National Assembly for Wales

Croeso, pawb, a phrynhawn da. Welcome to the Health and Social Care Committee this afternoon. I move, first of all, to item 1. We have just a number of housekeeping matters, first of all. If I can say that this session this afternoon is all being conducted remotely, so Members and witnesses are taking part virtually, and it has been previously agreed that Mike Hedges will stand in should there be any issues with my connection at all. Standing Orders all remain in place as normal and, as always, our meeting is being held bilingually. So, I move to item 1, and if there are any declarations of interest, I'll invite Members to speak now. No.

In that case, I move to item 2, in regard to our inquiry, and today is the third meeting dedicated to taking all evidence from various stakeholders to inform our inquiry into hospital discharge and its impact on patients going through hospitals. So, I'd like to welcome Members and our witnesses to the session this afternoon, and I'd be very grateful if you could introduce yourselves for the public record.

Good afternoon, everyone. My name is Jake Smith and I am the policy officer at Carers Wales.

Good afternoon, all. My name is Kate Griffiths and I am the director for Wales for the British Red Cross.

Thank you ever so much for being with us and for your evidence paper ahead of today's session as well. Can I first of all ask an extremely wide question? Tell us what the main issues and problems are with regard to hospital discharge in Wales, from your perspectives. Who would like to go first on that?

I'm happy to kick off, Chair, if that's okay. We are told, from carers and from our network partners across Wales who are providing care and support to carers as part of their hospital discharge services, that hospital discharge continues to be experienced as happening rapidly for carers. Carers aren't always feeling as if they're fully involved in that process, that communication isn't great around that, and that the cared-for person is often discharged without an appropriate care package in place to meet their needs. So, that means that carers are having to step up. But, of course, that places significant pressure on them, and often over a prolonged period, which is not sustainable in itself. We're hearing about people who need a package of care waiting upwards of three months at this point for support, and when perhaps a person is discharged from hospital, there might be a person who is becoming a carer for the very first time, then. That places a significant pressure on them to deliver around-the-clock care in some instances. So, those are the concerns that we're hearing in particular, as a general overview around hospital discharge.

Thank you, Catrin Edwards. Jake or Kate, do you want to come in? Jake. Jake Smith.

Thank you. I would, of course, agree with everything that Catrin has just said in terms of hospital discharge often being a very unexpected and daunting prospect for so many unpaid carers, that can find, with very short notice and with very little consultation, that suddenly they may be being asked to provide huge additional caring duties that they weren't originally expecting to.

We actually held, just last week, a carers summit, and we had a session on hospital discharge, so we've been able to talk to some carers about this very recently. One of the interesting points that was raised was about the sense of moral obligation that many unpaid carers feel that they're being placed under to provide that care and to agree to a discharge that may be sooner than it should be and may potentially be unsafe. And, of course, we all know and appreciate the huge challenges that health is under, that social care is under, but it is very much unpaid carers that are being caught up in this, feeling pressured by hospitals to agree to discharge before it is safe to do so, feeling pressured to take on caring duties that they would otherwise not wish to. And, considering the Social Services and Well-being (Wales) Act 2014 has a very strong focus on carers only caring if they are able and willing to do so, that important principle is being undermined by all of the pressures around hospital discharge that are forcing unpaid carers to do more than they would wish to and as they have that right to under the Act.

Thanks, Jake. Kate, did you want to come in at all?

Please. Thank you, Chair. I think we all recognise that the pressure on health and care services at this time is at an all-time high, with waiting times for hospital treatment reaching record levels, et cetera, and hospitals still dealing with COVID-19 patients, and patients also being unable to enter or leave hospital because of workforce pressures. So, we do recognise that there are significant pressures within the system at this time, but we have some upcoming research, 'Listening to What Matters', and there was broad cross-sector agreement within that research that patient outcomes tend to be better when people are able to recover at home, as long as there is capacity to provide a follow-up assessment and support at home after discharge. And our experience as a service provider, working in partnership with the NHS, and our research show that whilst there's evidence of best practice, the hospital discharge process currently is not meeting the needs of all patients and carers, and we see that there are three main reasons for this.

The first is around a lack of communication, and that could be communication between teams in hospitals and community-based staff, but also a lack of communication between health and social care professionals and patients and carers during the discharge process. Pre- and post-discharge arrangements are not always carried out when patients felt they had support needs. And there's a lack of resources within the community, so that includes the availability of social care services in the community, and those services not having the capacity to run seven-day services, which we all, I'm sure, are in agreement are very much necessary. And there are also barriers to the voluntary and community sector being able to provide support in the community.

So, I think those are our three key areas that our research has drawn out, and we do strongly believe that the voluntary and community sector can help relieve the pressure on the health and social care sectors to improve patient flow and achieve better outcomes for people, and the VCS can also help to tackle some of that fatigue that exists within the health and social care sectors at the moment and deploy flexibly along the discharge process. So, we do have some recommendations as a result of this upcoming research that we would like to share.

Thank you, Kate, for that. And I won't ask you to share all your recommendations, because they'll no doubt be drawn out through questions from different Members this afternoon. But I'm interested in just one aspect: you detailed the issues around poor communications and the consequences of poor communication. But what do your recommendations state in that regard? What needs to change? What needs to happen to change the issues that you've outlined in terms of poor communications?

I think a primary recommendation is around the consistent involvement of families, including those with lasting power of attorney or nominated family members for patients living with dementia, and carers in decisions made during that discharge process. We know that that's challenging, particularly in an environment where visits have been restricted, for example. That has been particularly difficult to achieve, but that communication and that involvement and the consistency of involving all of those—from a carer's and family's perspective, as well as the patient's—is essential, and we really do feel that hospital teams should be working in addition with relevant organisations to help identify all of those who are relied on to provide care—informal carers included—and ensure they're linked to sources of support for carers.

What you've outlined as a solution just seems pretty basic to me, that the hospitals need to have better communications with the family in terms of discharging them. So, why on earth is that not happening now, do you think? And I can see Catrin nodding away as well. So, happy to bring Catrin in, perhaps to add to points that Kate Griffiths outlined as well, because you mentioned poor communication in your opening comments as well.

Yes, absolutely. Thank you, Chair. So, pre pandemic, of course, there would have been a discharge office whereby your discharge nurses, your social workers, perhaps your OT, and many of the third sector would have been there physically in the hospital—very present. I know many of our network partners had hospital discharge services where they were either in that office or they were out there on the ward, and, of course, since COVID, that just hasn't happened. Those services, quite rightly at the outset of the pandemic, weren't seen to be essential; they were the non-essential services and people started working from home. Now, without that physical presence there, of course it was inevitable, really, that that communication and that link that the third sector was providing between healthcare professionals, the patient and the carer wasn't going to be as strong when the physical presence on the ward wasn't there.

And in many ways, Chair, I would draw out that point around—. Building on Kate's point, of course, around communication, one of the important things around that is to recognise, of course, that whilst the third sector—that carer support service—was seen to be non-essential at the outset of the pandemic, in fact, it's a preventative service, and preventative services really are essential. It might be non-acute in the medical sense, but it really is essential and we need to be thinking about this as a strategic approach, about how we can bring back those preventative aspects of the service to better facilitate that link between healthcare professionals, patients, carers and the wider family and the wider health and care system, so that we're—

How's that done? How should that be done?

It would be great if we could have—. Well, I think we're moving now, hopefully, from a position where we're in the pandemic, where it's an acute situation, to a longer term situation. And I think, naturally, of course, our focus is on reducing the backlog, as you as a committee have heard, but we also need to be thinking about the longer term funding of preventative approaches. Some of the things that I'm hearing from my colleagues on the ground who are running hospital discharge services for carers are around—. Well, they recognise that, right now, they can't be physically present in the hospital, but they're thinking about—. So, colleagues in the Carers Outreach Service, working across Conwy, Gwynedd and Môn, are thinking about whether they can put together a third sector hub, where carers services, Care & Repair, Age Cymru and the relevant agencies join together, and at least there they're able to tap in, in a co-ordinated way, to the hospital service so that it's one person feeding in, rather than many.

I think we also need to get to a stage where we can take advantage of some of the virtual approaches that are making communication better. I've heard of some colleagues running hospital discharge services for carers where they've got a virtual ward and they're present on the virtual ward, involving carers in that space and in multidisciplinary team meetings that can happen in a virtual way. There are some ways that we can think about doing it, but we need to be taking that step back to appreciate the value of third sector and preventative services that really are essential if we're going to have a sustainable approach.

I was just thinking, you probably don't need to convince the committee of the need for better comms—we all agree on that. We're just trying to understand how that can be done. You've outlined some positions there. I think, Jake Smith, you wanted to come in. I'm particularly keen not to rehearse what's been said. We want some further examples of how the comms could be improved in terms of the discharge process. But just before you come in on that, Jake, can I just ask you as well—? In your evidence, you talked about there being a legal obligation under the Social Services and Well-being (Wales) Act to ensure that carers are willing and able to provide care and to fulfil this there must be a meaningful consultation with carers throughout the process. I think that was in your evidence paper. I'm just trying to understand as well whether you think that all involved in this process understand that. Is that why you're highlighting it? So, perhaps you could address the comms bit and that bit as well.

