent of carers are actually having their needs assessed, and half of those are receiving a support plan to meet their needs. That report noted that early identification is key, and as Rob described, that role for healthcare professionals and the health board, alongside local authorities, is really key; they need to connect together. This research, I think, in addition to the Association of Directors of Social Services Cymru rapid review in 2023, is really compelling. That review itself highlighted that there are waiting lists for carers' assessments in most areas, which prevents carers from having the support that they need, and many carers are not being offered an assessment as a result. The report also captured the lack of referral from healthcare to local authority as a barrier to effective support for carers, describing questionable engagement from the NHS in some areas, with one interviewee saying that they had not received a single referral from GP, district nurses, or the hospital discharge team in three years.

I just want to speak to the anecdotal evidence, briefly, from our network, which would suggest that there are still areas of Wales with commissioned third sector hospital discharge support services that receive disproportionately low levels of referrals from hospital staff, with most support being provided as a result of self-referrals. So, I think when we focus that planning for discharge is something that happens ideally at the point of admission, it's clear that the local authority's role in supporting unpaid carers through discharge will likely come much, much later in the process, which I think in itself could be a point of failure. The local authority could become involved if the carer is referred to a carer support service while the patient is on the ward and the service could then refer to the local authority, or it could happen as part of a formal discharge process, with the discharge team referring to the local carer organisation or to the local authority's social work team directly. But at the moment, that patchy provision is really, really varied.

Thanks for that. That's really concerning, because unpaid carers are just fantastic and they fill a huge void in our care need, and I hate to think that they're being taken for granted. Their assessment needs are fundamental, and I absolutely hear the point you make that that should happen in advance of, certainly, the people they're caring for coming home. So, I suppose that leads me into the next question a bit, really, because, talking about barriers, what are the current barriers to ensuring that unpaid carers can access local authority support when the person they care for is discharged from hospital? It seems that unless they know what that carer is up against at home, how will the authorities support them, unless they know that, so I don't know—have you got any views on that?

Yes, I think there's just a massive lack of knowledge and data Wales-wide, but, again, practice varies, with regard to carers' needs. Some of that is because such a pitifully low number of carers are having their needs assessed. You can measure it a number of different ways. By the most generous measurement in our 'Track the Act' report, 8 per cent of the carer population in one local authority area are having their needs assessed over a 12-month period, which is not what the Act sets out—far from it, in many ways.

So, the lack of carers who are having their needs assessed is a massive issue, in terms of them being able to plan. We know that via regional partnership boards there are meant to be population assessments and planning going on, and carers form a part of that. But if you aren't having carers having their needs assessed, how on earth can you adequately plan and try to be deliberate and strategic over the medium-to-long term in terms of the issues that they face? I think there's a significant failing there.

I do have a lot of sympathy for colleagues in local government, because they've faced a challenging period for a number of years—they're juggling a million and one other duties. There are ways that, without additional capacity and resource, practice could be improved, and we work closely, along with colleagues in the Carers Trust and along with colleagues in local government, to try to do that. But without greater capacity and resource to permit local authorities to carry out more assessments, that will have an impact on their ability to plan and that will have an impact on carers being able to access support as well. There needs to be leadership that comes with that capacity and resource too. The Wesh Government—. Yes, it's councils' jobs to implement the Act, but, you know, can we stop passing laws that we can't implement? There needs to be leadership around that implementation gap there as well.

Yes. I'm not sure if—.

I don't know—Kate, did you want to come in on these points?

Yes, absolutely. I, of course, would agree that unpaid carers are exceptional people, and I would like to highlight to the committee some of the barriers that unpaid carers face by sharing a story from an unpaid carer. This story is from 2024, so relatively recent. It revolves around an older couple, both with health problems and poor mobility. I'm not sharing geographic information about this case study—I'd be happy to do that privately with the committee, but I don't want to remove the anonymity of this carer who has shared their story.

