National Assembly for Wales

Thank you, Chair. Good morning, Minister. It seems strange calling you Minister.

I know. [Laughter.]

I first wanted to ask you—and this will be something that you're aware of from when you were on the committee, but evidence that we've taken in discussion with carers would suggest that their awareness of their rights under the social services Act is somewhat limited, or even non-existent, really. So, I was just wondering if you could tell us what Welsh Government is doing, or has been doing, to try to improve that situation and raise the awareness of carers around their rights, particularly in relation to assessments.

Yes. Well, obviously, awareness is absolutely crucial, and that's something the Welsh Government has been working on. In terms of raising awareness, we believe that the best way of doing that is probably through the third sector because the third sector works so closely with carers and has got a much closer rapport, perhaps, than other organised bodies.

So, we have funded a number of third sector organisations in order to promote rights. From 2016 to 2020, funding of over £1.7 million has been awarded from our third sector sustainable social services grant scheme to Carers Wales and to the Carers Trust Wales. And there's been direct funding to Carers Wales and Carers Trust Wales of over £80,000. So, that's an example of how we have been actually funding, and I can give you other examples: £45,000 to Carers Wales, which was funded to develop the Employers for Carers Wales hub to support employers to support their staff who are carers; support to develop a young carers identity card to improve awareness of their needs for support; and direct grant funding, which has been each year since 2016, to the all-Wales forum of parents and carers to raise carers' awareness of rights under the Act. So, there is quite a bit of funding going out to third sector organisations, and we see them as the best people to raise the awareness. But I absolutely agree, there's an awful lot more work to do and many people are not aware of their rights, sadly.

I think that's really helpful because, certainly, in the conversations we've had with carers, the third sector seems to be their primary source of information. But do you think local authorities also need to be more proactive in terms of making carers aware of their rights, and also, perhaps being more proactive in terms of the training of professionals? Because it did seem to us, as well, that quite a lot of professionals don't seem to know what's contained within the Act. So, again—I mean, those professionals directly employed by the local authorities—there's a role there for the local authorities. So, is there any work going on around that?

Well, I think one of the big issues, of course, is that there is quite a changeover in staff. And so, I think when the Act first came in, there was a lot of training carried out then, but since then, there has been quite a lot of churn of workers, so it's really important that we do keep professionals up to date with what's actually going on.

And, the officials stay in touch through the care workers and the local authorities, through the Carers Officers Learning and Improvement Network. And they do hear, then, about the work that is going on on the front line and hear about the support groups. There are quite a few support groups for professionals who are working with carers, and some sort of peer groups where they support each other. So, there is work going on in that sort of way, but obviously, I do think a lot more can be done to support carers—

There's still more to be done, absolutely.

—and it is crucial that professional staff are up to date and clear about what's happening.

Sure. Just within this kind of group of questions, are you satisfied that all the Welsh language aspects are also being taken into account? Because again, that tends to be one of the areas where there's a little bit of deficiency sometimes, so, in terms of all the awareness raising, we're also ensuring that the language aspects are not being forgotten about as well.

Well, it's absolutely crucial, because obviously, the health board, the local authorities, they're all under the Welsh language standards, so it's crucial that they do follow those standards. So, that is there; those regulations are there, and so, in terms of following them, that's what the local authorities have got to do.

Obviously, in this sort of field, it's absolutely crucial that people are able to have services in the language of their first choice, of their own language. And so, it's absolutely crucial that they do follow the standards that already exist.

Okay. Thank you for those answers. Can I just move on, now, briefly, to the NHS and its role in this? Because there's been some concern that NHS involvement with carers is probably weaker and less consistent across Wales since we repealed the Carers Strategies (Wales) Measure 2010. Did you share those concerns, and if so, do you think there is possibly a case for strengthening the duty on NHS bodies in relation to carers?

This, I think, is repeated quite a bit—that the carers Measure has weakened the service and has weakened carers' rights, but I wouldn't agree with that, because I think the actual Act does make carers' rights much stronger. And in terms of the rights to assessments, I really do feel that they are embodied in a new way in the Act, and it's important that that's how it should be. But, of course, in terms of making healthcare staff aware, and training, I mean, all that applies in the same way as it does to the social services and the local authority.

I accept what you're saying there. So, do you see there being a role for Government in terms of ensuring that the NHS are more actively involved? Because certainly, it's something that I pick up; that local authorities do complain about the fact that they find it sometimes difficult to engage NHS partners in some of the work that they're doing around these sorts of issues. So, do you think there's a role for Government in trying to get the NHS to be more proactively involved?

I think one of the areas where the NHS is involved is in the regional partnership boards, and I think it's crucial that those organisations in the regional partnership boards work together. I know carers have said that they feel a bit out on a limb in those boards; that they don't feel that they're there with equal status with some of the bigger organisations. So, I think that's the area where we've got to ensure that carers and the third sector feel that they are equal partners, because I've certainly had people saying to me that they don't feel that they're equal partners in those boards.

And there's probably something to be said for that devolving even more locally, as well, isn't there—the involvement of NHS partners, local authority, third sector and so on. So, I think what you're saying is, if I'm not putting words into your mouth, that the social services Act does actually provide the vehicle for that; it's just a question of ensuring that that is followed through by all the bodies responsible. 

Yes, I think there's—. You know, carers' rights are strongly enshrined in that Act, and I think it's an Act that has been widely supported and praised. Along with all Acts, it's how it actually works, which, I think, we obviously see with all legislation. The structures are there, but in order to make it happen, that's what we've got to do.

But all the bodies identified in the Act, whether it's social services, whether it's the NHS, in your view, have all got a responsibility for helping to identify and support carers as well. 

Yes, absolutely. Yes. 

Lovely, thank you, Chair. 

A supplementary, David. 

Just a quick one, Minister. I fully appreciate that the Act says that the rights are there, but how do we ensure health boards are actually putting the money in, because in my area in particular we have carers services provided by the local authority who are struggling to get funding from one of the health boards? So, how are you ensuring that health boards actually meet their duties to ensure that there's funding going into some of these services? 

Obviously, it is their duty to put the money in, but in your experience, if that money isn't going in—. I don't know if the officers have got any views on that. 

The health boards, local authorities and the third sector are joint partners in those regional partnership boards, and together they should be assessing and agreeing the needs of people in their areas, and commissioning plans to meet those needs. I appreciate that sounds like a technical answer as to how that's implemented—

Let me ask you a question, then: how do you ensure that's happening? 

We ensure that's happening through monitoring of the integrated care fund. The Minister mentions the extra resources that are going in. So, there's £50 million of revenue that's been allocated through the integrated care fund in recent years. There's £80 million revenue going in next year, so we've got quite a robust monitoring approach for the integrated care fund, where we take quarterly reports from each of the regions, and in quite a granular way they describe the progress with the projects that are being implemented on the ground. Many of those relate to carers. Carers is one of the four priority areas in the integrated care fund, and the additional £15 million that was put into the integrated care fund for 2019-20 is purposed for adults with care needs, and carers specifically. So, we watch that quite closely.  

So, if it's not happening, you should be able to spot it and you should be able to take action on it. 

We should be able to scrutinise that and to take action. There's a balance to be struck, I think. Government isn't always in the best position to determine what the nature of provision should be on the ground. Regional partnerships boards are those mechanisms that are there to assess needs and commission plans. It's Government resources that we are accountable for, so we take that role very seriously and we do scrutinise. We host a learning event for integrated care fund partners every year to try and exchange best practice there on the day, and to do that in between meetings. So, we try to link good practice and we do absolutely scrutinise that very significant investment the Government makes. 

Before we leave the NHS, can I just ask another supplementary? As regards discharge from hospital—patients/carers, same person, or their loved ones—are carers actually being identified at that point, and are they being sent home with the appropriate information? We've had a bit of evidence—quite a bit of evidence, actually—that suggests that, actually, there's a missed opportunity as regards identifying carers at that point, really, and then easing a path into care at home afterwards. 

Obviously, that is a crucial point, isn't it? I think there has been some money particularly given for that particular area. Was there £3 million given? 

Three million pounds in respect of respite primarily, and another £1 million into health boards last year and into the next financial year specifically around effective transfers of care. I think we'd absolutely acknowledge there's an issue there. Some moneys, as we say, have gone in in the last 12 months. We're keen to understand the good practice that's been identified and see that spread more holistically. There's a lot of attention around effective transfers of care, clearly, at the moment with the NHS delivery unit looking at that alongside ourselves and the social care team. 

Okay. We'll move on to the education sector. Lynne. 