Thank you. So, I think, first of all, in terms of the communication, a very large piece of this issue is the unfortunate situation that unpaid carers are not being routinely identified in healthcare settings, especially through the hospital discharge process. And if carers aren't being identified through the process, then it's highly unlikely that they will be communicated with and meaningfully consulted with. Just some examples: we've had many carers say to us that the paperwork that they're asked to fill in in hospitals doesn't actually specifically refer to unpaid carers; it might talk about next of kin, it might potentially talk about paid care workers, but unpaid carers themselves are, in some cases, not actually being recorded in the process. 

So, you're suggestion is that that document asking those questions should include unpaid carers. That's what you're—

Absolutely. Just as a first instance, it would be so useful if all of the paperwork that health boards were asking families to fill out, and such, specifically made reference to unpaid carers, not just, say, through being next of kin. The social services and well-being Act has a legal obligation to be identifying carers and to be offering them information, but we hear from carers that that, very often, isn't taking place in hospital discharge, and I think that that says something about the training and the awareness of the staff in the process. So, actually, if health boards could be doing more to make sure that discharge co-ordinators and the staff involved in the process were trained in carer awareness, were aware of carers and probably were fully up to date and fully aware of their legal obligations to be identifying and consulting with carers, that would go a long way towards it.

And in terms of the point that you raised about willing and able, it is only through meaningful consultation with carers that health staff will ever be able to arrive at an accurate and honest appraisal of what the carer is able to provide after discharge. Because where there isn't that meaningful consultation and that good communication, then they're discharging patients into a home where they don't actually have a full picture of what the family can provide, what services might need to be provided. So, to fulfil that willing and able principle, you absolutely need to be meaningfully consulting with carers and giving them that choice that they have in law that, very often, isn't coming out through hospital discharge.

Okay. Thanks ever so much, Jake. Thank you for that clear answer. Jack Sargeant.

Diolch yn fawr, Cadeirydd. Can I stick with Jake and Carers Wales, please, Chair? Just to come back to your written paper, your evidence suggests and highlights that, from summer to winter 2021, six of the seven health boards in Wales—that's all of them apart from Powys—and their associated local authorities announced that they would no longer be able to honour all previously agreed care packages and would be asking families and carers to step in and provide more care. That seems pretty significant to me, but perhaps you could just help the committee out and give the actual scale of the situation, with an idea of the proportion of the care packages affected and the impact that that's having on carers, and, additionally to that, whether or not there have been any additional measures put in place to support carers as a result of those health boards announcing that.

Thank you. Over August and September 2021, we conducted a 'State of Caring' survey that measured, amongst other things, the level of disruption that there was to services. And we found, for example, that only 8 per cent of carers said that day centres and sitting services for their loved ones were fully operational.FootnoteLink Only 20 per cent of carers said that NHS-funded care was fully operational and fully reopened at that point, and only 40 per cent of carers said that support from paid care workers was still fully operational.

This data was, of course, gathered in August and September 2021—many, many months after the end of the previous lockdown. So, it's very concerning that we were still picking up then widespread service disruption. And actually, in that survey, two thirds of carers—66 per cent—said that they expected service disruption to continue into 2022. So, unfortunately, there is also widespread pessimism that services will be restored, because, so many months on from lockdowns, it just hasn't really happened. When the health boards were putting out those statements, as well as our initial concern that they were asking already exhausted unpaid carers to provide more care—. Because, for example, research released for Carers Week in June 2021 found that 72 per cent of unpaid carers in Wales hadn't been able to take any breaks whatsoever since the start of the pandemic over a year previously. So, we were very concerned that health boards were asking even more of unpaid carers, but particularly concerned that these statements didn't give any form of timescales or reassurance of when care packages would be reinstated. So, the health boards talked about this as an extraordinary and temporary situation but gave no indication of when packages would be restored. And we haven't had any indication that they have been better at communicating with carers on a one-to-one basis, and that means that carers are already having to provide more care with less support—it feels like an open-ended situation. And, no, we're not really aware of health boards introducing new measures to try and mitigate the additional pressures they've put on unpaid carers.

Thank you for that. That's very useful, actually. The start of your answer leads me on to my next set of questioning. You said there that the data you collected for us was from August and September, about the availability of support services, and perhaps, on the back of that, there is an expectation from some that disrupted services would continue into 2022. Do you have any evidence to suggest that is the case? And, if that is the case, then what needs to be done? What can health boards do and what can Welsh Government do to address the problem? And perhaps I can open that up—. I'll start with you, Jake, but perhaps I can open that up to other witnesses as well.

And just because we're a little short of time, just perhaps concentrate on the what-needs-to-change aspect, because I'm just conscious of time as well.

Sure. Of course, Chair. So, what needs to change is the Welsh Government needs to work with health boards and local authorities as a matter of urgency to be restoring these disrupted services as quickly as possible. So many other aspects of society have been opened up in recent times, but we just haven't seen that with unpaid carers. So, I think there's a strong role for the Welsh Government in providing that impetus, but also the funding for local authorities to do so. They've been given a quite generous funding settlement recently, but we need to see that monitoring and that direction from the Welsh Government to make sure it translates to the restoration of carer services on the ground.

Thanks, Chair. Just to open the question up—I'm conscious of the Chair and the time—is there a measure that could be implemented really quickly to help take the burden off that, or is that too much of a question to ask? Perhaps, Kate, or, Catrin, you would like to come in there.

I'd like to come back with a really urgent and rapid solution to that, but I think it is a systemic problem, isn't it, around the social care pressures. I absolutely welcome the bonus that we've heard being delivered for paid care workers and the introduction of the living wage. Unpaid carers tell us that the most important aspects that they'd like to see changed—. So, in a recent Carers Trust survey, we found that the three big issues that would affect carers would be: better finances, reducing their financial hardship; and then, secondly, more breaks, more respite; and thirdly, better care for the person they support. And that absolutely demonstrates the relationship between unpaid caring and paid care work. So, I'd completely agree with the points that Jake made around that funding going from local authorities to the paid care workforce, to help relieve pressure on unpaid carers, to make it a sustainable approach for them and to reintroduce those respite breaks. So, just to come back, Jack, on perhaps an urgent or rapid change that we could make, we could be thinking more about the respite options that are available to us, even within some COVID restrictions. Certain day centres can operate safely, and we could see an introduction of more respitality options.

Okay, thank you. And just briefly, Kate, and then I'll finish there, Chair.

Certainly. Some very quick points: I suppose the first, really, is around updating the current guidance on hospital discharge so that hospital discharge teams check what support family and carers can provide and build that into the discharge process. I think that's something that could happen rapidly. I think the other element is that—certainly our recent research has found this—communication on discharge or even pre admission is not always there. So, the COVID-19 hospital discharge requirements in Wales emphasise the need to provide information leaflets, but, from our research, we've seen that that doesn't always happen. And where it does happen, those leaflets don't always include a point of contact, locally. So, actually, those are some quite quick wins, I suppose, in terms of solutions that could be made relatively quickly and improve the discharge process for people.  

There is also a wider issue around knowledge of the discharge to recover then asses solution. That was implemented at pace during the pandemic, understandably so, and the right thing to do, but it has meant that knowledge and interpretation of that guidance is variable. So, I think there needs to be guidance and tools for hospital teams and discharge teams to better determine the appropriate pathways for patients.

Thank you, Kate. That was very useful. Chair, I'll leave it there now.

Thank you, Kate. Thank you, Jack. That's a helpful answer. Rhun ap Iorwerth.

Thank you. I think there are a number of elements. The first, as I've just mentioned, is around the communication around the guidance and the tools. I think we would suggest that national policy should be amended or complemented with guidance that includes advice for hospital staff around how to determine appropriate discharge pathways for patients, building on recent complementary guidance, such as the 'Home First' discharge to recover then assess model, which was published just in January. So, I think that there are some elements there. But it's also important to note that, when we looked at our survey, we did actually find that there is quite a significant proportion of discharges that actually don't fall into the criteria required for that specific D2RA pathway, and therefore we're seeing quite a lot of discharge needs not necessarily being picked up because they're not following that specific pathway. So, I think it does come back to guidance and tools specifically, but also ensuring that patients who are placed on the D2RA pathway have appropriate access to assessment following discharge. So, that might need to involve updating the pathways policy so that it's clear where an assessment is required following discharge, and then, again, complementary guidance around that to ensure that there is capacity within the community to carry out assessments post discharge.  

And you're happy that it's a lack of understanding of those pathways and the requirements of those pathways, and nothing more dangerous than that at play here—the interaction of financial responsibilities between different people and so on. It's just a lack of clarity that's allowing this to happen.

It's a lack of clarity, it's a variation in implementation across health boards and across hospitals, and it has to be said that there are workforce pressures, as we're all very familiar with, that actually, I think, are meaning that, potentially, those pathways aren't always implemented in the ways that they are intended to because we are working within systemic pressures around workforce that are limiting the effectiveness of those pathways.