So, in this example, the husband has been in hospital for eight months, and his wife, despite significant health problems of her own, visited daily. The journey took her two and a half hours each way by bus. During the eight months he was in hospital, a discharge plan had been discussed on several occasions. However, a decline in the patient's health had meant that that had not been possible, and the discharge was delayed. One day, the carer arrived to visit her husband as usual. But on arrival, she was informed that her husband had been discharged and was in an ambulance on his way home. Understandably, the carer was upset and was anxious, as there was no provision for her husband to get into the home, and she didn't know how she would be able to cope and provide the care that he needed.

A health board-funded commissioned care officer was able to respond really quickly, liaising with ward staff to explain the gravity of the situation. The hospital arranged a taxi for that carer to get back home, and also arranged for an emergency response team to provide support that weekend, until a social care package could be put in place. However, the carer was unable to cope with the level of care that her husband required and without the necessary home adaptations being put in place. The following day, an ambulance had to be called and her husband was readmitted just 40 hours after his discharge from hospital. He remained in hospital for a further two months.

As you can imagine, that carer was really exhausted and disillusioned by that experience, and felt in some way that she'd let her husband down. But with the support of a carer officer, a full two months later, the patient was successfully discharged home, with adaptations having been made to the home and a full care package in place, alongside support for that carer. I think this is a really important illustration of what can happen and the impact on people when discharge goes wrong.

The timing of assessments and the involvement of third sector care officers is really key in making sure that we plan effectively, and there are barriers to that. In some areas, we see third sector involved in multidisciplinary team meetings, and that has been hugely impactful in improving the experiences at discharge. In other areas, because of general data protection regulation concerns, those officers are not able to be part of multidisciplinary team meetings, and that is definitely a barrier for unpaid carers being both identified and having their needs supported.

I think it’s also worth noting that local carer organisations tell us that many carers really aren’t aware that they have been assessed. Some conversations that are had around discharge are not clear to them that they count as a carer’s needs assessment. So, a barrier in terms of access to their support is actually understanding what process they’ve been put through and having access to an advocate to support them to make the most of that opportunity.

Finally, I’d like to note, as has been referred to, waiting lists for assessments. That is a real barrier, whether it relates to the delaying of the assessment of the need of the person who is cared for, but also that carer being able to have an assessment prior to discharge being appropriate for the person that they care for.

Thank you for that. Sometimes, the picture you build up in your mind’s eye can be worth 1,000 words, so that was really interesting. My last point—actually, I think you’ve answered it in many ways, because I wanted to talk about what you think would help to ensure that the role of unpaid carers in supporting hospital discharge is sufficiently recognised. Well, of course, an assessment is a clear recognition of them, I can see that. However, perhaps we can put the assessment practice aside to see if there’s something else we need to perhaps explore. How can the role of unpaid carers in supporting discharge—how can that be recognised more, along with the duties to support carers and the cared person? For example, does hospital discharge guidance need to be prescriptive on what should or shouldn’t happen?

Rob.

Yes, I can go. So, I think, yes, Kate’s given some good examples of good practice already outside of the assessment piece. Both Carers Wales and Carers Trust Wales are involved in the Care Aware project, which aims to upskill and train and provide resource and support to professionals in health and social care settings. Carers Wales look after the social care side of it, and Carers Trust Wales look after the healthcare side of it. So, we provide training in Carers Wales for social workers and provide resources, all co-produced with carers and social workers, to try and get that nice kind of Goldilocks moment of what works best for both sides and both sets of experience.

So, yes, it's greater training, greater support and resources. Guidance I think is important, but I’m conscious as well that lots of guidance exists on shelves. Again, we’re talking about people that are not time rich, whether it’s in healthcare settings or in social care settings. So, having the ability to look through that and understand it and implement it is difficult. So, yes, I recognise that as well.