Thanks, Chair. The committee's taken very powerful evidence from young carers, in particular about their experience in school, where many of them still feel that they are invisible really. And one of the things that they've suggested is that the Welsh Government could issue guidance to schools on better supporting young carers. What is your view on that suggestion, and what else are you able to do to ensure that schools do offer the support that is needed to our young carers?

Well, first of all, I absolutely agree with you. It's absolutely crucial,—schools are crucial in helping young carers, recognising young carers and making their pathway a bit easier. So, I think it's an absolutely crucial area. And the Government certainly recognises the importance of schools in identifying young carers. Now, the development of the new curriculum, with its emphasis on well-being, that should provide an opportunity, I think, for there to be more empathy in schools and more understanding, because, obviously, of the fact that it is concentrating on well-being. So, I think that's an opportunity to take forward.

And there have been two guides produced for schools. Carers Trust Wales has produced two associated guides for schools, the 'Supporting Young Carers in School' guide and toolkit, and 'Supporting Young Carers in Schools: A Step-by-step Guide for Leaders, Teachers and Non-teaching Staff.' So, the Carers Trust have produced those, and they were written in association with teachers and with school staff, to make the identification of carers as easy as possible.

The Carers Trust have also developed a toolkit aimed at supporting students with caring responsibilities who are in further education, and those are there for schools to access, but, obviously, I think we do need awareness training in order for these schools to know that they need to access them. I don't know if you've got anything you want to add on this, Ceri. 

We're very much aware of the importance of young carers. They're an important strand for us from a strategic policy perspective. I have close links and have met with Carers Trust Wales and Carers Wales, and, in fact, recently, the young carers council of Carers Trust Wales met with the Minister's predecessor, Mr Irranca-Davies, last autumn to hear the issues directly from a couple of the individuals who came to the session the other day. So, there are resources out there. There are some very effective resources, very useful resources. They have been piloted in some areas. Some schools are very good. I'm aware that there is much more to be done, obviously, in terms of making schools aware, and also governors, the leadership bodies, et cetera, in relation to schools and their duties. There is much more to be done, but we are strongly aware of the focus and need to help support young carers. 

You've hit the nail on the head there really, haven't you, in that some schools are very good at it, some schools aren't. And that's something that's very familiar to me with the work that the children's committee has been doing around mental health and a whole-school approach to mental health, really. So, do you think there is scope for Government to be more prescriptive really, or to link in with the work that is being done around developing a whole-school approach to mental health, to ensure that there is a consistent approach to young carers across Wales?

I think the whole-school approach should automatically include young carers, so, yes, I do think that that's the way to go ahead. 

Estyn is also undertaking a thematic review on young carers in schools and colleges. That's in the 2018-19 year, and so I think that will provide us with a much better understanding of some of the barriers that young carers face in education, and in identifying good practice. So, I think that Estyn report will be helpful as well when that comes out, and that will be coming out in the spring some time. So, I think you're right, and, as Ceri has said, there are very good patches, and others which are less aware, so I am hoping that this whole-school approach and the emphasis on well-being will be ways in which Welsh Government will be able to use to ensure that there is a more uniform response, because young carers spend so much of their time in school, when they're able to get there, that it's crucial that they are treated sympathetically there. 

Absolutely. Can I just ask about young carers' ID cards? Young carers have told the committee that they think that's a valuable idea, and I know that Welsh Government announced some funding to support a national roll-out of the scheme. Can you just update us on where things are with that and when you expect that to be completed by, really?

The programme for implementation is being finalised now, and we'll be writing to the local authorities and the other delivery partners very shortly and we'll be able to provide the details of the scheme there and say to the local authorities what we hope their role will be in implementing it, and the support that the Welsh Government will provide to enable the scheme to really meet the needs of young carers. Because it's very important—we will be producing this card, which will be a national card and will be specifically for young people, because I know there are other cards that are more localised. There is absolutely no point in producing a card in isolation, because if you just have the card and nobody understands what it means—. So, it's absolutely essential that we get the real benefits of that card. I think that means that we've got to make sure that the professionals understand the issues related to young carers, because if they haven't had any briefing or understanding of the issues of young carers, they're not going to be able to respond to it. So, I think there's quite a lot of work to do. It's not just about producing a card, as I know you know.

Diolch, Cadeirydd. Good morning, Deputy Minister. We've had published statistics—we always get statistics—obviously, but this time they relate to a small number of carers actually being assessed in their own right. I suppose the first question I want to ask is: do you recognise the statistics, and, if not, what are you doing about it?

We're committed to publishing data relating to carers and their services, and we think that's really important to do. We are determined to get reliable data, but it is difficult to get it because the local authorities all measure it in different ways. So, in order to actually get reliable data, we have to try and get the local authorities to measure things in the same way. And I think we are planning to start that, aren't we, now? I don't know if you want to say that.

Indeed. I think you're aware that experimental statistics were published quite recently for the 2016-17 year. The issue, as the Deputy Minister said, is getting standard definitions across the 22 local authorities. So, we're making progress on that. I know, in your terms of reference, you're interested in potential variation between local authorities, but the statistics, as they are, don't really help us to shed any light on that at the moment, but the more robust that we can make that approach, then those sorts of insights will then come through. So, we're making progress with that. 

The take-up of the Welsh Community Care Information System—the community infrastructure around care information—I think will help in that again, as the intention is to roll that out across Wales, and the committee will be well aware of that. I think the data's quite interesting, isn't it— absolutely acknowledging your point that there is a relatively few number of assessments that are undertaken in respect of the population size of carers. Of course, as we say in the evidence paper, not everyone with a caring responsibility necessarily needs an assessment. There's a gradation towards that point. 

The data also shows that more people who were offered an assessment actually refused that assessment rather than took it up. So, I suppose that bears out the point, really. It's harder then for us to determine what's the right number. I think we would absolutely acknowledge that it seems that fewer assessments are taking place than there should be, but it's hard to identify what the right number is. So, the evaluation that's in train to look at the impact of the Social Services and Well-being (Wales) Act 2014 and the 'Measuring the Mountain' report, which is qualitative, citizens'-jury-style information, will start to shed some more light on that, I think, to help us understand the extent of the number of assessments that we need, which would not necessarily be the whole population, but it's probably more than we have currently.

Thank you. You raised a couple of points that I wanted to pursue in one sense. The WCCIS, you've identified, which is going to come into place—have you got a timescale for that for when we can see that it is operational and when you can expect actual outcomes from it?

Yes, I wouldn't be able to give you a definitive answer to that today. Some of that is at the discretion of those organisations. Clearly, Government can't mandate that. We're strongly encouraging that approach. It featured in 'A Healthier Wales', our long-term plan for health and social care, which was Government's commitment to push that along. We've set aside resources in the integrated care fund to do that. We're being more specific in the integrated care fund for 2019-20 where we'll say that, rather than a pro-rata allocation across regional partnership boards for WCCIS, we're going to invest specifically in those boards. They're on the cusp of implementing—[Inaudible.]—WCCIS so that the money is being used more clearly for that purpose.

If you can't mandate that approach, are you confident that that approach will work?

Yes. 

So, there's an expectation therefore as to when you can get something out of it. 

There's a clear expectation, as stated in our health and social care plan. The important thing about that approach is it transcends—both those sectors having a real community resource, I think, is in-keeping with the approach that most developed health and care economies are taking to their services, that it needs to be a much more stronger community-based service. The professionals in a range of organisations being able to share information and see the same information is absolutely critical to our vision for health.

But you're not committing to when you'd expect that outcome to be seen and the benefits that come from it. 

I'm just not aware of the timescale—[Inaudible.]

We can look at that and come back to the committee. 

They also talked about—obviously, the original question was about the number of carers that were actually getting assessed and support and the statistics. We've talked about that some refused the assessments. Have you done—? I understand the problem with data collection; that's another question I want to come back to. Have you done any analysis, or has any data been collected, as to why people are refusing assessments? Is it because they don't think they need assessment? Is it because they don't even know what it's all about? Do we know why people are refusing assessment?

I think there's certainly evidence that people did not want an assessment because they felt they didn't need it, because I think many people do carry on with their daily lives and think they don't need it. Certainly, there is some evidence of that. But that's why I think if we make people more aware of what possible help they can get that they might be more willing to identify—. Because a lot of people don't identify themselves as carers, do they? A lot of people—many of us in this room are probably carers, but we don't maybe identify ourselves as carers. So, I think there is a big thing about awareness. I'm sure you know these figures. In 2017-18, there were 6,891 who refused one.