So, I think they're the right pathways. I think it is about embedding them and understanding them, and having teams that are familiar with them and have the appropriate guidance to support them. But it's also about making sure that we have the capacity to deliver. I really do think that the assessment post discharge is an important element, and ultimately one of our recommendations within our report is that we do want to promote the five-point independence check. It's a holistic check of a person's practical, social, psychosocial, physical and financial needs prior to discharge, so that it can all be incorporated within that pre-discharge assessment process.

And from your point of view, Jake Smith, that the carer too is assessed is something that you've referred to already.

Absolutely. Carers, of course, have a right to have their needs assessed under the social services Act, but we hear from many carers that they're not being offered that assessment before hospital discharge takes place. Especially in a situation where health boards are asking carers to take on more duties because of insufficient services, it's even more important that those assessments take place.

Another point I might quickly make in terms of assessments is that, in many cases, of course, the patient in hospital might themselves be an unpaid carer. Public Health Wales released some research in November talking about how unpaid carers, even controlling for other socioeconomic factors, face poor health. If an unpaid carer is stuck in hospital because of the problems around discharge, it raises the issue of who is caring for the person who relies on that unpaid carer. Unfortunately, we have quite a lot of evidence that shows that emergency and contingency planning, which should feature in carers' needs assessments, very often doesn't, so you have the situation where carers themselves might be in hospital for an extended period, and because their carer's needs assessment didn’t cover contingency or emergency planning, there could be a quite dangerous situation with the person who relies on them, at home or in the community. So, it's so important to get assessments right and to make sure that all carers are receiving them.

Thank you. Ultimately, that five-part check, as I mentioned earlier, is a checklist to be used by an MDT team—a hospital discharge team—to support the conversation that focuses on what matters to the patient. It includes things like talking about and assessing a person's practical needs, their social needs, psychosocial, physical and financial needs. Our research has shown that professionals have reported inconsistencies and confusion around assessments, with examples of the same assessment being carried out in the hospital and then repeated in the community. And 15 per cent of the survey respondents felt they needed an assessment after leaving hospital but didn't necessarily receive one. 

In terms of introducing that five-part independence check, that will start to bring into the conversation at a much earlier opportunity those practical and emotional support needs that feature outside of the hospital and, in particular, will start to improve that conversation and that communication that we've talked about being quite difficult to build. If you're starting the process early and having those conversations that are opening up discharge beyond being a clinically-led discussion—. Obviously, it needs to maintain clinical input, but having those other broader, social elements included creates an environment with that broader communication, and you're starting to think about the implications for carers, the implications for community support availability, access to that support on a seven-day basis. It starts to open up that conversation and broadens it. It's something that I'd very much like to see us welcome here in Wales as well. 

Joyce Watson. 

I'm going to ask, very quickly because we are running out of time and we want to get the critical points in, about specific issues around discharge that you've mentioned, so I can bring them out to the fore. One of them was rushing things so that, instead of it becoming a rushed discharge it becomes an unsafe discharge, and the difference between those, particularly people being discharged at night and delays to prescriptions and medication being prepared. So, if I could have some key feedback on that so that we can put it in our report, it would be really good. Thank you. 

Thank you. Can I come in again and just say that I think, again, that this is a communication issue? Under the new process, of course, the discharge planning process begins as a person is admitted to hospital. You start thinking about those checks right at the outset to make sure that the discharge happens appropriately. So, at that point, it is about identifying whether there's a carer involved, making that holistic needs assessment. A rushed discharge is not necessarily a bad thing; an unsafe discharge would mean that you hadn't consulted the carer, that medication wouldn't be available, that no-one is available at the house when somebody is returned home, et cetera. Again, I think, for me, this comes down to communication. 

Can I just ask: do you think that discharging patients at night is okay in some cases, or should it be stopped altogether? 

I don't think we would have a clear view on that point. I think it would be down to individual and personal circumstances as to whether the person is safe and able to be discharged at that point, and whether they are being discharged to a setting that is ready for them, is expecting them and has everything set up for them, including aids and adaptations that need to be there regardless of what time that would be. 

Who else wants to come in on that? Jake Smith.

Just to add very briefly to Catrin's point, on the significant issue around unexpected discharge and people not being given much notice, and often people being delivered home with the carer not having had any notice in advance that this was going to happen, this whole situation assumes that unpaid carers can put their lives on hold to then just receive the cared-for person at the drop of a hat. But, of course, unpaid carers have jobs, they have children, they have hobbies, they have lives to maintain, and they can't be expected to, essentially, sit by the phone 24/7 and pick up their loved one at a moment's notice. So, we would say that, as well as all of the very important points about whether or not it's a safe discharge, the lack of communication and unexpected discharge also has significant impacts on the carers' lives outside of caring.  

Joyce, any further questions from you? No. Thank you. Gareth Davies. 

Diolch yn fawr iawn, Gadeirydd, and good afternoon to all the witnesses this afternoon. I just want to use my section of questions on the role of the third sector. I'll throw the first question for everyone, really, to try and establish a view on what role the third sector should play in the discharge process and any improvements you'd like to see in the current arrangement. And just to consider as well at the bottom of that, what would be the challenges to those being achieved in the environment that we're currently in at the moment. So, I'll throw that open to any takers, really. 

Who'd like to come in? 

I think the third sector is in a really unique position there, isn't it, to support broadly the health and care system in a sustainable way. In terms of hospital discharge, what we need is to address the needs of the individual that's being discharged, but to do that, we need to look at the family, at the carer situation. So, we need to approach discharge not only about that patient, about that individual, but in the wider, the more holistic sense. For me, that's about prioritising the strategic approach that we can take across health and care to look at prevention, to commission for prevention, to see prevention as an essential service within our health and care system. Hospital discharge is, in many senses, the microcosm of that broader concern. But, the third sector offers that really valuable opportunity to make connections. We're nimble, we're dynamic, we're flexible, and we are able to refer. We have a good knowledge of community bases and assets, and we connect from one place to the other in a way that perhaps our healthcare settings at this point don't have the capacity to do, but they need to be making those referrals to us, speaking to us, communicating with us, so that we can do that work that we're best placed to do.

Any other views? Thanks for that, Catrin. Anything from Jake or Kate?

Jake wanted to come in, I think. Jake.

Thank you. So, the third sector, of course, can play a really useful role in terms of helping unpaid carers manage with the discharge of a loved one through providing information and advice, be that condition-specific charities with advice about caring for them after discharge, especially if they're receiving less help than they might have otherwise from a health board, or an organisation like Carers Wales or Carers Trust Wales, who can advise on general issues for carers and their entitlements and such. The third sector can also be really useful in terms of—. An issue that springs to mind is home adaptations and the great work that an organisation like Care & Repair Cymru do.

What are the challenges and the impediments to that? Well, first of all, much of the third sector exists on short-term funding settlements, and they might only be one, two or three years' long. That means, of course, there is high turnover of services, but it also makes it harder for people in healthcare settings to signpost people to third sector services, because the service that existed a year ago might not even exist any more. Another issue as well is that it's so important, therefore, to make sure that staff involved in hospital discharge are adequately informed and knowledgeable about local services and the third sector support that might be on offer. So, there is also a piece around making sure that staff in the process can adequately inform carers about the third sector support that may be available.

Thank you. Kate, did you want to come in, or—?

I would second, actually, those comments that Jake just made—absolutely. It can be awareness of the resources and services provided by the voluntary and community sector, but, yes, absolutely. There is this ebb and flow of those services because of the nature of the funding attached to them. So, longer term, more sustainable funding really allows the sector to be far more responsive, but it also means that the partners that we work with are more familiar with those services and develop relationships and have more of a history and an understanding of the services on offer, but also the impact they make. Ultimately, we do want to shift the direction and the prioritisation towards, ultimately, prevention. And as a sector I think we're well placed to do that and to be able to respond to needs so that they don't escalate into demand on health and social care. Again, that comes back to funding of the sector and its ability to be able to progress in that direction on a much stronger footing in future.

Thanks for that, Kate. My final question is probably best directed to yourself, as the British Red Cross says that the majority of patients will be discharged without any further formal support, and we've found out that people aren't always managing with informal support networks, or informal support networks aren't always there, so do you have any more information about that, or views on the solution to these problems?

I think we're going back to the main crux of what we talked about several times already, which is communication. It's about that discharge documentation, that discussion that happens between a multidisciplinary team within the hospital and involving other agencies as well as the patient and their family or carer as well. So, I think that that's the root and the solution; getting that right means that ultimately those issues that we see later on down the line aren't necessarily coming to the fore.

In terms of, yes, those—. The discharge to recover then assess pathway, it doesn't apply to all patients who leave hospital, so we are going to see a number of those patients who are leaving without having that very comprehensive assessment, so we would be recommending that anyone leaving hospital undergo that five-point independence check, so that there can be that broader assessment of need. So, yes, as I say, communication is key to all of this.

Yes. I just wanted to come back on communication in particular, because I suppose if the third sector don't feel valued as part of the MDT, the multidisciplinary team, that's going to jeopardise effective communication, isn't it? So, I'm just wondering: do the third sector feel valued in the MDT, because my experience is that they sometimes don't, and what would go some way to improving that?