I think there are things that we could be doing, but ultimately, as well, we know that lots of unpaid carers struggle to be identified as carers in both healthcare settings and social care settings. So, by upskilling and training staff, having more information and advice available to help prompt people who might be helping to look after someone in those settings to think, 'Oh, maybe I am an unpaid carer, maybe I am looking after somebody', and then seek support, whether that’s through third sector organisations, whether that’s through statutory services—it’s that almost kind of one-door-in approach where we can work together to help signpost those carers to the best sort of support that’s available for them, whether that’s locally or nationally. I think more can and should be done to raise awareness as well, and that’s one of the key critical factors.

That's a really important point, actually, for carers to understand if they are a carer and not just a concerned family member. Because there are certain things you start doing—Siân, you know first-hand about that. That seems quite fundamental. They don’t know to go to anybody to get signposted to get support unless they know what they actually are.

That's right, yes. So, we've done some research, and I can't remember it off the top of my head, but I'm happy to share it with the committee afterwards, so I don't get my figures wrong. But it takes years sometimes for unpaid carers to become identified or to recognise, and we know that the largest way in which carers are identified is by other carers. You have that conversation to be like, ‘Oh, by the way’, as I know from my experience. Again, Siân's nodding, so I imagine this is resonating with you here. I think that identification piece is really key. We are doing some work with the Welsh Government to try and spread the good word on this. But there's no silver bullet. Some people resonate with the term ‘unpaid carers’, others don't. It can be quite polarising. There are cultural competencies and differences we need to take into account here. Unpaid carers are viewed differently, depending on your background and your culture. So, yes, it's really hard, but a really fundamental part of the process is that identification piece in the first place.

Okay, Peter? Kate, did you want to add anything to what Rob has said on those particular matters?

Yes, and, to support Rob's point, in terms of minoritised ethnic communities in particular, the cultural recognition of being an unpaid carer may be lower. We've undertaken some research in this space and the programmes that we deliver nationally have evidence that there is a gap in terms of awareness, and some of that is a language barrier—there may not be a word for being an unpaid carer—but also a kind of stigma around the cared-for person's needs or taking that role as a carer and describing it in such terms.

I'd also like to highlight the work that Rob described in terms of the Carer Aware project. It is a Welsh Government-funded programme that has run for over five years, and, whilst it is not a silver bullet, it has made significant inroads in working with local health boards and health professionals to improve awareness of carers and the importance of healthcare professionals as individuals who have the opportunity to support carers to understand themselves in such terms and connect to their rights.

Rob referenced the good practice guide to supporting carers through hospital discharge. I'm really proud of the way in which that was developed. It is a solid piece of guidance at a service and policy level, and also for front-line professionals, but awareness of it is again patchy, and uptake of the advice set out within it is not consistent. So, I think there's a real action there, that there is something that has been developed, that is effective and just needs to be rolled out and embedded.

I think it's also worth noting evidence from Carers Trust's network of local carer organisations that demonstrates the importance of integration. So, when we talk about what else we can be doing, integration is really key. And by that I mean between health and social services, in support of unpaid carers through the hospital discharge process. It can be absolutely transformative when things connect up well for carers and that pathway is clear to them and to the professionals that are working with them. And that does demand a more integrated approach to the funding of unpaid carer support at a regional level. I think it has to recognise those multiple touch points for carers across health, social services and third sector organisations.

To provide a positive example of what works well, Carers Outreach, a network partner of Carers Trust, has in the past few weeks been able to reinstate a hospital facilitator in the discharge lounge at Ysbyty Gwynedd. Carers Outreach is co-located in that hospital with the social work team and other third sector organisations such as Care & Repair, Age Cymru Gwynedd and Môn, and they're helping to facilitate joint working that really wraps around that patient and the carer and their wider families. So, I think being located on site means greater awareness, both for the carers and for staff, to be able to refer into that service.

As I referenced really briefly earlier in the session, Swansea Carers Centre has a really effective hospital facilitator project, which has been substantially enhanced by their ability to participate in multidisciplinary meetings. They've supported really significant improvements in carer identification, they've supported learning for staff, improved connections between wards and the social services team, and advocated for unpaid carers on occasions where they were concerned about the safety and sustainability of proposed discharge plans.

Okay, Kate, thank you very much. Siân Gwenllian.