I also wonder if some people may refuse because they're nervous about the officials coming in and seeing what's happening and thinking that they can't cope. There is some evidence that people are nervous of officials getting involved. I think that does happen with children as well, that, when children are doing tremendous tasks in looking after people, family members, at home, they are nervous of social services being aware and what's going to happen to their children. I think that's another thing. So, I think there's a multitude of reasons, but the more awareness that we can get of the fact that we do recognise the hugely valuable job that people are doing, the more willing people will be to say that they are carers and will be prepared—or want an assessment. Although I think, as Matt has already said, a lot of people don't really need an assessment, because, if you look at carers, the range is so huge. You could say someone was a carer who was just doing a couple of hours a week and who fitted it in their normal lives and certainly doesn't see any need for a carer assessment. Whereas people who are doing a lot more, over 19 and 20 hours sort of thing, that's when an assessment may be able to bring something that could help them.

I understand that, and therefore clearly there is a question as to the assessment process to ensure the needs of carers are identified. You've identified that there are some who have fewer needs and others have more complex needs, young carers in particular; also it may be appropriate as to what they're actually doing. I suppose, in a sense—have you looked at the assessment process? Because I've heard cases where some assessments of carers have been done with a holistic approach—in other words, they've taken the family. But that sometimes is to the disadvantage of the carers, because they've focused on the individual who's being cared for more than the carer. In other cases, it is of benefit, because you actually see how the whole picture and the whole thing works together. Are you looking at the assessment process to ensure that the right assessment process is being undertaken in those circumstances and no-one is losing out as a consequence of the way they do it?

Well, the carers assessment is clearly starting—should be starting—with the individual who is the carer. So, with a young person in the school, you start with the young person and look at what their needs are. But, of course, you would draw in other members of the family if you were going to do a holistic approach, but it must always start with the individual themselves, and that is how the assessment should take place.

I agree that's how it should take place, but, as I said, there are people who are going in to assess the individual being cared for, and then they tag on, effectively, a carers assessment and, as a consequence, the carer actually isn't receiving a proper assessment. How do we ensure the process doesn't—? Is this an easy way for certain councils to actually do assessments? Perhaps some people might call it a lazy way of doing it. But how do we ensure that that isn't taking away from the needs of the carer, simply because it was a quick way of a social worker going out, seeing it once, and not actually necessarily doing a full assessment of the carer?

Right. Do we have systems now to regulate that?

We do. So, the capability of the workforce, if you like, in the first place, is absolutely critical, isn't it—that the individuals, the local authority social workers who are going into those households, are aware of their responsibilities—and their responsibilities are as you described them. The assessment should be holistic: primarily the needs of the person who needs care, but also the carer and the family around that. That's the way that it should be done. So, there's a huge role here for Social Care Wales in terms of ensuring that the workforce has the skills that they need. Social Care Wales have funded the Institute of Public Care to develop, if you like, the next generation of workforce tools around assessment, to ensure that social workers understand their responsibilities fully. I think, for us, we've mentioned already that our relationship with the third sector is absolutely crucial here. The Minister engages in a number of ways, including through a ministerial advisory group, so we can take the temperature of this at face value. The monitoring and evaluation process that I mentioned earlier—so, the evaluation of the impact of the Act and 'Measuring the Mountain'—there's a key role for the inspectorate as well, isn't there, here, in terms of making sure the intentions of the assessment process is the experience of people and families. We'd acknowledge the point, I'm sure, that that's not universal currently. So, there's a good way to go.

And, of course, Carers Trust Wales have also highlighted the fact that, some young carers, the assessment—the level of care they provide isn't always appropriate. So, are you also ensuring that—as you go about those toolkits, that process to assess—the needs of those young carers are being addressed correctly?

If I may come in there on that particular point, yes, the statutory codes of practice are very clear in terms of the role of the assessment. It must consider the extent to which the carer is able and willing to provide the care and to continue to provide the care. The new carers assessment toolkit that Social Care Wales are producing and should be available shortly, from around March onwards, will help very much in terms of undertaking those assessments, whatever age the carer. It's work very much with the individual, the carer and the family—the young carer—to look at the capacity resources and the outcomes that they want to achieve. It's very much outcome-focused on what does the young carer want to achieve. We are aware that there can be sensitivities, in terms of taking this approach, of how you encourage a young carer to articulate, to help them to understand in the conversation—and it is a conversation—how they can articulate what it was they want to achieve. So, it is very much the importance of considering needs holistically, and we don't make any judgments. The assessment should not make any judgment; that's very clear within the duty on the Act. It's looking at what does everybody want to achieve and what are their needs and what are their care and support needs coming out of that conversation, and that's the crux of the matter, really.

Okay, and, just to put a point in, perhaps, when you talk about how much young carers are 'willing' to do, I always assume every young carer is willing to participate in the care for their loved ones. So, we want to make sure that we don't overburden them as a consequence. Just accepting a willingness—it doesn't mean to say they necessarily don't need that support, because they will need that support.

I think the point that's being made is that we don't judge what they're doing. We want to offer the support, which you've said, David.

Okay.

Happy?

Yes.

Right. Turning now to support services for carers, and Jayne has the floor.

Thank you, Chair, and apologies for not being here at the start of this meeting. We've heard from carers and organisations that represent and support them and they've told the committee that support services are scarce and difficult to access, particularly for young carers. We heard from Barnardos Cymru, who said:

'We've got some services now that can only provide six weeks of support. On average, they need in excess of six months. If circumstances change they should come back in and have the support they need for the duration they need it.'

What is Welsh Government doing to ensure that capacity is built in, particularly with the third sector, to meet the needs of carers?

Thanks very much, Jayne. Obviously, capacity is a huge issue, and yesterday I went to the Carers Trust Wales forum and heard directly from carers and people in the field about their actual experiences of the capacity. So, it obviously—. I mean, it is an issue. But the third sector is crucial, as, I think, we were discussing before you came in, because that is often the best way to deliver services because it's less threatening to individuals and much closer to people. So, from 2016 to 2020, funding totalling over £1.7 million has been awarded from our sustainable social services grant scheme to Carers Wales and Carers Trust Wales, and direct funding to Carers Wales and Carers Trust Wales for other projects was just over £80,000. I did go through some of these figures before. But we also had an additional £30 million via the integrated care fund to strengthen integrated working, and £15 million of this funding will be used to specifically develop preventative services for adults in need of care and support for carers. So, there is increased investment in trying to improve the capacity, but, obviously, it has got a long way to go.

Thank you. And I just think it's important to read this quote from one of the young carers who came before us. You might have heard it, but one of the young carers told this committee that:

'Going back to the limited support and what I was trying to say, once you are in the system of getting that support, you only stay in the system of support for six months, and then you have to be re-referred, which then means you go on a waiting list and then have to go back through the whole process again of being assessed as a young carer. Again, this is due to awareness and funding.'

I think that was particularly powerful, and some of us were taken aback, obviously, about the difficult system where they're going back in to have to be reassessed. Do you think that's a reflection of the insecure funding arrangements, or what would your comments be on that?

Well, I think I and the officials actually found that hard to understand, really, exactly what was happening there, and we thought that the officials should contact Carers Trust Wales to explore this because we don't really recognise what that example is, but obviously something is happening because it's come from the young person themselves. So, we certainly want to follow it up. But I think that was the view, wasn't it, that we didn't understand, really, this—.

Yes, we were just slightly confused, because that's not how the system should work. There's an annual assessment process for reassessment through social care, but that's not a kind of cliff-edge scenario where you stop something and start again. There can be, absolutely, continuity through that. So, we're just a little stumped as to why that individual clearly has been told or got the strong impression that there's a review every six months. So, if we can—you know, we work with Carers Trust closely—

It's good to hear you're taking that on board, then.

Yes. So, we will take that up.

Just moving on to respite care now, and everybody, and particularly carers, emphasised to us the importance of the respite care, but they say it's getting difficult to access, and particularly for young carers. Do you think there should be a stronger requirement on local authorities to provide respite? I know there's that example in Scotland. Are you looking at the Scottish example?

Yes. I heard the older persons' commissioner, I think, talking about some of the work that's been done in Scotland, and I think Scotland has a legal requirement, doesn't it, I think, for—. But I suppose we're trying to look at respite in a much more flexible, person-centred way, because I think we've always thought of respite as the person who's cared for, maybe, going away for a couple of nights to give a break, and I think that is very important, but I think we also want to think about it in a much wider way, that people do sometimes need to go away as a family together, and there are different ways that you can approach that, and also basing it on the individual, on the individual's need, rather than a blanket requirement. There are some examples of how we are working with the leisure industry to look for breaks. I don't know whether you want to give any more detailed examples of that.