I think there's a lot of variation, in all honesty. In some areas, there are quite well-established relationships between partners in the sector with health and social care teams. Catrin mentioned earlier the approach around using a hub, so having partners across the third sector within a hub model, so, actually, as a statutory provider, if you're working as part of a hospital discharge team, who do you go to to connect with, and how do you make sure you reach across the sector in one go, and that hub approach is a really useful tool to be able to do that.

There are some really strong examples of very well-engaged teams. I'm certainly aware of the Pembrokeshire intermediate voluntary organisations team service, which is down in Pembrokeshire, which has a really good integration between the voluntary community sector and health and social care, and it's a really shining example of where it works very well; I think there's a lot that could be learned from there. But I think, in other areas, the interaction isn't as routine and familiar, and, on that basis, it's difficult. When, let's face it, health and social care staff are very busy, how do you find the time to build those connections and make those relationships, so it becomes a natural part of the conversation around discharge?

Diolch. Thank you, Chair.

Jack, you wanted to come in. Jack Sargeant.

Just very briefly. We hear in pretty much every evidence session we have, in certainly this inquiry, and perhaps most inquiries, that communication is pretty poor. There are obviously some examples of good pockets of communication, and best practice isn't shared as well. I'm just trying to gauge, really: have the communication levels always been this bad, or has something happened that's changed it? Has the pandemic changed it? Has something else changed it? What is the case here, or is that too much of an open question to ask?

Can I come in on that point? And just picking up on the idea of the MDT, so, whilst the question was around the third sector involvement in the MDT, in preparing to gather this evidence, I spoke to several carer support agencies who were telling me about carers who were involved in that MDT, and that was physically on the ward pre pandemic, and in that case, of course, it is the pandemic that has made that a difficulty. And the third sector were then the low-level advocacy that that carer needed to be able to speak their own concerns and to put forward their own needs and what they were willing and able to do, as we know around assessment.

So, the pandemic is the issue that stopped that, where the MDT is physically present on the ward, but, of course, we know from community colleagues that, actually, MDTs work really well when they're done virtually, if you have somebody that's able to facilitate that. So, there's no reason that—. Perhaps it might be impractical to think that every MDT on a hospital ward around discharge would be done virtually, but I'm sure there can be circumstances where we could involve carers, the third sector and all those professionals who aren't able to be physically present on the ward in that MDT, which would be—. It's one of the things about the pandemic that's been positive, that we've become used to that virtual approach, and, in my view, we should be extending that where we can to involve the third sector and carers who need to be part of that conversation around discharge.

So, is it a case of sharing perhaps best practice better, then, rather than starting from scratch?

It absolutely could be. It's happening in some places, so I'm not aware of reasons why it couldn't happen in others. Yes, it's about roll-out.

Okay. Thank you, Chair. Thanks, Catrin.

Thank you, Jack. And Mike Hedges.

Diolch, Cadeirydd. Two quick points from me. I heard what Jake Smith said earlier about funding and annual funding. Has the move to three-year budgets been of any benefit to you?

I'm not aware of what impact it's had on the ground in terms of services health boards can refer to. Longer term funding, be it of three years or longer, will always be of benefit, but there's still that lever of churn and turnover in those services. But we don't have any specific data on that point.

What I meant was specifically about third sector organisations. As people working in the third sector know, just before Christmas, three months' notice is given fairly regularly to staff because there's no continuity of budget certainty, and then when they get the money then the redundancy notices are taken back. I'm just wondering whether having three-year budgets to the third sector will actually help them. I've got a 'yes' from Kate.

Can I come in there? Thank you, Chair. We are actually starting to have those conversations now with statutory commissioners, which is really positive. So, it's trickling through, but I think it's about understanding how that funding arrives and how it's managed, and, from a statutory perspective, getting to grips with that change in funding approach. It will be of immense value, and it's a really positive move, definitely, in the right direction from a sustainability perspective, but also in terms of the sector being able to strengthen those existing services. So, it's very much welcome. And, yes, certainly from my perspective, we are starting those conversations with some of our commissioners already, which is good. We hope for more.

Can I come in at that point as well? Just to say that, absolutely, longer term funding is really helpful in terms of being able to plan and deliver services. We've recently heard, of course, that the regional integration fund is moving the ICF from that shorter term to a five-year funding arrangement. There'll be many hospital discharge services that will be funded through that position, and that's to be welcomed, of course, but I'd also say, above and beyond the idea of sustainable funding or longer term funding approaches, of course the third sector needs to be involved at that strategic level in the planning. So, it's early conversations, pre-commissioning conversations, to ensure that commissioners understand what the need is and what's available and how we can be part of that solution together as part of the health and care system.

And finally from me, I'm very keen on reablement. Too many people come out of hospital, they get sent to a care home, they were okay before they went into hospital, they've lost capacity and muscle strength when they were in hospital, they're sent to a care home or they're sent home and they get carers, and nothing is done to reable them to get back to the state they were in before they had their knee mended. What I'm asking is: is there more you as a third sector can do in order to engage with the statutory sector to increase reablement?

Can I come in there? The short answer is 'yes'. There absolutely is more that we could do. As a sector, we provide regulated services as well, which does mean supporting people with personal care so they can return home from hospital, rather than to a formal care environment. So, yes, there is capacity to do that. We are in the same challenge across the sector, from a health and social care perspective, in that the workforce availability is quite a critical issue. But, yes, there is more that could be done; there is more that I think the sector is keen to do to be involved in, in that respect. But, yes, there are some challenges around it that we will have to navigate.

Thank you. Thank you, Kate. Can I just ask the witnesses, finally, just to give us, in bullet-point form—so, no more than bullet-point form—your key messages in terms of recommendations that you think that we should be presenting to the Welsh Government? Who would like to go first? Catrin, you look like you might want to go first.

Diolch. Improving communication between healthcare professionals, the statutory sector and carers and the cared-for person. Longer term funding and sustainability, involving the third sector in planning so that we're funding prevention as well as acute need. And, to be bold, to trust us, to involve the third sector in delivery. We're key elements in involving the family and the carer in hospital discharge and wider across the system; involve the third sector and draw on our expertise.

There we are. To be bold and to trust you. Yes, absolutely. Jake Smith.

Training for staff in health boards to make sure that they have the knowledge and are able to routinely identify unpaid carers, so that unpaid carers are seen and are meaningfully consulted with throughout the process. Health boards should also be looking at reviewing the information that they provide to unpaid carers to make sure that it is effectively conveying their rights to support and to assessment, so carers at least go through that process with high-quality information that will, then, enable them to care, should they choose to.

At a time when health boards are reducing the amount of support that they provide to unpaid carers and sometimes discharging people with very little or no support, then there needs to be more flexible use, for example, of direct payments, which enable unpaid carers to source alternative forms of support.

If unpaid carers are going to be taking on more care because of the discharge, then there needs to be proper training for those unpaid carers on things like medicine management and manual handling to actually help them to manage. Because if unpaid carers can't manage and their health and well-being continues to deteriorate, not only will their loved one be back in hospital before too long, but the unpaid care worker will probably be as well. So, that failure to adequately support unpaid carers is only storing up problems for the future.

Thank you, Jake. And, Kate Griffiths.

My five points would be, firstly providing all patients with a leaflet and information about discharge when entering and leaving hospital, and that is within the current discharge guidance, but it needs to be implemented by the hospital discharge teams. Secondly, improved communication. We've talked a lot about that today, so I'm not going to expand on that any longer. Thirdly, provide hospitals with the guidance and tools that are needed to better determine the most appropriate discharge pathway for patients. Fourthly, it would be to update the current discharge guidance so that holistic checks—those five-point independence checks that I referenced earlier—are used to support conversations with patients, families and their carers, and to ensure that they have the support that they need at home. And then, finally, the fifth point would be around increasing investment in community-based support to address some of those gaps that we are seeing in provision, including seven-day services, so making sure that we have weekend coverage.

Thank you, Kate, and thanks for summarising those key messages at the end—that was really helpful. And thank you also, all, for your evidence papers, particularly the examples, which I thought were helpful, that you presented in your evidence from carers and others. That was helpful to see as well, to help us understand the issues. So, diolch yn fawr iawn. Thank you very much. Thank you for your time, all. We'll have a 10-minute break and be back at about 14:13.

Welcome back to the Health and Social Care Committee, and this is our next session this afternoon with regard to our work on hospital discharge. I would be grateful if the witnesses could introduce themselves for the public record. First on my screen is Chris Jones. Do you want to go first, Chris? And then I'll come to Catherine. Chris.

Thanks, Chair. Yes, it's Chris Jones. I'm the chief executive of Care & Repair Cymru.

I'm Catherine. I'm the manager of the Tyfu Tai Cymru project, which is a research project based at the Chartered Institute of Housing.

Faye.

Hi. My name's Faye Patton. I'm the policy and research officer at Care & Repair Cymru.

Thanks ever so much for being with us this afternoon and for your evidence papers ahead of the session as well. So, thank you very much, diolch yn fawr. Our first set of questions this afternoon is from Mike Hedges.