Diolch, Siân. Okay, Kate or Rob. 

Happy to let Kate go first on this one; I've gone first for all the other ones, so I'll sit out. 

Kate. 

Yes, happy to speak. So, to begin with, focused on GPs, previously quality and outcomes framework points were available for the recording of the number of carers that were supported. That doesn't exist anymore and hasn't existed for a long time. I do think there's a real opportunity in both GP and hospital settings to look at our record keeping, and how we can make sure we have really good data about the number of carers that are coming through. Nationally, there's a real paucity of data in terms of unpaid carers, and this feels like a real opportunity to address that. 

But I think secondary to that, and perhaps most important from an unpaid carer's perspective, is supporting GPs themselves and staff within GPs to be able to signpost effectively. Where there have been posts funded for GP facilitators, usually through the third sector, we can see real improvements in terms of signposting into services, so that carers at an early stage might be identified using language that's helpful to them. So, something along the lines of, 'Are you supporting someone?', 'Who are you here with today?', can open doors far more than, 'Are you a carer?' So, I think encouraging that professional curiosity and supporting really busy people to know where they can signpost to is really important. 

When we've asked professionals within the health service, including GPs, why this presents a challenge, one of the issues that they do reference is the changing nature of the services provided by the third sector, and that is caused by the annual funding that they often receive. So, the lack of consistency in what is available feels like a really insurmountable thing for very busy workers within GP surgeries and in hospital environments to keep on top of what is available and where they can signpost to. We know that first point of contact can give a really positive experience if we signpost carers to a good first point of contact. But we also know that, in other areas, carers have reported not receiving adequate information, advice and support. And the evidence from the Association of Directors of Social Services Cymru review supports that position. So, reflecting on what can be done at GP, there is a lot that can be done, but it requires investment, and it requires the investment over the long term.

Okay, Kate. Did you want to add anything, Rob?

I just wanted to pick up on some of the points that Siân raised about choice, and this factors in to how statutory services, including local authorities, can and should support unpaid carers, through discharge but also just more generally as carers. So, the Social Services and Well-being (Wales) Act 2014 says that carers must be asked whether they're willing and able, or what, sorry, they're willing and able to undertake. But we know that—

It doesn't happen.

Yes. So, we know that, by and large, that isn't the case, unfortunately. This has a massive knock-on effect, and the risks that you alluded to earlier I think are really stark. So, we did some research last year, and found that 64 per cent of current and former carers surveyed in Wales said that they had no choice but to care—that was their only option. So, that's a pretty high number, if we're honest. In some further research last year, 27 per cent of carers who care for somebody who had been discharged from a hospital setting in the last 12 months said that they were involved in those decisions and care planning—so, one in four. And only 12 per cent of carers were identified in medical settings. So, the scale of the challenge is vast.

The risk in terms of carers having no choice but to perform that role, I think I want to point out, immediately, will have a disproportionate effect on women, because the vast majority of unpaid carers are women. So, there is an equalities angle, which is just staring us in the face. But, equally, it's completely juxtaposed with any sort of Government initiative around economic growth. The amount of carers that we speak to who have had to retire early or who have had to give up work altogether and rely on a now-diminishing welfare state and system to provide care—. They're saving the Welsh Government £10 billion every year with the care they provide—that's how much it would cost to replace that care—and the thanks they get for it is poor mental health and having to be pushed into poverty because they've given up work, and that strips away their identity as well. Anecdotally, if I had £1 for every unpaid carer who'd said to me, since I started this role, 'I'd love to go back to work but it's just impossible'—. That's the risk. And hospital discharge is a critical part of that. If you're being launched out of hospital to try and avoid bed blocking, and having to have unpaid carers pick up the pieces, who are having to try and balance work and care, that is another dimension to this that I think just isn't really appreciated in the grand scheme of things. So, I just wanted to pick up on those points as well.

Thanks very much, Rob. Siân.