Yes, so it's very much a focus on flexible, non-traditional forms of respite care. We have had reports from the RSG and the £3 million of funding that went through to local authorities in 2017-18 on forms of respite care. There was a report discussed at the carers ministerial advisory group, and that shows that, actually, a lot of progress is being made and it is looking at short breaks, family breaks. There is still a demand for traditional forms of respite care and overnight stay, but it's very much on looking at new forms and innovative ways, and people helping themselves, perhaps using direct payments as well, in terms of pooling funds and being able to purchase different mechanisms that actually give them a break rather than it being a form of care and an overnight stay, because respite can take many different forms, even if it's just popping out to the shops, going to a local coffee shop et cetera, meeting up with friends, meeting up with a carers' support group et cetera. So 'respite'—we understand the term itself can sometimes be a little confusing on what it actually means. I think it's understanding that it something that gives people a break.

So, you're looking at those innovative approaches in Scotland but also the ones in Wales as well.

We are aware of the Respitality scheme. Yes, we are certainly going to look at that example. And there's also the south-west Wales—apologies if I get the name slightly wrong—tourism network, which was launched last autumn, Link Cymru, Bridgend council, and there's been funding from the Welsh research side as well in terms of creating a research network to actually look at developing short breaks and engaging the Welsh hospitality sector in that area of activity. So, we are perhaps not as far but we are also looking at those elements as well.

Brilliant.

Could I just say at this point that we've mentioned that this has been considered at the ministerial advisory group, and a lot of these issues are coming up at the ministerial advisory group. So, I was wondering—I will perhaps address this to the Chair—if, when you've done your report, whether you would come along to the ministerial advisory group when we could take forward these issues that you are bringing up, because, certainly, respite has been discussed there and will be discussed again.

That sounds like a very good idea.

Yes.

We know that the additional £3 million to local authorities for additional respite care is now provided by the local government revenue support grant. Are you confident that the funding will result in additional respite provision, even though the funding's not ring-fenced?

Well, it is a duty on all local authorities under the Act to ensure that a carer receives assessment of their needs and that eligible needs are identified and a care and support plan is drawn up. And that is their duty. We have this issue about ring-fencing, don't we, with local government constantly? I mean, it's an issue that comes up in every subject on every issue, and you could either end up with everything being ring-fenced and then why would you have local government or you decide, eventually, that local government does take it. I think that we have written a clear letter to local government saying what we do expect of them. So, we do expect them to do it. I don't know whether either of the officers have got anything to add on that. The expectation is there that they should do it. 

Thank you, Chair.

Happy? Right, moving on now then to data collection and that is actually tracking the numbers of carers. David.

Diolch, Cadeirydd. We touched on this a little bit earlier. I appreciate that data collection was recognised as something that was a challenge. If I remember rightly, when the Bill went through back in 2013, it was highlighted as a possible challenge. You've already indicated that the Welsh community care information system is going to be rolled out, but as I understand it's only in half the local authorities at this point in time, so there are half that haven't got it. You've not been able to give me confirmation of a time when you expect to have benefit from that. You were talking about a performance improvement framework, which will be in place, hopefully soon, but the outcomes or returns on data from that aren't expected until March 2021. That's five years since the Act was enacted, seven years since it became an Act. Is that good enough—that you won't have any data you can work on until seven years after the Act actually became an Act?

Well, you have to work with the information that you've got, and I think we did say earlier how difficult it is, actually, to collect the data because of the disparities between the different local authorities. Ideally, it would be good to have had this data available right from the beginning. I agree with you. But this is what we've got to work with.

Well, I appreciate that you're only just in the post, Deputy Minister, but the question I'm asking is—. We've had the Act be operational for almost three years now. We have had the Act actually passed as an Act and it given assent for five years. Why are we taking so long to actually recognise how we can collect the data? It's a long time before you can actually get the data, and then you have to act on that data. So, it's really at least five years since the Act came into force before you can start acting on the data. So, I'm just wondering why we are so long in doing that. Why weren't we actually putting the information and the processes in place a lot earlier?

We're certainly doing it now—we're working in partnership with the local authorities to develop new, more robust approaches to the data, for April 2020 onwards, and that will include more data on carers and how local authorities are meeting their needs. The new performance framework is being developed in partnership with local authority heads of service and data leads, and, as you said, the new framework will be in place in April 2020, with the first data returns due for submission in March 2021. And there'll be a full consultation taking place in spring 2019. I know you think it's too late, but it is happening.

Okay. Then let's go back to one other point, then, because I swung over the question. There's evidence to suggest that data on carers be collected by third sector organisations as well, and, obviously, there's another challenge to co-ordinate all that together. How are you approaching that challenge? Are they going to be included in your performance and improvement framework?

Well, the new performance framework is being developed in partnership with the local authority heads of services and data needs, and, obviously, the data that the third sector is collecting is specific to them. But, obviously, if we could incorporate that, if the third sector were willing for their data to be incorporated with the local authority, obviously that would be very helpful.

Have discussions been going on between third sector and local authorities, do we know?

Frequently—almost on a weekly basis we're in touch with third sector partners on different issues. I think a key mechanism is the ministerial advisory group that was mentioned, so all the key third sector organisations, the commissioners, the key public sector bodies, health boards and local authorities, primarily, are around the table. So, that's opportunity to share information. That is a constructively challenging forum; that's not an easy meeting because you've got people from all sides of the discussion there. There's a wealth of information, much that you've uncovered through your committee inquiry so far. I think our evidence paper also includes some of the census and national survey data. That's not to say that there doesn't need to be a further trajectory of improvement over the coming years, which is the plan that we have.

And the collection and sharing of data is part of that discussion at those ministerial advisory meetings?

Indeed. There's a focus on respite at the moment. So, that's the first piece of work that the ministerial advisory group is looking at. The report that the older people's commissioner did around rethinking respite—some of the information that's in our paper—the qualitative information, the stories are as important as the quantitative information and the benchmarking. So, quite soon, the 'Measuring the Mountain' citizens' jury report will be published. The three-year evaluation of the Act—there'll be reports through the three-year period; it's not that we have to wait until the end of the three year-period for that. So, I think it's that we feel that it's not insight that we're short on, it's making sure policy is implemented correctly and fully, which is often the challenge, isn't it?

Thank you, Chair. We have covered the third sector quite a bit, and in answer to my first question, you talked a lot about the amount of money that Welsh Government's put into a number of third sector organisations. But the sector are concerned that they should have core funding rather than project-based funding, because I think they struggle with the way in which funding is allocated on a year-on-year basis, because they need to offer stable, secure services, and I can understand that. But I just wonder if you agree with that view, and if so, how do you think Government can actually address that? Is there a way in which the third sector organisations can have some kind of security of funding so that they have an element of core funding and that can be supplemented with additional grants. Have you given that some consideration?

Well, certainly, this comes up, I think, from the third sector in every type of work, really, that they want—and you understand why they want the core funding, because it does give stability. But, basically, I suppose the purpose of having the third sector is that it is more of an independent body, and they do have their own funds as well, don't they? So, I think this has been considered, but I don't know whether you can say—

Certainly insofar as the integrated care fund is concerned, we've put a two-year time frame on that for the new tranche of funding. So, I think annualised funding is a particular gripe, isn't it? I suppose there are two issues—core funding and annualised funding. So, we'd look to give it a two-year timescale. We've also set a goal that 20 per cent of those resources should be used for third sector projects. So, we know from our data that one of the seven regions can meet that test at the moment, but not all of them. If we believe, as we do, that the third sector has a fundamental role to play, we're keen to see progression towards that goal.

Okay—

Lynne wants to pick up on this point.

Yes. I think you know yourself, Minister, from other committees, that this is an ongoing issue, really, that we depend increasingly on the third sector, but the third sector are very unhappy that the funding doesn't always reflect that. In your answers, you referred to what seems to me to be a critical role, really, that the Carers Trust and Carers Wales are playing. I heard what your officials said about the ICF, but there is a lack of transparency there, really, isn't there, in terms of what's being delivered on the ground? Is this something that you could maybe look again at, really, because I think that there is an issue here, in that if we're depending on the third sector—and you'll have seen it in the perinatal mental health inquiry that we did—then, it only seems fair, really, that we should be seeing some more concrete funding reflected in that arrangement?