As Chris knows, because we've had this discussion over the last 11 years, or perhaps even longer, I believe that housing is very important for people coming out of hospital into adequate housing. But I'm not supposed to answer the question as well as ask it, so can I ask our witnesses to give their view on how important good-quality housing is for people being discharged?

Shall I go, Chair?

Oh, yes please. Thank you, Chris. Thank you. Chris Jones.

Thanks. Yes, absolutely, Mike. You've probably heard a lot of evidence about discharge to care homes—you know, from a point of view of care and a medical point of view—but, from our point of view, the lived environments, the places where people live, their surroundings, their ability to be warm, safe, living in an accessible, adapted home are equally important. You know, the Government policy is discharge to recover then assess; in my view, unless housing is a part of that then it won't work. So, that's a short answer, Mike.

Thank you.

Faye Patton wanted to come in as well on this, and Catherine May as well. Faye first.

Thank you. Yes, just to follow on from what Chris has said, I totally agree with you, Mike: I think housing plays a really essential role in the continued recovery of a patient. So, it's vital that this place is warm, it's accessible and it's been adapted to meet the changing needs of a patient following that hospital admission. So, patients who are discharged into a home that is going to make their health condition worse, or is hazardous to them, is essentially just as a result of a housing issue that could have been fixed, it could have been adapted, and it ultimately could have been avoided. And we know that housing is a wider determinant of health, but I think it's lesser embedded how structurally we can actually factor in housing and integrate it fully into health through, in this case, hospital discharge planning. But, again, more widely, in community service, perhaps in a preventative role. So, I think that is really, really important.

Just to quantify it a little bit: the last housing condition survey in Wales was in 2018, so predating the pandemic, and that showed that 18 per cent of homes posed an unacceptable risk to health. We know that housing does play a really integral role in people's health, and especially in Care & Repair's case, because we deal with an older cohort of patients. This is particularly important when those kinds of illnesses, such as respiratory, cardiovascular illnesses and infections, are exacerbated by poor housing, cold homes, damp homes, et cetera. So, yes, I think, when it comes to health, and specifically for unscheduled care pressures, housing is essential really to that whole-system approach. Thanks.

Just to continue the theme, obviously, as the Chartered Institute of Housing, we think that housing is absolutely central, but Public Health Wales told us that poor housing costs health services in Wales £95 million a year. So, just simply on economic terms, it doesn't make any sense if we're not investing more in better housing. And while hospital discharges are only one part of that process, it is a really key opportunity to find out the conditions that somebody is living in and look for improvements to that. The issue that we often come across, in terms of hospital discharge, and our research found, is that it's too late—it's done too late in the patient's stay in the hospital. So, by the time they've realised that the housing isn't suitable, they're ready for discharge.

Thank you. Can I—? Joyce wants to come in.

Joyce Watson.

Sorry, I was going to let you finish.

I've got two very brief things. Do you agree that health, care and housing should be the three legs rather than health and care only being two of them?

Yes.

Yes.

There we are, that's a brief answer.

And my last question: you've got people who need minor modifications to their homes, and can I just say what a good job Care & Repair do on that? My father-in-law was a recipient of that fairly recently, so 'thank you' from our family. But some people need more major adaptations, and some people need simple things like carpets. Do you know how difficult it used to be—I don't know whether it still is—to actually get a carpet into a house when somebody's got lino on the floor, which is slippery for them? People will put £10,000 to £20,000-worth of grab rail rather than £1,000 of carpet in. Is that still the case? And should we be looking to what is best rather than what fits in to the rules?

Chris Jones.

Yes, Mike. You know, the Hospital to a Healthier Home service is a brokerage service that tries to solve problems to get people out of hospitals quicker. Probably people will know about small adaptations, but there's a lot more to it. There are issues around people who hoard, cluttering, moving beds and furniture, putting in key safes—it's an individual basis. Whatever it takes to get somebody home and discharged safely is what that service is all about.

Again, from a housing point of view, it's not just adaptations; it's making sure that people are going home to a warm home. We've all heard about the fuel cap increase and the impact on fuel poverty and the increasing energy bills. If somebody isn't going home to a warm home or they're not able to put the heating on, then there's going be a significant increased risk of them being readmitted, and similarly, going into damp properties in disrepair. So, yes, if what it takes is some carpeting or something that is specific for that person, that's what the Hospital to a Healthier Home service tries to arrange.

Any further questions, Mike? No.

That's me finished.

Thank you, Mike. Joyce Watson.

Just a very quick one to Catherine May, really. It's about building houses of the future, and if we build the right houses with the right layout—all houses, that is—in the future, and I know there's legislation around it, at least we're not storing up the future problems. I know that it won't do anything to alleviate what's there. So, what sort of progress is being made in that direction that you think is good progress? And is that progress right across the board?

I think that's really exactly where we need to be: talking about making sure that our homes are fit for now and for the future. As a population, we do have a high level of disability, we also have an older population, and we need to be really looking at all of these issues with the house building. I think the work that's been done and the commitments that have been made are brilliant, and we need to keep that going, but we need to keep the pressure on to make sure that's being delivered, make sure that the housing developers are building the houses that are needed, not the houses that they, perhaps, want to build, and also that we're keeping up the kind of quality standards that we see. But one of the issues we have is that the stock we have isn't really of a good enough quality. So, while we can build for the future and keep that pressure on, we also need to look at how we're retrofitting the houses that we've got, because we're adding to this the pressure of the climate change and the challenges that that's bringing, and we need to be looking at the stock that we've got and how we can improve it. It needs to be across all the tenures. So, as well as social housing, the private rented sector needs support to be able to get their homes to a good enough quality that they keep people well and safe and do their bit in improving our challenges in terms of meeting climate change.

Thank you, Catherine. I'm just looking at who's next on my list here, sorry—Rhun ap Iorwerth. Sorry, I beg your pardon.

Yes, our caseworkers are telling us that because older people weren't accessing healthcare during the pandemic, when they end up in hospital they're actually sicker, so the deconditioning is worse than it would be. Therefore, the periods in hospital are longer, and some of the solutions are more complex and cost more to get right and put into place. 

I think, generally in terms of the pandemic, in the early stages there was a big push, rightly, to empty hospitals and create bed spaces. So, during the pandemic, our Hospital to a Healthier Home service actually got really busy, albeit our caseworkers were remote, and what we've seen over a couple of years is that, actually, that demand has increased, as you say, Rhun, and as we point out in our evidence, and that continues. So, since that evidence was submitted in writing—I think the figures were to September—the number of people needing the service and being referred has continued to increase. We can provide more up-to-date figures to the committee if they want to see that.

I think also I would like to say that, just in terms of Hospital to a Healthier Home, I think some of the increases in the figures have been because the service has become more embedded over time as well. So, what really needs to happen, and what has been happening with that service, is that, as our caseworkers have become more integrated into the hospital, and with multidisciplinary teams and with ward staff, the trust has built up—trust and knowledge of the service has built up—and the level of referrals has increased. I think we've seen a bit of that as well—that embedding of the service in the hospital, which happens over time, we've seen that over the last two years. 

Faye, you wanted to come in there as well. 

Yes, so, as an update on the figures, our referrals from last year are actually up 34 per cent now, which is a massive increase. I think during the pandemic we've seen increased rhetoric about the importance of the home to health, because we've all spent more time in our homes. But, actually, older people already were spending quite a lot of time in their homes, and what's changed during the pandemic is that the number of people going into their homes, whether that be friends, families, carers, et cetera, has reduced. So, that means that older people are now presenting at hospital increasingly frail and increasingly in deconditioned condition, but their home environment has also become increasingly frail, and it has become deconditioned with them, as a package of the whole person in their whole house. That's why we're also seeing increasingly complex adaptations required to get that person out, and make sure that they are returning to a safe home.

Thanks for that. Catherine. 

Just in relation to the pandemic and housing particularly, an issue we found was in relation to homelessness, and, again, the rightful decision to try to get everybody into accommodation so people weren't sleeping on our streets, which was a very good, laudable drive, but an unexpected consequence of that was that temporary accommodation became full and then local authorities were using more bed and breakfasts, more temporary accommodation, and then local authority housing departments told us that they weren't able to then use that accommodation for people who were in hospital who might previously have been able to use it. Therefore, they were having to stay in hospital longer or be put into temporary accommodation that wasn't suitable for their needs, around, for example, substance misuse, or something. So, in terms of looking to the future, I think it's just making sure that we have enough temporary accommodation to have that flexibility for those particular circumstances. 

Thank you. That's very useful. And if I could come back to you at Care & Repair, going back to the purpose of this particular inquiry, it's obvious that the more people waiting for adaptations, the more complex the adaptations that they need, the more challenging it is for you to fulfil those needs. Could you immediately then see a build-up of people who were being held in hospital because you were unable, just because of sheer scale of work as organisations throughout Wales, to get those homes ready for people?

I don't think that's the case, Rhun, and the reason I say that is because, with the Hospital to a Healthier Home service, the capacity for that has been created through funding through Welsh Government, and we have staff in 17 hospitals. And what's been happening is, as time has gone on and that demand for adaptations has become clear, we've been working closely with Welsh Government colleagues in the housing directorate as well as colleagues in health, to say, 'Look, we've got some demand here. Are there any additional resources that you can make available so that we can meet that demand?' So, at the moment, that capacity is there in the system. My concern, and we'll probably come on to it later, is: what happens next year?