It's the $1 million question, isn't it, I think. To caveat everything I'm about to say, this problem is never going to be easier to fix than it is today. The trajectory that we're on as a society, with developing complex care needs, an ageing population, means that this is only going to get more difficult to fix the longer we wait to take action. And I personally feel—and everything that we hear from unpaid carers tell us—that this isn't achieving a sufficient level of priority at multiple layers of Government and successive Governments as well. So, I think, in terms of the direction that we're going, I don't know, is the honest answer, where we are going, but the facts are stark that more people are going to need care for a greater period of time and in more complex ways as we get into the future. I don't see an alternative where that isn't inherently reliant on unpaid carers to step in and do that, otherwise we're talking about, again, £10 billion-worth of replacement care to do that via statutory services. I'm not sure that's ever really going to be a realistic option for anybody.

So, it's multifaceted in terms of the way that we need to address this and start to build a health and social care system that's fit for the future and addresses these needs, whether it's through discharge or everything else. There needs to be greater flexibility for carers to be able to balance employment, work and care, because, again, anecdotally, lots of carers who otherwise would be able to work want to do that, but there are barriers in place to stop them from doing that, and that's to do with the welfare system, but that's also to do with employers and supporting employers to be able to support carers. But I think, equally, unless we have a support system in place via statutory services that is able to recognise carers' needs on a local but also a national basis, and plan adequately to support carers, we're going to be back here again in a year's time, scratching our heads, thinking about, 'How has it got to this point?' again. And while we're doing that, the trend for carers' health and well-being is heading in just the most alarming way. Between 2023-24, in our State of Caring survey, there was a 36 per cent increase in the number of carers reporting poor mental health. The surveys are always bad; the findings are always, always bad. We read them every year; they always make for stark reading, but last year's was just so alarming, and paints a picture of things going the wrong way. That's not in spite of will; there's lots of good work going on, but I don't think, if we're honest, that it's anywhere near to meeting the scale of the challenge.

Okay, Siân. Kate, did you have anything to add to that?

Yes, please. I think Rob makes some very stark points, and I'd like to note that if we do not invest in the support that carers need, we really do risk doubling that pressure on the health and social care system. It's going to see higher rates of failed discharges, it's going to see those readmissions that we don't want to see, and that couples with the potential for carer burn-out and need for more intense intervention moving forward.

The Social Services and Well-being (Wales) Act 2014, I think, is really ambitious, and I would applaud Welsh Government in their policy direction for unpaid carers. There is a clear strategy, real intention to deliver for unpaid carers, but there is an implementation gap, as we've already discussed. We know that community-based support for local carers is truly preventative, and it is an essential component of well-being provision that local authorities and regional partnership boards need to commission for their population, but they can do a better job of commissioning that, and it's important, I think, to reflect on recent guidance through the national commissioning framework, which I think often isn't met across parts of Wales.

I wanted to reflect very briefly on some good examples of national approaches and learning that we've taken from them. We know that poverty is a significant issue for unpaid carers, and poverty alleviation is a key priority for Carers Trust, therefore. We have been fortunate to be the national delivery partner for Welsh Government on the carers support fund, which is designed to provide emergency grants for unpaid carers, meeting the most urgent need of those at the sharpest end of poverty, but also to support income maximisation. These have been really effective schemes, but it's surprising to me that almost half of those that are accessing the carers support fund have not previously had access to any other support. So, when they join that service or request something to support them with heating, with eating, with having a bed—not replacing a bed, but purchasing a bed for themselves because they do not have one—they are not already connected to statutory services or commissioned services, and that has been a consistent finding across five years of delivery. When we ask unpaid carers where they would go for support without that carers support fund, a common answer is 'loan sharks'. So, I don't think we should dismiss the level of poverty that we have amongst our caring population and the impact that can have on their ability to flex and meet new needs as somebody might be discharged from hospital in a different condition to that in which they went in.