Well, I think, as Matt said, this 20 per cent is there, and I agree with you completely: we do need the third sector very strongly. And so, obviously, we can look at this again.

So, are you confident that the 20 per cent is being spent on the third sector?

It's not currently. One of the seven regions exceeds that goal, so—

Which one is that?

I think it's Powys, but I would have to check, perhaps, before putting that on the recordFootnoteLink. So, just in the last 12 months, we've improved the quality of our data on ICF so that we can kind of categorise with a bit more granularity where the resources are going. So, for the two years of the remainder of the integrated care fund, we've set that as an aspiration for all regions to get to, and we monitor progress on a quarterly basis.

So, what do you do if they're not coming anywhere close? What if they're way off the 20 per cent? What do you do in relation to the regional partnership board?

The Minister has many opportunities to engage directly with the boards to—

But, there's no formal mechanism, then, to pick them up on that.

Potentially, the extreme option is to withdraw funding in some areas of the health main expenditure group. In recent years, I know we've taken the opportunity to do that where objectives haven't been met. If you have a full spend on the fund, you've got to balance that against potentially harming the delivery of services in other areas. But we've been really clear about the critical role of the third sector in response to meeting those needs, so we would expect to see progression towards that.

Okay. Back to Dawn.

Yes, thank you, Chair. The Association of Directors of Social Services have talked about having a single carers fund. I don't know whether you've picked this up, but it's a single grant for carers, which they're suggesting could be given to the partnership boards and allocated through them. Is that something you've thought about or given any consideration to?

Regional partnership boards are required to consider whether to establish a pooled fund whenever they do anything jointly, and so this could include pooling budgets in relation to the delivery of services for carers. So, they could do that now. We could establish a pooled—

All right. So, you don't think that, necessarily, Government needs to be more directive about that. You're saying, basically, if the ADSS are saying that this is what's needed, they could go ahead and do that.

The regional partnership boards could do it. They could do it now.

Okay, right. That's fine.

Okay, thank you, Chair. Some witnesses have said that Wales has disaggregated delivery of carer services, and that we need a more strategic approach. What are your views on that opinion, and does the Welsh Government have any plans to develop a more strategic approach to supporting the growing number of carers in Wales? 

I think there's a balance between what you do from the centre and what you allow to happen locally, and I don't think it would be appropriate for the Welsh Government to dictate what the regional partnership boards do, because I think local is usually best. And I think it's very important that things do grow up organically, and part of the philosophy behind the Act is that the users of the service should play a major role. And so, I think, really, that it's more important probably for services to grow up organically and locally, and you have to measure that against any more strategic approach.  

Okay, so in terms of mechanisms for—. Because we don't have a strategy any more, do we, because we're moving away from strategies, but we've got the ministerial advisory group. What role is that playing in driving forward change, and how effective do you think that's being? Are you able to point out any achievements or anything? 

I haven't actually been to one yet, but I'm looking forward to going to one, and I think one is planned. But I don't know if you could report on them, Matthew. 

In truth, I guess it's quite early days. The group met on two occasions last year. The initial focus is around respite, so, a sub-group of the diverse membership around the table is taking a look at that, and constructively challenging each other to develop the ideas that we should take forward. In truth, in terms of saying that that group hasn't delivered things yet, it would be too soon to say that. But it feels to me like the right forum for taking things forward.  

Okay. Have you got any comments on any general tools you think you've got to hand to ensure that the provisions in the Act relating to carers are implemented to greatest effect? 

Well, we've got the data, such as it is, and we've had a long discussion with David about the data, and we know that that is experimental statistics, basically, what we've got so far. So, we've got that. There's also the performance management data, and information about the annualised EF revenue and capital funding. So, we've got all that information, and we've got reports and data on the use of the £100 million transformation funding and the £3 million provision to local authorities for respite services. That led to reports being delivered to officials highlighting the uses for the fund, and the new innovative means by which this has been used to deliver respite. And again, these have been considered by the carers ministerial advisory group. And we are looking to create a new engagement and accountability group to be part of the carers ministerial advisory group this year, and that will provide us with mechanisms to monitor and to review progress against the national priorities. So, there will be a system there to do it. But we're trying to work and deliver in a more holistic, preventative way, and I think it's essential that we measure what we do strategically against what grows up organically.  

Okay, thank you. A final question from me. You're undertaking an evaluation of the Act, which is in itself a big piece of work. When do you expect to be able to start publishing the results of that? 

Interim reports will be published in January 2020 and April 2021, and the final report will be published in October 2021. So, that will be very helpful as well, because I think in this field we've got lots of little bits of information all over the place, and that evaluation is absolutely crucial to show how the Act is working, because it's a challenging Act, and I think we're all very supportive of it. But how it actually works—and that evaluation and things like your committee inquiry show where the issues are, basically. So, I think that that'll come out of that data. 

And will that evaluation take account of all the groups of carers, really? I'm thinking more of the some of the carers who perhaps haven't had such a strong focus in recent years, such as parents caring for disabled children. 

The evaluation will consider what effect the Act has had on carers directly and what's changed for them since implementation as well as considering what improvements can be made for a greater voice to carers—that is carers generally, but that would include the groups that you referred to. But I think that's important for us to bear in mind—the particular groups.

Thank you.

Okay, a supplementary—David.

A quick one. You just mentioned, Deputy Minister, that your draft report is for April 2021 and the final report for October 2021—you said, around about that time—

October 2021, yes.

Can I assume, therefore, that the final report will reflect upon the data you are going to be collecting, which you've identified will actually be returned in March 2021?

Will that be—?

Yes, I believe so.

Diolch, Cadeirydd. Good morning. Last time you were before the committee, back in 2014, you stressed very clearly that you didn't feel you had sufficient resources to be able to deliver on your responsibilities, and even then if you had been at full complement. Can you tell us how you've improved? From what I understand, following the Marks review and the Welsh Government's concept of that, responsibilities haven't really changed. I'm assuming, from what I understand from your operational plan, funding has decreased. So, are you at full complement able to undertake your responsibilities?

I think it's probably fair to say we've been on quite a journey since 2014. We have managed to recruit some very good staff to a lot of the vacancies that we were holding at that time. We've also done a lot of other developmental work in terms of the way the organisation works in terms of improving its underlying infrastructure, its methodology, the way it uses intelligence and the way it focuses its plan in a very risk-based way. I think what you'll see if you track through the amount that we've managed to deliver since going back to that time, is that the number of visits that we've been undertaking has gone up to somewhere around about the 300 level, and I think, in 2012-13, we were talking about maybe 50 visits a year, so it's quite a significant increase in the number of visits we've been able to undertake. 

I think there are still some challenges for us as an organisation. What you'll see in the strategic plan is that we've started to think about whether we can be most effective; it's not necessarily the case that we need to do more, but we need to make sure that what we're doing is actually having an impact. We need to make sure that we're taking action when standards aren't met, which is in there. We need to make sure that there's a lot of transparency and visibility for the work that we do, because, obviously, one of the key levers that we've got is that people can read what we're finding, and that becomes part of the mechanism for helping things to improve. And we are also developing ourselves as an organisation. One of the things that we're working on very much at the moment is a change programme to bring in electronic inspections. But we remained under pressure in terms of capacity and the choices that we were making, so I'm pleased to say that the Welsh Government has awarded us some additional resourcing going forward, which will help to bolster our capacity going forward. We've recently been out recruiting for more lead inspectors and assistant inspectors, and we're expecting another nine individuals to be joining us over the next three to six months. So, we are building up our capacity, but I think, in the meantime, what we've also done is we've been able to use the risk and intelligence and prioritisation process to use what we've got in the most effective way possible.  

Are you at full complement now, then? You say that you're recruiting nine more. 

We're not at full complement, because we've been able to increase our complement. So, we are now bringing in an additional nine inspectors over and above what we previously have had. 

And, on your operational planning, you've had a reduction of £3.5 million, but I don't think the Welsh Government investment is actually going to equal that reduction, is it? So, technically, you have still had a reduction in funding. 

Technically, we've still had a reduction in funding, but we've also refocused and changed the way we work. One of the things we're looking to do with the additional capacity, for example, is to do more thematic reviews. And one of the things that I'm expecting thematic reviews to be able to do is to enable us to follow a patient pathway, which will mean that, rather than doing individual inspections of individual wards, or individual parts of hospitals, or individual directorates, we'll be able to follow a patient through from their encounter with primary care through to potentially diagnostic services, and maybe all the way through to rehabilitation, jointly with Care Inspectorate Wales as well. So, I think there are different ways we can use the capacity we've got, so that we are making more impact. 