Yes, and we can look at that now. Maybe that's something that one of my colleagues wants to go into. But just, again, trying to understand the realities on the ground now, Catherine, in laying out clearly the shortages that you see have emerged in suitable accommodation, are you seeing a response? Are you seeing more action being put into making sure that there is more suitable temporary accommodation for people, or is that not yet being heard?

I would say that's not yet been heard. For a lot of people, we're operating on crisis management, it feels like. There's that feeling that we're just getting by. I know staff in local authorities have told us they're really worried about the temporary accommodation, about the people who are in temporary accommodation, getting them into longer term accommodation, which really is the answer—finding those longer term solutions for people so we're not having to rely on it so heavily. It feels at the moment as though we're not yet at that place. I know there are some initiatives happening that are looking to find better ways, but they aren't yet happening, it seems.

Okay. And finally from me to Care & Repair, you say that you've been able to get your hands on additional resource, if you like, to carry out the work needed to meet the higher level of expectations. Is that going to become unsustainable, moving forward? Because, as we move out of the pandemic, everybody expects a return to some sort of level of normality. There'll be an expectation by the people who pay for care and repair that, hopefully, that care and repair bill will come back down again. Is that pressure starting to appear?

Yes, for us it's not the end of the pandemic and the ability then to say, 'Look, because of the pandemic, we've got more demand.' Actually, it's more basic than that; it's, 'Can we resource this service next year?', which is uncertain at this time. We're talking to all the health boards. We started to talk to them back in June. The service has been funded by Welsh Government. It started as a pilot. That continued because it was successful. The pandemic meant that we couldn't have those conversations with health boards so the Government continued to fund it, but that funding finishes at the end of March. And the conversations that we've been having with the health boards since the summer have been inconclusive. One health board has committed and said yes it's going to fund the service from next year, but the others haven't yet, and it's getting very close to the point at which we're in a position now—something really familiar to third sector organisations coming towards the end of the financial year—where we don't know if we've got funding. We need to put staff on notice of redundancy and we need to start thinking about decommissioning services, which, from the point of view of this service, which has been so successful, seems just a big backward step. Now, the health boards haven't said they're not going to fund it, but we're getting close to the point where, from a business point of view in the third sector, we need to start making those kinds of decisions about staffing and future services.

I know colleagues want to tease some more out on that finance issue later on, but, thank you. Thank you, Chair. 

Thank you, Rhun. Chris, perhaps I can ask you as well, and going back, perhaps, to some of Mike's earlier questions, when it comes to delays in equipment or adaptations being identified, how often is it typical that there are delays in that regard? 

So, what we try to do through the rapid response adaptations programme for hospital discharges is same-day works, whether that's a small ramp or grab rails, hand rails or a key safe, or whatever it might be; it's same-day discharge. I was chatting to one of our Care & Repair managers in the Swansea bay area, actually, and she said that typically on a Friday, they can get ten to 12 referrals for same-day discharges. Towards the end of the week, I think, there seems to be an increase in the level of activity for discharges, and we do get numerous discharges in a day, to go out and do very, very quick adaptations to make sure that somebody can be safely discharged at that point.  

That sounds very positive. So, what you're saying is that there aren't any typical delays occurring for equipment or adaptations. Once they're identified, they go out the same day—that's your experience. 

For small ones, that's the case. For larger adaptations, practically speaking—. So, if you start talking about stairlifts and level-access showers, if we can have those conversations in the hospital with patients and MDTs at the point that somebody's admitted, then they can be done by the time the discharge happens. I think it's where that process doesn't work smoothly—so, somebody is medically fit for discharge and we get referred for the first time for somebody's housing issues—is the point at which delays can occur, except for the very small ones where we can go out on the same day. But, for larger adaptations, there will be a delay at that point. 

Okay. Faye, you wanted to come in on that. 

Yes. Chris actually covered what I was going to say. I was just going to say that it's the smaller adaptations that we can do same day. It's when housing—. Well, in all cases, housing must be really concerned from the moment someone enters hospital so that those adjustments can start to be put in place. And it's with those admissions to hospital where discharge isn't imminent—for example, perhaps a stroke—where having that communication early on for more complex aids and adaptations, is where it's really, really vital that that is started from the very beginning, not just when there is that golden window of opportunity where the patient is medically fit for discharge. 

If we're talking about those conversations not happening as perhaps they should, what delay are we typically talking about at the moment for some of those more difficult adaptations to be made, such as stairlifts? If those conversations aren't happening, as perhaps you're suggesting, then what typical delays are we looking at that actually add to the issue of being able to discharge a patient from the hospital correctly? 

I would say several weeks to a couple of months—about that type of timescale. As the scale of the adaptations needed increases, so does the time it takes to get them organised. For example, an extension will take a long time, won't it? But, it's to do with the scale of the adaptations that are actually needed as to the level of delay that will be incurred. And the later in the day that referral is made into the service, obviously the longer the delay. 

What I'm trying to get to, I suppose, just trying to understand if, in the perfect world, communications were all being undertaken correctly and as you would like to see them, if that's not happening, then what further delays—? To what extent are delays now occurring, and what are the scenarios? Are there any particular examples that you have where you can say, for example, 'If that communication had taken place, then that stairlift or that other adaptation could have been in place a month earlier, and, as a result, that patient's not been able to be discharged from hospital'? I'm looking for the extent of that actually happening in terms of the delayed time, if you like.

I think we'd need to speak to our colleagues in the hospitals to get some specific examples and some better data on that for you, Chair, if that's okay.

It would be really helpful to have that, because I think that would be key to our piece of work. With regard to discharge practice across Wales, what kind of variation takes place between health boards, and, more specifically, hospitals? Is there a great difference in the variation in terms of hospital discharge across the country?

I suppose we can only speak to the services that we run in partnership with health, and I suppose, from 30 years of working in public services, what I know is it's hard to get good practice to travel and to be replicated. But, again, talking about some positives here, I think for this service, Hospital to a Healthier Home, having it in 17 hospitals across Wales has meant that there's some local variation, but, by and large, the general availability of that service and how those caseworkers are being embedded in the hospitals, working with the MDTs, the physios, the nurses and the occupational therapists, has become fairly consistent. So, I would say in terms of that specific part of the discharge process, because the service is becoming embedded, variation is becoming something that doesn't exist too much. Sorry to go back to my other point, but the concern we've got is that that will disappear.

What you did talk about, Chris, is about there being elements of good practice, so I presume there's good practice and there's bad practice. Of course, as a committee, we'd want to find out where that good practice is. So, it'd be good to have, perhaps, an example of good practice in terms of good hospital discharge that you could point to, or any of the other panel members. I think, Catherine May, you want to come in on that, perhaps.

Yes, just to back what Chris said. What we've found is that where there's a hospital where there is housing expertise embedded within the hospital, that makes a difference, wherever that may be. Aneurin Bevan have had a long-term project that involves having housing expertise based within the wards, who accompany the ward rounds, and that seems really good practice.

We certainly came across, anecdotally, really poor practice, to the point of people being taken home by ambulance, and the ambulance turning round and taking them back to the hospital, because it was only at that point they realised that the house was not in any way accessible. So, there are examples on both sides of both good and bad practice, but what we found, most importantly, was that having that housing knowledge, expertise, adaptations, the stuff beyond the bricks and mortar as well—. Having that involved in those multidisciplinary teams early and throughout the process, because patients' needs change, made all the difference.

What's your assessment of why, perhaps, other health boards don't operate in the same way as Aneurin Bevan, as you just pointed out? What's the blockage?

I think, for some, there's a better understanding of how important housing is and that need to have it as part of that patient's recovery. Perhaps that's part of the reason why. There are historical reasons; definitely the kind of commitment of staff to work in particular ways makes a big difference. We did a whole piece of work around partnership and what makes a good partnership, and it's quite basic things, really. Particularly, commitment from senior staff to partnership working makes a big difference, and, backing what Chris was saying, long-term projections in terms of keeping these projects going, not rolling from year to year, or dependent on a staff member.

Chair, can I just add to that? The best example of good practice for this particular service, Hospital to a Healthier Home, has been in the Princess of Wales Hospital in Bridgend, and the reason I say that is because it's been there since 2014. It's been there for seven years, so what happens is the relationship develops between us in the third sector and health colleagues in hospital. The trust develops, the referral pathways become clearer. In that case, the service has been added to over time, so you end up with a situation where you've got not one but a couple of caseworkers embedded in the hospital, and you've also got handypersons on site with their vans, just ready to go to do those basic repairs and adaptations that are needed on the same day for an adaptation to take place. I think that comes with genuine partnership, genuine trust, building relationships, and that's about longevity and sustainable funding.

Jack, you wanted to come in.

Very quickly, Chair. Chris, you said earlier that it's hard to get good practice to travel. I just want to ask simply: why have you made that assessment?