I would also like to reflect briefly on the national short breaks scheme, which, again, we are the national co-ordinating body for. Eighty six per cent of people who fill in a survey after the break they receive through this scheme tell us that they have not had a break in the year prior to that, and that dropped slightly to 75 per cent for young carers. To me, seeing three quarters of young people who are providing support not having had a break in a year feels very stark. So, these schemes are making headway; they are creating flexible and person-centred short breaks in a really place-based way, but we're still finding, year on year, that those accessing this essential support that will prevent carer burn-out aren't connected into wider support. So, again, a little bit of a theme of the evidence I'm providing today is that integration, signposting and a clear pathway for carers are so important. That no-wrong-door approach that we've discussed so many times has never been more applicable.

Diolch yn fawr, Kate. Thank you very much. Lee Waters.

Thank you. Yes, we've discussed discharge quite a bit. I just wondered if there was any particular good practice you've been able to identify that you think should be scaled that the committee might recommend.

I'm happy to speak on this. In terms of hospital facilitators and hospital officers, we know that co-location is really important. If we have those experts in carers' rights and carers' needs at a place where they're accessible to healthcare professionals to support their learning and be there to take on that role, it is not the role of the hospital doctor or the hospital nurse to provide that hand-holding or advice to the unpaid carer, but to have somebody within a hospital location that they can signpost directly to is quite important. Also, to pick up those that haven't been identified—a stand on a concourse, a hub within a hospital, really, really helps to capture those unpaid carers who might not self-identify or might not have been identified whilst the person they care for is in hospital. The co-location with local authority social services teams has also been a really positive example of how we can join things up effectively.

And I think finally, to note, I've already said it, but multidisciplinary team meetings: it surprised me within a Carers Trust network to see, in some areas, carer officers, carer hospital facilitators sitting on multidisciplinary team meetings, and in other areas them being told they can't—'GDPR says "no".' So, what is the answer, and what guidance can we provide to health boards and carer services to take a consistent approach across Wales that prioritises getting the right people in the room to advocate for and connect with unpaid carers?

Thank you. That's clear. Carers Wales says in the evidence, in terms of the challenges around discharge from hospital, that a system of fast-tracked direct payments to enable families and patients to purchase the support they need to short-circuit the system would bring benefits. Can you tell us whether this has been tried? Is there evidence of this?

So, the practice massively varies on direct payments, no matter how you look at it. I think a lot of this is through co-production of evidence with carers. So, when we ask them what would be good in that respect, that's one of the things that comes through to us. But I would also just add a caveat around direct payments that there is a bit of a postcode lottery around that. This definitely isn't a silver bullet; I think it's one method by which we can help to support unpaid carers. And also, with direct payments, there's that element of choice and control, but the services have to be in place for the carers to be able to commission and pay for as well, and we know that that's patchy too. So, I think it's an option; it's something that we need to look at in more depth and detail, but there are pitfalls as well.

Just so I'm clear, at the moment, it's a concept rather than the existing practice anywhere?

Yes.

Okay. Thank you.

Okay. Diolch yn fawr, Lee. Laura Anne Jones.

Diolch, Chair. I was just wondering, considering what you were just saying about the carers saving Welsh Government lots of money, of course, by what they're doing, what are your views on the effectiveness of the Welsh Government's strategic approach on hospital discharge, and what further action do you think is needed at a national level to tackle these delays? Thank you.

I think anything that talks about hospital discharge, as a general rule, often doesn't give adequate consideration or recognition of the role that unpaid carers play in that process. Just to give an example of this, I think the recent—. Is it a 50-day challenge that happened recently? I would encourage Members to go and look at that. I wasn't able to find any mention of unpaid carers in that, despite the fact that the success around hospital discharge inherently hinges on unpaid carers' ability to provide that care once people are discharged.

We all agree that the vast majority of people that are in secondary care settings don’t really want to be there. It’s also the most expensive point in the system, so it’s in all of our benefit and interest to have people out in the community, but there has to be sufficient support in place to do that. And to make sure that happens, we need to see that clearly communicated from the very top, and I don’t think that that is done adequately with regard to unpaid carers at the moment. I think there are examples of good practice more generally with unpaid carers, but in relation to hospital discharge not nearly enough priority is put on unpaid carers or recognition given, I would say.