So, from that response, and the response to the previous question, I'm assuming that you now feel confident that you're able to undertake your duties as required and that patients can be assured that you are ensuring that safe practices are in place across the health service in Wales. 

I think you have to think about what the role of the inspectorate is, and this is something that I think I've mentioned with committee before. We're part of a system of assurance. So, the first level of assurance is the individual professionals, in their interaction with the patients. The second level of assurance is, obviously, the board, but also, certainly within the NHS, we have the Welsh Government that has a performance management role, and there are a range of external bodies, including the public services ombudsman, the community health councils, the NHS risk pool, the delivery unit, the Wales Audit Office. All of them play a part in that assurance mechanism. 

So, we meet regularly with them on a bilateral basis. We also, twice a year, bring together what we call a health service summit, in which all the different bodies get around the table to talk about the work they're doing to make sure that it's complementary, to make sure that it's not overlapping, to test the intelligence that we've got coming out of some of those individual bodies. We use what comes out of the summit process then to feed into the escalation and intervention meetings with the Welsh Government—so, the tripartite arrangements.

So, what I'm trying to say, I think, is, if you're asking me whether I individually think that what I have is sufficient to provide assurance on its own, then, obviously not, because we're quite small. But if it's whether I think the system itself is working much more efficiently together, to make sure that what we do is complementary and is using capacity in the most effective way, I think that has improved significantly over the past few years, and that will provide the public with assurance. 

Not quite the total reassurance I would have expected, but it's far better than where we were four years ago, five years ago. 

Far better. 

Ruth Marks has obviously identified similar points, because, following that session and our report, clearly, Ruth Marks was asked to undertake the review. And you've put in some of your responses to Ruth Marks's report in your written response to the committee. Are you now confident that you've addressed all of her points raised and that you are now in a position where, if she came back, she wouldn't be saying any of the same things again?

I think what Ruth Marks found when she came the first time was that we were already starting to make progress across a number of the areas that she'd highlighted. I think what you'll find if you look within the objectives we've still got within the strategic plan is that there is still some way for us to go. We've identified, actually, that we want to be more visible to the public, but actually part of being more visible to the public is improving the way in which we communicate with the public so they can actually understand what we're saying and understand what we're telling them about the service. I think we'd probably say that we've still got a way to go with some of that. We've identified that we want to improve the way in which we report, for example.

Some of the things that Ruth Marks was highlighting—actually, the world has moved on. So, at the time, we were responsible for the local supervising authority for midwives. We are no longer responsible for that because the system itself has changed. Some of the areas that she identified I would probably disagree with. She suggested, for example, that we shouldn't be doing death-in-custody reviews. I actually think it's positive that we do death-in-custody reviews and it's part of the way that we look at offender healthcare. So, no, I'm not going to give you a categoric assurance that every recommendation has absolutely been buttoned down, but I think the world has also moved on and I think what we are is very clear about where we still need to get better.

Can you confirm, therefore—? You just mentioned that you don't do supervision of midwives any more. That wasn't one that Welsh Government had suggested; I think that Welsh Government suggested that the assessment of nursing agencies shouldn't be a part—

We don't do that—

No. That's the one that Welsh Government said that they'd remove but they didn't remove the supervision of midwives. That's no longer your responsibility.

That's no longer our responsibility because the Royal College of Midwives has changed the system of supervision across the whole of the organisation, so health boards are now responsible for their own supervision of midwives.

Okay. Also, in your operational plan, based upon everything you just said now, which I appreciate, you did actually say,

'we will need to make difficult decisions to ensure that we focus our resources in the areas where they can achieve most.'

Can you give an indication as to the areas of priority you wish to focus on now, and if those are difficult decisions and what is likely to be difficult?

Can I tell you a little bit, then, about how we put our plan together and how we prioritise, because I think that might be helpful to you? So, when we put our operational plan together, we have what we call a relationship manager, and a relationship manager is responsible for each health board. We will ask them to highlight on the basis of the intelligence they've got and their discussions with partners where they think the concerns and issues are that we need to be looking at for the coming year. We pull that together into the operational plan that we publish so it gives a broad sense of what work we need to be doing where. What then happens is that we receive, obviously, intelligence and concerns on an ongoing basis throughout the year. As that comes in, it gets analysed and looked at by the relationship managers and, monthly, we have something that we call a risk and escalation committee, and in the risk and escalation committee we look at how our intelligence has changed and what our plan says that we are doing. And we use that to adjust our plans to make sure that we're doing different things.

So, that's the way that we adjust our ongoing inspection plan. We also have what we call a long list of potential thematic reviews—so, areas we could look at. At the moment, for example—so, without having made our formal decisions on what we're going to take as thematic reviews next year—we've got a number of issues on there, such as, for example, crisis care in mental health, which is something that has come through from our stakeholder group; we have, potentially, maternity services; there are issues about primary care, preventive care. We're doing some joint work with Care Inspectorate Wales at the moment on reablement services. We've got a clinical leadership teaching fellow working with us at the moment looking at falls, and that itself might generate other areas that we want to look at. So, we are constantly adjusting on the basis that, despite somewhere we might have wanted to go, actually we're going to go somewhere else because something has come up that is more important or more concerning or it's come to light that, actually, there might be a lack of knowledge of what's actually happening in a particular area. And I think it would be almost impossible for an organisation of our nature not to be having to make those trade-offs and those prioritisation decisions during the course of its work.

It all sounds very interesting and very acceptable in the sense that I appreciate the direction you're moving in, but it does worry me that, if certain things pop up, then you have a resource issue again to be able to actually deliver on some of the areas that may still be important—

But it's not only us that would respond. So, we have other tools and techniques that we use. So, for example, with some concerns that get presented to us, we might write to the Welsh Government and ask them to look into it themselves. Typically, if something arises within a health board, we will usually write to the health board to ask them what they're doing, and if we are satisfied that an issue has been identified and it is being responded to appropriately, then I don't think there's a need for us to act.

If I could give an example that might reassure you, I can think of examples over the last year where we've gone in and done an inspection within about 12 hours of receiving intelligence, and, to do that, we had to pull someone off from something else they were doing—maybe they were writing a report that was low priority—bring them in to go off and get peer reviewers, such as doctors and nurses, to accompany our inspector on that inspection. And there are also instances where we've done an inspection within a couple of weeks in the NHS, which is quite a short amount of time, really, if you've got to bring experts in to do that inspection. To do that, we postponed a different inspection. We took somebody off something that was routine, if you like. We hadn't been there for a while—it was an inspection, and it wasn't necessarily based on any particular intelligence other than we hadn't been there a while. We brought that person in instead. We said, 'We're going to send you in to do an inspection at a high-risk service in the NHS'. But in terms of the inspection that we then lost, we would weigh that up with the rest of the programme for the year, and we would say, 'Do we want to put that back in somewhere else?' You lose an inspection somewhere as a result of that, but it's a rolling programme of inspections. We can make a decision when to bring that inspection back in. So, there's a sort of constant assessment, really, of the pecking order and risks on that basis.

Okay. Darren, you had a supplementary on this point.

If I can follow up on this issue of the supervision of midwives. Obviously, they've had some terrible reviews in Cwm Taf of late, and I just wonder whether you think that is something that the inspection regime ought to pay closer attention to in terms of midwifery services? Staffing levels, obviously, were the main concern in that place. To what extent was HIW involved in exposing the problem there and the follow-up work that is now taking place?

Do you want to talk about specifics?

Yes, I can start. We've been in to Cwm Taf fairly recently. We published our inspection report—for maternity services, we published our inspection report at, I think it was, the end of January. Within that report we have made observations about supervision of midwives. To some extent, we're holding the health board to account for that and expecting them to make improvements.

In terms of maternity services in Cwm Taf, I think that's a tricky one in the sense that a number of serious incidents came to light and they hadn't been reported. Because of that, it's very difficult for any regulator or for Welsh Government to know about a situation if they haven't been reported. I think what's interesting about that case is that we see serious incidents, we have access to that information. Welsh Government also drew our attention to that, so they were very transparent about, 'Look this has happened. It's something we're concerned about'. We shared their concern and worked with them to decide—. Well, we decided what action we wanted to take on the back of that intelligence.

Equally, having carried out an inspection ourselves, we know that the Royal College of Obstetricians and Gynaecologists have been in and carried out a review. They've been very transparent about their findings. Their high-level findings have been—. They contacted us directly to tell us about those findings, even though they haven't been published yet. Kate describes a system, and that system works in a sense that we're all sharing our findings. You know, when we're ready to publish things, we do that.