Just experience from 30 years—20 years in local government and 10 years working in the third sector. I've been involved in reviewing housing adaptation services in the past, and when you go across Wales what you see is great practice in some areas, but not across the board. So, whatever service you're talking about, whether it's local authorities or whether it's health, you can get some great people come up with some great ideas, put those services in place and they work well, but replicating that across Wales is difficult. That's just been my experience, which is why we were over the moon, really, when Government recognised this—what we've put in our evidence—as good practice, and they funded it, for three years now. That's allowed that to build up and that good practice to embed itself into the system.

Faye wanted to come in.

I agree with Chris; Hospital to a Healthier Home is a really good example of good practice, but the reason it's got to this point where it is an example of good practice is because it was commissioned nationally, so we have that ability to share internally our good practice and expand that across Wales. The issue we have now is that from March 2022 this will become a local decision, and that's where it becomes essentially like a postcode lottery again of which areas will commission this service, which areas won't, and in which way. What it's revealed to us is that housing is not fully integrated in health. Our service is really well received—it receives loads of referrals—and the pre-commissioning conversations that we've had have been really positive, but then who takes ownership of actually funding this service? That's the big question that we don't have an answer to, with six weeks to go before the end of funding.

So, you don't agree with those decisions being taken at a local level.

I think that's a difficult question. At a local level, decisions can be responsive to local need et cetera, population assessments and things like that. With this example, where it is good practice across Wales, what we're basically seeing is a reduction in the service and a reduction of good practice because it's being moved to a local decision.

Okay. Catherine May.

I think also one issue that we came across quite quickly when we were looking into this area was that there is no kind of clear definition of what housing advice is. Every hospital board has its own interpretation. We've worked with Care & Repair and took their very good example as an example of what housing advice could be, but if all health boards had that agreement, that might then help that good practice to travel, because there would be a better understanding of what's needed in place within the hospitals.

So, what should happen? The Welsh Government should define that definition.

Yes. There should be a shared definition that's taken on and understood within those health boards.

Chair, what's quite interesting is that—. Care & Repair is grateful to receive additional funding from Welsh Government for next year, which includes additional capital funding for rapid response adaptations. So, it might end up being quite perverse, I guess, that we've got additional funding for rapid response adaptations to get people out of hospital safely, quicker, and we haven't got the bodies in the hospitals to build those relationships and take those referrals. So, it's that thing about national versus local there; there's a disconnect. Nationally it's been recognised that there is a need, and that need has been met in terms of additional funding, but locally—. Faye's right, you know; the principle of local decision making is great. A local needs assessment, and then putting in place what you need to tackle those needs, in theory, is fantastic, but it will end up inevitably with decisions being taken to not do it in this way, or not do it at all. I'm not quite sure what the outcome is going to be.

So, what should happen?

What should happen? The easy answer is for Government to continue to commission the services.

Okay. That's clear. And then there's the discharge to recover then assess model. How is that working?

It's early stages of that, isn't it—the 'Home First', the six goals in Government policy, discharge to recover then assess? What I said at the start was I don't think that can be successful if you don't get the environment where somebody's discharged to right, and that's mostly people's own homes. I haven't got any kind of data about is it working well or not, or is it being rolled out consistently across Wales or not; I don't know. But what I do know is I don't think that that would work well unless housing, in Mike's words, is part of a tripod of services.

I was just thinking in terms of the assessment process, and if there are any issues that you thought needed to be resolved in that area. I'll open it up to anybody else that might want to come in on that. No? That's fine. Gareth Davies.

Diolch, Chair, and good afternoon to all the witnesses this afternoon. I was quite staggered, actually, to read Care & Repair's evidence saying that the value of home adaptations is up by 117 per cent, which is extraordinary, really. But I think that's twofold in a way, because I think it's partly down to inflation and increased costs of labour and materials, because I know the price of wood has really gone up in the last few years, hasn't it? And I suppose as well, it's also older people requiring increasingly more complex adaptations to their homes. Do you have any more information about this, and whether this point is being adequately recognised by funders? Are they giving you more money as a result of this in the knowledge of those issues and increases in costs?

I think I'm right in thinking that that increase relates to those small adaptations, the rapid adaptations, in which case, as I mentioned earlier, we've had positive conversations with Government and local funders about meeting the demand for those adaptations. We haven't got specific figures for hospital discharge when it comes to the more medium size and bigger adaptations; that's probably another exercise. But yes, I think the reasons for the increase are things that we've talked about already: our service becoming more embedded, therefore receiving more referrals; the needs of older people becoming more complex and the deconditioning being coming greater, and the length of stay in hospital becoming more. And also, as you rightly say, practically speaking, with the cost of building supplies and labour, that's gone up, so that will have contributed to increased costs as well.

Thanks. I suppose what I'm trying to get at is: bearing that in mind, are steps being taken to try and take the burden off yourselves and deal with those costs, to mitigate the risks to your service?

From our point of view, I can say that we have good relationships with Welsh Government colleagues, who have listened to what we said to them over the last two years, when it comes to highlighting what that increased need and cost has been. We've had good positive discussions and we've received more money to meet that. I'm not saying that all the needs will be met with the funding that we have, but generally speaking, those conversations have been positive, and the funding has increased.

Okay. And is that to a point where you're not in any worse of a financial situation than you were before the 117 per cent rise in costs?

I think we'll see next year, from next April. So, when it comes to this year's funding, we received some additional capital directly from Welsh Government, but also from slippage funding—sorry, from winter pressures funding—via the social care bit of Welsh Government. And colleagues—Care & Repair chief officers—have also had local discussions with their local authorities and health boards, and, between all of that, that's met the need this year. Next year, we've got increased capital allocation for rapid response adaptations, but I guess we'll know three or four months into the year how that's going.

Thanks for that. Does anyone else want to comment on that at all, or shall I move on? Okay. Just as a second question, I wanted to talk about some of the regional variations across Wales in terms of Hospital to a Healthier Home. It's reported that the success of this service from a senior level health board level has varied across some of the regions and health boards. Is there any more information about this and why that's happening in different areas, and why the success rates vary in different areas as well, and what we can do to try and get a higher success rate across the country, essentially?

Yes. So—

Faye to come in to start with, I think, and I'll come back to you, Chris.

Yes, sure.

Sorry. Yes, previously, I would have said that this was because of, over time, a service becoming more embedded, and I think that's still the case, because we've now had three years nationally of this service being embedded. I do think there are some variations when it comes to strategic-level engagement of the service and, as Catherine said as well, the understanding of housing. So, interestingly, in Aneurin Bevan, the service was commissioned for an extra hospital in April 2021, and that's been really well embedded. So, there's a desk in the hospital; they've been given access to wards et cetera. So, I think there is variation, and I think it does come down a little bit to individual understanding within those areas and, again, historically, how integrated housing and health have been over a period of time.

Chris, did you want to come in?

Yes. The only thing I'd say is that we sought to have early conversations with health boards at the most senior level, which we had in most cases quite early on in the year, but it was—. We were surprised at the level of turnover of staff. So, we had really positive conversations at a senior level in health boards with executives and good, positive engagement, and then discover a few months down the line that there's been turnover in staff, and then you've got to start again. So, that's been a bit of an eye-opener and quite frustrating, I think.

That's all from me. Thanks, Chris and Faye.

Thank you, Gareth and Chris. Jack Sargeant.

Diolch yn fawr, Cadeirydd. Can I thank Chris for your earlier answer as well? I think you're not alone in feeling that. I'm going to talk about communications now, and avid listeners of the Senedd health committee will know I talk about communications and the importance of communication just as much as our colleague Gareth Davies talks about the Denbigh plum in the Senedd Chamber. I was going to touch on the effectiveness of the current working relationships, but am I right in drawing from your earlier answers—and this goes to everyone, really—that you have made your concerns about where the service is leading to and that any changes, or certainly the proposed changes or what it looks like it might be, will not be as effective as the current working relationship? Would that be a fair assessment?

Catherine May.

So, in terms of communications, what we found was that there are times when the staff thought that the communications were really clear and that the patient had understood what was happening and why they were going home and so on and so on. But, actually, on reflection, the patient didn't realise that that was a conversation about their housing need, or didn't realise that there was an opportunity to have that discussion. So, we also were concerned that there wasn't always an offer of the advice in the relevant languages or in easy read—those kinds of accessibility ways that we'd like to see that done across the board, really, in terms of the communications. Because, so often, the language will be couched in a kind of jargon that we all use without realising and that's one thing we really—. There's good practice and good examples of those where it's very clear to the patient why that conversation is happening and what the outcomes could be. Often, patients are very keen to go home, and we all understand that and we all know that, particularly during the COVID pandemic. But it's about those staff being able to communicate, in a way that the patient can understand, about the needs that they're going to have within their homes or within wherever they're being placed.

Thank you, Catherine. Does anyone—? In terms of improvements needed, then, Catherine made a few there, but Chris or Faye, have you got any particular recommendations that the committee could make?