Diolch. 

If I can come in there, I would agree it's really notable that Welsh Government's 50-day winter challenge, which was only published in November, and the 10-point action plan to support people to be discharged from hospital sooner, did not include a single reference to unpaid carers. It really was a missed opportunity to bring together existing Welsh Government-funded work streams, which includes the £1 million allocated between all health boards annually to support unpaid carers through hospital discharge.

Okay. Thank you. That's very useful. In terms of preventing avoidable admissions, we've heard today that there needs to be a more proactive approach in the community to support frail older people at risk of falling and preventing them to need to go into hospital in the first place. Is a similar approach needed for unpaid carers, who are struggling to cope, where there are risks of carer breakdown? What are your thoughts on a more a proactive, preventative approach and how that can be progressed? Are there any practical steps that you could perhaps suggest? Diolch.

So, for me, in terms of prevention, we know that our third sector organisations, those local carer organisations across Wales, do an amazing job at being that preventative force, and they do do so in a way that's really dynamic in terms of generating funds to expand services. We know it's a difficult financial environment, and the third sector are incredibly lean and incredibly good at generating match funding to do the things that matter to their communities. That co-productive approach that is really embedded in what local people need and where they want to receive that service is really strong. But statutory funding remains really inconsistent, and whilst things like the regional integration fund should be providing funding over five years, that isn't the experience of our network partners. Some are receiving in-year funds, 'Please get this spent in the last six months of the year', and others are waiting until the end of March to find out if they still have the funding for those important preventative services in the next financial year. So, the plea from me, really, would be to look at that, how we are commissioning our third sector as important partners in that prevention journey.

Thank you.

I would echo all of what Kate has said there. And just, again, to reiterate that point around prevention, what the Act sets out to achieve, I think, nobody really broadly disagrees with. It is the implementation gap that is the issue here. The Act is in and of itself inherently slanted towards prevention, but the fact of the matter is that, at the moment, everything is just hitting crisis point and we’re having to deal with just consistent firefighting. And obviously, you can’t just drop that to then focus on prevention, you have to get that mix right and balance between the two and try and shift away from the firefighting towards preventative approaches. But, again, I just don’t get the impression that this is of sufficient priority within the agenda of successive Governments, and, again, that’s at local, devolved, reserved level, to meet the challenge—the scale of the challenge.

In our 'State of Caring' report, again, the numbers of carers who tell us that they’re worried about their ability to provide care in the future increases year on year, and we’re talking—. I think it’s nearly three quarters of unpaid carers that we surveyed last year who said that they’re worried about their ability to continue to provide care. And if they can’t provide care, people are going to be admitted into hospital and treated again in the most expensive part of the system where their needs, often, will struggle to be met and carers will again feel guilty about burn-out, and it’s just a self-depreciating cycle. So, I think a greater emphasis on priority is what we would call for in addition to all of the things that Kate’s spoken about there with regard to commissioning services too.

Okay. Thank you. So, your key recommendations to the Government in terms of your absolute priority actions—. What would you say those are, on top of what you said—or reprioritising?

Close the implementation gap of the Act, if I can give it in a nutshell. 

Well, it's useful to be that clear. Thanks, Rob. Kate, did you want to add anything at all?

I would absolutely concur with Rob's point: close the implementation gap. The legislation is good, the strategy for unpaid carers is good, let's deliver on that.

Okay. Well, Kate, Rob, thank you both very much for giving evidence to committee today. You will be sent a transcript to check for factual accuracy in the usual way. Diolch yn fawr.

Diolch. 

Thank you. 

Item 5 on our agenda today is papers to note. We have one paper: additional information from the Welsh Local Government Association regarding our work on housing support for vulnerable people. Are Members content to note that paper? I see that you are.

Item 6, then, is a motion under Standing Order 17.42 to exclude the public from the remainder of this meeting. Is the committee content? I see that you are. We will move to private session.