I wouldn't say we were specifically involved in exposing those issues, but as soon we became aware of them, we dug quite deep and we had a lot of contact with the health board in terms of not just inspections, but asking them to provide assurance to us on quality and safety governance, and how they operate their committees and what they do themselves to ensure that the board is sighted on issues at an operational level and action is being taken.

I think people will be concerned that it appears that the problems at Cwm Taf were taking place over such a long period of time before they were identified in terms of the lower staffing levels, in terms of some of the deaths at birth or shortly after birth. You didn't give me much confidence that this is something that HIW had picked up on at all during the two-year period that's now being reviewed backwards. How frequently does HIW look more generally at maternity services?

I'll go on that one, yes? One of the things we've been quite clear about within the response to Ruth Marks is that we don't operate a frequency-based inspection regime for the NHS; we operate a risk-based inspection regime. So, if those risks aren't, in some way, bubbling up—and, in some cases, risk can be a lack of information, blind spots; we don't have to necessarily have a concern in order to go in, but, if those things aren't coming to the top of the concern list, then we may not choose that area to test. So, we have tested other areas in Cwm Taf; we've been in to look at mental health services, we've been in to look at general medical wards, but we may simply not, in that instance, have checked on, for example, maternity services.

What is interesting about the role that I think we play is that this is the type of incident that makes us question whether it is necessary for us to think about doing a thematic review, for example, across the whole of Wales to see if something isn't working, maybe, in terms of supervision—so, to think about looking at this in other health boards. Because you could argue that it's very well known that Cwm Taf has had an issue; there was a lot of attention being paid to addressing this and to dealing with it. I think the role of the inspectorate is to think about whether, actually, we need to see whether this is a wider issue and, potentially, whether the removal of the local supervising authority function may or may not have had any role in this coming to light or not coming to light.

So, is that something that you are now planning?

It's on the long list.

Okay. Can I just ask you—? I appreciate that you've got limited resources and you've got to do a risk-based approach, but surely one of the things that appears to have been missed here—it's very obvious—is the number of deaths occurring shortly after birth or during birth in the Cwm Taf area. Isn't that a flag that you should obviously, as an inspectorate, be looking at on a regular basis: deaths in hospitals?

We have a wide range of information that we look at. We also look at—

I appreciate that, but surely there's a red flag that pops up when there are so many deaths taking place in a particular service in a particular health board. Isn't that something obvious that you ought not to wait for somebody to report and blow the whistle to you? You ought to be looking at these figures all of the time, I would assume, because this is part of an intelligent suite of data that should prompt questions about the quality of services, is it not?

The weaknesses at the health board here were that they didn't report those, so I believe that they didn't exist in the way that we would've seen. So, you can't know about something unless it's been recorded. We—

So, deaths in hospital aren't recorded?

The deaths are, but these particular incidents—I think it's 43 serious incidents—were not recorded.

I appreciate that they may not have been flagged appropriately as serious incidents, but that number of deaths surely ought to trigger questions in any case, regardless of whether they were recorded by the hospital or by the board itself as being serious or not.

I think what's important here is to come back to the idea that there is a system of assurance. So, what we need to look at here is what was known and what was responded to by all of the parties in that system. So, because I can't tell you exactly what numbers we had available to us at that time, it's very difficult to be specific in the answers to your questions, but we do get, for example, the results of national clinical audits that come in, where we do get communicated with by the national clinical audit bodies, which will write to us with outliers. We do have regular communication with the quality department within the Welsh Government, which will flag up to us if there appears to be something that is slightly out of order. We have contact with the NHS peer review processes, so specifically, for example, in cancer services, there is an explicit escalation mechanism to HIW that will draw things to our attention.

So, I think the question, probably, here is to look at exactly what data existed in the system and who they were available to at that time, rather than us speculating on what we may or may not have known and what we may or may not have done with it. And I think—I'm happy to come back to you afterwards to tell you what we may or may not have done with it.

I'm just interested in this issue of, surely, death rates are an indicator. It is publicly available information; it certainly ought to be available to the inspectorate, and, as you say, if an outlier is identified, that ought to trigger—I'm not saying necessarily a full-blown inspection of a service, but it certainly ought to trigger some questions to that service in order to establish what the situation is. You mentioned the national audit figures to try to identify outliers. How regularly are those available? Did this flag up a situation, potentially, in Cwm Taf?

I'd have to go back and have a look at that, because I can't answer. But the issue is, of course, that, when you're talking about death rates down at the level of individual specialty, there is a vast data set that you've got to analyse. You've got to work down to the level of the individual, and then you've got to begin to distinguish between expected and unexpected deaths, which of course was part of the debate about hospital mortality statistics when they were being published anyway. So, there's a difference between numbers and really getting to the bottom of what are meaningful numbers that should therefore trigger action, and there are a range of bodies that need to be alert to that, all the way from the health board up to national review bodies.

It's just that it was so clearly an outlier in terms of the deaths—in terms of the rates. Okay. Thank you, Chair.

Dawn's got the next batch of questions. Some of them are covered already.

They have been covered—[Inaudible.] This one was in your answer to David, but I just wanted to pick up on a couple of the recommendations from the review, particularly around measuring outcomes. Your written response that you gave the committee wasn't very clear, really, about what you were doing to demonstrate that you're measuring the outcomes. You've accepted the recommendation, but I'd just be interested to get a little bit more information from you about how you're approaching that.

So, outcomes in terms of the direct, causal relationship between our work and—.

Yes.

Okay. I'm going to let Alun give you some specifics on this in a moment, but, in broad terms, this for me plays into what I think we need to do in terms of strengthening our approach to follow up. We do have a range of different ways in which we follow up on the result of our inspections, either from asking people—whether just simply writing to them and saying, 'Have you done what you were expected to do on your plan?' to potentially doing a full reinspection to make sure that the changes that we expect to see have happened. It's quite easy, to a degree, to demonstrate that we asked for something to happen and it has happened. That, to me, is a very limited effect for an inspectorate. What we started to see is that, whilst the specific recommendations may be addressed in the area in which we've made them, we don't always see the learning being transferred within the health board, so we might reinspect a similar specialty or a similar ward in a similar place and find the same issues, even though they've been addressed in the first one. Now, that's why, to me, outcomes are slightly—. It depends how you define them. They can be slightly blunt. We could say, 'We're very effective because people do what we ask them to do', or we could say, 'We're not being nearly effective enough, because the way that we work isn't helping to spread that learning and spread that improvement across the service.'

So, would you be—. Right. Okay. So, what you're suggesting, then, is things that you find—and the point that Darren was raising, actually, about the maternity services in Cwm Taf. I've had quite bit of involvement; it's in my patch. There may well be lessons that can be learned from that that might prevent or be an early intervention or flag for other health boards, because what we don't know is whether there were similar issues in other health boards, they just haven't been uncovered. So, are you suggesting that, when you're going through this, part of your measuring outcomes shouldn't just be, saying, 'We have found that here and this needs to be put right here', but, 'This is a flag for everybody else as well.'

Yes, and I think the reason that we're focusing on impact in the strategic plan now is because I think that there is more that we can do to spread the learning and to encourage people to learn. Whenever we publish a major national report we say, 'We hope health boards will read this, will take on board the lessons here and will apply to their own practice'. What we haven't specifically done is gone out to measure to what extent that is happening. It leads back to what I was saying to Darren then about maternity services, which is: I think we need to be asking ourselves whether there is something broader here that we need to be testing across the system as a whole.

So, it's not that I don't think that what we do makes a difference. It's that I think it is very difficult to demonstrate that causal relationship. There are some things that I—at the beginning of my work within the inspectorate there were certain issues that I used to flag up year after year after year, which used to drive me absolutely up the wall—even quite simple, basic things like ID bands. We see that very rarely now. I'm not going to say that's because I kept banging on about it and was getting frustrated, but we see it rarely. The world has moved on. But we continue to raise issues on medicines management, for example. Whilst we continue to raise issues on medicines management, then I think it's only right that I should question myself on whether the way in which we're communicating what we find is sufficient and is making a real difference. The counter to that is when we started doing work on dentists, for example. We found a number of issues around the ionising radiation regulations. We took what was coming out of there and we went back to the deanery so that we could help to influence the training that was going on for new dentists coming through, which is a quite clear and specific example of how we're trying to prevent us saying the same thing repeatedly. So, it is very difficult to make that causal relationship, and I don't think we should ever become complacent and say that what we're doing is good enough. 