So, I would say, just on the subject of communication, I think that's one of the key roles of the caseworker in the hospital. So, what you've got is a third sector person embedded in the hospital, integrated into the system but with the flexibility and agility to problem solve, to liaise with the family, to liaise with statutory services in housing and in social care and that kind of central point of communication and solving problems, which, for somebody who is medically involved with a patient and dealing with their clinical care, is really time consuming and actually quite difficult to find out, 'Well, okay, so, who is responsible for this particular aspect of that in social care?' or 'Where can I get funding to do this particular piece of work?', for example, if it's decluttering or if it's making sure that somebody's got heating in their home. The caseworker knows. That's what they're really good at; they're really good at joining up all of those different strands of what's needed to get the patient safely out of hospital when it comes to their housing conditions. So, communication is something that's difficult, isn't it, between health and community-based services, but that this particular post brokers really well.

So, in terms of the caseworker, then, and that's the role that the third sector should play in this discharge process, going back to best practice, then, is there standard good practice across Wales, or are there variations across Wales, again? And how do we address that problem? And are there, perhaps, any changes in the way the current caseworker role happens within the health service?

I think what's happened since the service went from pilot to being rolled out is that—. And as the number of caseworkers has grown, what we've done is we have a network meeting that happens with them quarterly. So, what we do, as Care & Repair Cymru, is we join up all of the different elements of how caseworkers work in a local hospital and talk to them about what works really well, and try to, through that forum of caseworkers who meet virtually every quarter, share that best practice across Wales. And that's a good model, I think. So, what you get there is you get all-Wales coverage, but it's a process where there's constant learning about what works well in the system as well.

With regard to the proposed changes, then, would that meeting, all-Wales-wide, go ahead?

So, the risk is that we will lose caseworkers. At the moment, the service is only confirmed in one health board area. So, if we don't get funding for the other health board areas, then those caseworkers will disappear. That service that they provide in the hospital at the moment in terms of communication, linking up with the capital funding that I talked about earlier, working with statutory providers, liaising with families, that'll disappear. So, yes, I guess there won't be a network, because it'll just be in localised places. Yes.

Okay. Thank you for that. Just one final question from me, Chair, perhaps to Catherine and Faye. Just your views on how we can better equip the health and care workforce. Catherine, you mentioned perhaps not having the expertise in housing and we know that these are busy individuals, of course, but have you got any particular views on that? And perhaps I can extend that to Faye as well.

Yes. I think absolutely demonstrating the kind of senior-level commitment to seeing housing as the kind of public health arm that's needed, and understanding that people's homes are very central to who they are and to keeping them well and healthy. The costs are extortionate of having poor housing, and we could, as a country, be saving a lot of money by investing more in our housing, really. So, getting that message across to the very, very busy, very senior heads of health boards and those sort of people who do get it, but really helping them understand that, actually, on the ward level, it makes such a difference to someone to be able to get home more quickly and reduce the likelihood of them having to come back in. But also there's a real opportunity, when we're looking at our homeless populations, to help support them to stay safe as well.

And also just to say this does also extend to—. It's not just physical health hospitals, but mental health hospitals as well. There's good practice but there's also quite poor practice in not always recognising the need to talk to people about their housing from the beginning of their journey there.

So, this is a real top-down approach—we need to get senior leadership teams and senior management teams on board with this, and perhaps ministerial direction for it.

That would be good.

Okay. Faye.

I would fully second that, because one of the things we have found during the past year, when we have been trying to get this service commissioned, is the difference between—. What clinical staff say about the service and how important it is to them is not translated into the minds of those people who are actually making the decisions on the funding. And innovative policies, such as discharge to recover and assess, they need the proper infrastructure behind them so that patients are discharged into environments conducive to recovery. But that needs to be more embedded so that it's interpreted in a similar way across health boards. Because, at the moment, I think there's a difference as well across Wales.

Okay, thank you, both, for that. Thanks, Chair.

Thank you, Jack. Joyce Watson.

I don't know if there's a—. Because we've had a really good session, mine was a sort of sweep at the end—anything that you haven't mentioned that you think it is important for us to send as a message to Welsh Government, because, ultimately, that's what we're trying to understand. So, if there's anything you haven't said that you feel strongly needs saying, now's your chance.

Chris Jones.

Thank you. I suppose I would just say that, in the context of the NHS Wales budget, the service that we are talking about is a drop in the ocean—I think it's something like 15 staff embedded in 17 hospitals. But I think—. It's a relatively small cost, but they do different things, and it's a relatively big impact, and I just think it would be such a backward step after three years if that were to go. So, I suppose I would say just the cost-benefit analysis of that situation in the context of the global NHS Wales budget.

Can I just ask, before you move to the others, as we're rounding up, Chris? You also mentioned about the energy cap earlier on in the session as well. I'm just keen to understand—and you were talking in terms of people keeping their homes warm and dealing with damp—any other wider points that you want to mention in terms of the rising costs of energy, as well, in the context of today's session?

Yes. I suppose what I didn't mention there is—. I think we've focused quite a bit on transfers of care, on discharges, but what we haven't really spoken about too much is how do you prevent re-admissions, how do you get that admission and re-admission rate down. And that sort of thing, somebody living in a cold home who can't afford the energy bill, they're scared to put the heating on, because they know that the cost of energy is going up by 54 per cent in April, and it's going to go up by another whatever—another 50 per cent—in October, when the energy cap goes up again, that's going to have a massive impact on older people's health, living in some quite poor housing in some parts of Wales, where you've got 83 per cent of older people living in their own homes. So, yes, I think the impact of fuel poverty and cold homes on hospital admissions is something that maybe we should have spoken more about, so I'm grateful for the chance to say that.

That's fine. And, yes, so Joyce's question, and anything you want to add in terms of the points I've just raised as well—Catherine May.

Yes. So, my colleague is just this minute giving evidence about warm homes in another session today, so, it goes to show that it's something that's absolutely at the heart of a lot of the conversations in housing at the moment and that it's exactly as Chris said: bringing it all together to make all of our homes safer, warmer and healthier environments that we can all live in. I suppose, just to go back to the question that Joyce asked right at the beginning, investment in better housing, in better ways of living will yield great savings in health. It's just trying to get that message across.

Thank you. Faye, I'll come to you. Joyce's question was sweeping up anything that you want to say that, perhaps, has not been drawn out in questions, and just talking about the potential impact of rising living costs as well.

It has been mentioned, obviously, the support of the sustainability of good practice and what's working, and taking a once-for-Wales approach is really important to make sure that services continue to be funded that are working well.

We haven't spoken too much about the integration of the third sector, which I'm sure you hear a lot, but I do think that that is really, really key. In an environment where health and housing—. Care & Repair work in hospitals, in a health environment, as a housing charity and I think that it's really a challenge not to be seen as a lesser partner. In areas where our Hospital to a Healthier Home caseworkers are part of MDTs, they take part in ward rounds, et cetera, and have built rapport and relationships, we do get more referrals in those areas because those relationships are built on trust and staff know that we can be relied on to get results. So, I think integration in that sense, not being seen as a lesser partner, not being kept at the front door are really, really important for having an impact on hospital and patient flow. I think that's really it for me. I would like clarity on where housing solutions specific to hospital discharge actually sit funding wise, and that's something that we would like to push for, but I think that's it from me.

You say 'clarity'; is it not clear now where that funding sits? 

Well, I think, given the situation we're in, that we are being pushed around from local health board to regional partnership board, to wherever, with weeks to go before we're going to have to withdraw what is a really successful, or has been a really successful service, I think it's not clear to us and it's certainly not to our staff either.

Chris Jones, you were nodding in agreement. Is that right on that?

I agree. Health and social care integration has been something that we've been trying to get right for many years, isn't it? But is there still a disconnect in terms of ownership of certain issues? I think there is in this case. I don't think somebody is grabbing it and saying, 'Actually, yes, housing is really important to the health of its occupiers and it can have a massive impact on the number of times people go to GP practices or the number of times they're admitted into hospital or how quickly we can get them out of hospital into a safe home and keep them out of hospital.' I just think it's underestimated, and when it comes to funding arrangements, there is a lack of clear ownership as to who funds those services that have that impact.

Thank you, Chris. Well, thank you to all our witnesses this afternoon. Have you finished your line of questioning? I think you have, Joyce. Yes, I presume you have. Yes, lovely. Thank you to all our witnesses this afternoon; it's been a really useful and fascinating session that will certainly help our work in this particular inquiry. So, we'll send you a copy of the transcript, please look over it and add anything you feel that's appropriate and, by all means, keep an eye on the Minister's evidence to us as well and come back on any aspects you think are appropriate for us to be aware of. So, thank you very much, diolch yn fawr. Thank you for being with us this afternoon. 

Diolch. Thanks, everyone.

Diolch.

With that, I move to item 4, and we have two papers to note this afternoon. One is a joint letter from our committee and the Children, Young People, and Education Committee to the Minister for Social Justice regarding the legislative consent memorandum for the Nationality and Borders Bill. The second letter is the reply to that letter. So, those letters are there just to be noted this afternoon. Are Members content? Yes, thank you very much. Diolch yn fawr.

In that case, that moves us to item 5, and I would propose under Standing Order 17.42 that the committee resolves to exclude the public from the remainder of today's meeting. Are Members content? Okay, if Members are content with that, as they are, our next public session will be in March. So, with that, we'll go into the private session.