Okay. I understand that. That's helpful. Could I just move on to the announcement that Welsh Government have made that they're going to introduce legislation? This is around moving to the service-based model to give you more powers over prosecutions, and they're looking to introduce legislation, and they talk about that in a future Assembly term. Would you be happier if they sped that up a little bit, or are you quite happy that it's being kicked down the road a little bit while you think about how that might play out?

I think we were quite clear in our response to the original White Paper that we're keen to make sure that we move from our current establishment-based legislative framework to something that is more service and activity-based, and that would help us to align more with other inspectorates. But I'm also keen that we get it right, and I think there are issues associated with this, particularly if we're serious about moving to joined-up care between health and social care, about making sure that whatever works is aligned across the health and social care interface. So, if you're asking me, 'Would you rather have it sooner?', I would say, 'Not at the expense of having it right'. 

Okay, that's fine. That's helpful. Just one another recommendation around the Welsh Government placing a statutory duty on LHBs, trusts and CHCs to share complaints information with you. Now, the Welsh Government rejected that, saying they didn't believe there was a need for that. Is that a view that's shared by you? 

We can ask for it.

You can ask for it. So, this is—

If we want those, we can ask for it. But it is helpful—. It would be helpful to us to have it on a consistent basis across heath boards, and the Welsh Government is working on a consistent data set with regard to complaints. 

Okay, so a statutory duty would be desirable—it's not legislation as such, but—. 

I'm not sure it needs legislation. I think the culture in terms of data sharing with us is such that I think, once that data set is there, we will have access to it without the need for legislation.

Okay, that's fine, thanks. And I—. Sorry, I thought Darren was saying something then. Okay. So, just briefly, then, what your reaction is to the Welsh Government's decision not to pursue a merger with the social care inspectorate at this moment in time: are you happy with that, or is that something you want to see at some point? 

At the moment, ourselves and the care inspectorate both work within the same part of the Welsh Government in the same building. We meet regularly. We are working together on joint projects, so there are pieces of work that we can do together. It's not always straightforward, particularly in some of these services, because of the different legislative bases that we've got. So, actually, the closer we are aligned in terms of the powers and the standards that we're working to, it's almost the less structural change is necessary.  

Yes, it's more co-operative working. I think what Welsh Government have talked about is exploring a proportionate approach to addressing the gaps, the regulatory gaps. I think what's they've been talking about, and that's really what you're working on, is it?  

Yes, and we've done a few projects to test this. So, we did a piece of work around nursing homes medical support, and nursing homes in north Wales, which was not just looking at medical support to nursing homes; it was also looking at the challenges and benefits from the two inspectorates working together. But, of course, we've done it in the past. We've done it with learning disabilities. We're doing a piece of work at the moment around promoting independence for older people, in which we are supporting a CIW review. And we've got, as I think I mentioned earlier, a clinical leadership teaching fellow looking at falls from the perspective of, 'What does this mean for inspecting in an integrated way in that sort of service?' 

Okay. Okay. That's helpful, thank you. Thank you, Chair. 

Okay. Lynne. 

Yes. Thank you. I wanted to probe the issue of your powers a little bit more, really. Are you satisfied that you've got sufficient enforcement powers and powers to direct at the moment?  

Okay. Can I invite Alun to answer this one? 

So, there are two parts to what we do. We are a regulator of the independent sector, and with the regulations comes enforcement powers, so we have specific enforcement powers in the independent sector. 

Can I rephrase that? Are you happy with your powers of direction and enforcement in relation to the NHS, rather than private providers? 

I think there's an interesting debate about powers, and whether you can use legislation in order to leverage improvement and to achieve improvement. So, I don't think any chief executive of a health board in Wales would feel comfortable about us writing a report that said that the service was not fit for purpose, which is what we've done. And as a result of that, we have seen action taken. I think it's easy for us to tell a story about all the things we've done, why the public should feel assured, how that gains traction, that there's improvement as a result of that, but sometimes the public don't see that. They don't see the conversations we have and the meetings we're having, the fact that we've brought a health board in for a conversation about patient safety issues and so on. So, I think, going forward, one of the things that we've been talking about is the need to be a lot more visible—a greater visibility that we've done that thing. So, for example, we might designate an NHS service as a service of concern, and that would be a very visible thing to do, but, essentially, we're doing that at the moment anyway. We have a concern about a service, we take some action, we would escalate that through to Welsh Government and the tripartite arrangements; it might lead to somebody being in special measures or a level on the escalation process. So, I think it is about that. We think that we need to turn our attention to how we make sure the public know we've done that, how they know we've got a concern about a service. Clearly, we're going to tell other regulators about it, so we work closely with the WAO, the CHCs and so on, so that the network, the system, understands there's a problem with the service. But I think we would like to see greater visibility of that. 

I think visibility is very important. And if I can link this to the very serious situation that we've got in Wales at the moment, where we are unable to place any young people who are suicidal or self-harming in any in-patient beds in Wales at all. So, either Tŷ Llidiard, Abergele or the Regis Healthcare one. You'll be aware that I've met with colleagues of yours to discuss that. But what bothered me about it was that if—say, there'd been a school that had been seriously underperforming, Estyn would have put it into special measures, there would have been a press release, everybody would have known. I found out about it because I happened to be at a conference that one of your colleagues was presenting at, and I'm still not entirely clear about what's happened since you were flagged those concerns and put a moratorium on placing young people there, which means they're all having to go to England, where we don't have any checks or balances, really, that I'm aware of in place, to make sure that the quality of care is as we would expect it to be in Wales. I'm not clear what's happened between that and your discussions with the Welsh Government to actually drive improvement, so that we can place young people in appropriate beds in Wales. 

I think there are two issues there, and I'll deal with the second one first, which is young people in Wales are placed by the Welsh Health Specialised Services Committee, and there is a system, the quality assurance improvement team—

And I've written to WHSSC.

And the QAIT team—I think it's the QAIT team—will go out. They are responsible for Welsh residents in England. So, there is that oversight of quality that is going on for Welsh people who are placed in England. 

In terms of the visibility of what we find and what we report, I think this goes back to what I was saying about reporting. Alun's talking about, for example, the service of concern system. You could argue that the service of concern might flow from an inspection, and it would therefore be a judgment that would be made at the end of an inspection and communicated very clearly at the back end of that. I don't particularly want to get into the whole of issue of quality judgment frameworks at the moment, because I think that's a whole different conversation. But I think there is something that is about far more unequivocally communicating what we find, and whether the language that we use can be more direct in terms of, 'We have significant concerns about this service which are being tackled in this way and this is how you find out what's happening moving on.'

So, I think there are slightly two issues there. One is about how we communicate clearly where our concerns are, which is slightly different from the quality oversight for Welsh residents, where, of course, others are also involved in that. 

Okay. So, in terms of the in-patient units, obviously, we had a very tragic death in one of them, and I know that there's a process under way to deal with that. Were the concerns that you identified in the in-patient units as a result of that tragic incident, or were they flagged up in a general inspection?

We flagged up a number of issues over time, which I think, quite often, come together. And it's when they come together that you can have tragic incidents of this sort. But they relate all the way back to—. And the type of things that we flag up range from the environment in which people are being looked after; the quality of the care planning, which, quite often, is not as individually centred as it could be—there is so much based on that individual; the quality of risk assessments, which have to be specific to that individual and have to be discussed with that individual; the quality of record keeping as well and document keeping, which, of course, is an important part of handover between staff, to make sure that issues from one shift can be carried over to the next shift—the support so that that particular individual can be looked after. Those are things that we do find quite frequently. They get better, they get worse, and they flux a bit, which is why we have quite a strong inspection programme, particularly in the independent sector in terms of some of these more vulnerable client groups. So, the answer to you question is: yes, the type of issues will have been flagged up in previous inspections, but maybe not in the concentration that could lead to tragic examples of the sort that you're referring to.

So, how can the committee be assured, then, that under the current framework that you operate within, this is effective enough, really? Would it be better in this kind of situation, where you've got very vulnerable young people, to have a system where you are able to publicly put something into special measures, where there is that transparency? And how quickly should we be moving to that kind of situation? 

I think we already do say it, but maybe it's not as easy to find as might be necessary. I think the public can be assured that, in terms of what we do find, we work with our partners in the commissioning teams—both NHS commissioners and the Welsh commissioners. We work with Welsh Government to share what we're finding, the concerns that we're finding, and we do require both the providers themselves and the other external bodies that have oversight of these services to assure us on what actions they're taking in response to those issues.

Could I just—on this point?