Y Pwyllgor Cyfrifon Cyhoeddus a Gweinyddiaeth Gyhoeddus

Public Accounts and Public Administration Committee

12/05/2022

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Mark Isherwood MS Cadeirydd y Pwyllgor
Committee Chair
Mike Hedges MS
Natasha Asghar MS Cadeirydd dros dro
Temporary Chair
Peredur Owen Griffiths MS Yn dirprwyo ar ran Rhys ab Owen
Substitute for Rhys ab Owen

Y rhai eraill a oedd yn bresennol

Others in Attendance

Adrian Crompton Archwilydd Cyffredinol Cymru
Auditor General for Wales
Dave Street Cymdeithas Cyfarwyddwyr Gwasanaethau Cymdeithasol Cymru
Association of Directors of Social Services Cymru
Dr Andrew Goodall Ysgrifennydd Parhaol, Llywodraeth Cymru
Permanent Secretary, Welsh Government
Heléna Herklots Comisiynydd Pobl Hŷn Cymru
Older People's Commissioner for Wales
Maria Bell Cymdeithas Llywodraeth Leol Cymru
Welsh Local Government Association
Matthew Mortlock Archwilio Cymru
Audit Wales

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Elizabeth Foster Dirprwy Glerc
Deputy Clerk
Fay Bowen Clerc
Clerk
Owain Davies Ail Glerc
Second Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Cyfarfu’r pwyllgor yn y Senedd a thrwy gynhadledd fideo.

Dechreuodd y cyfarfod am 09:16.

The committee met in the Senedd and by video-conference.

The meeting began at 09:16.

1. Cyflwyniad, ymddiheuriadau a dirprwyon
1. Introductions, apologies and substitutions

Bore da, croeso. Good morning and welcome to members of the committee. Apologies for absence have been received—. Or is that not the case now? Fay, do we have any apologies for absence? 

Yes, we've received apologies from Rhianon Passmore.

Thank you very much. Do Members have any declarations of registrable interest they wish to declare? No. Thank you. Headsets are available in the room for you for translation and sound amplification, translation on channel 1 and amplification on channel 0. Please ensure that any electronic devices you have are switched to silent, and in the event of an emergency, an alarm will sound and ushers will direct everyone to the nearest safe exit and assembly point.

2. Comisiynu Cartrefi Gofal i Bobl Hŷn: Sesiwn Dystiolaeth 3
2. Care Home Commissioning for Older People: Evidence Session 3

We move on to our first evidence session today on care home commissioning for older people, our third session on this issue. We have two witnesses, and I welcome them to the meeting. I would be grateful if you would state your names and role for the record.

Yes, certainly. My name is Dave Street. I'm director of social services and housing at Caerphilly County Borough Council, but I'm here today in my capacity as joint chair of the national commissioning board. Thank you.

Maria Bell ydw i—I'm Maria Bell. I'm the head of policy for the national commissioning board, which is hosted by the Welsh Local Government Association.

Thank you very much. Welcome, both. As you'll expect, we have a number of questions, and I'd like to—. Well, I do; I ask Members and witnesses to be succinct to enable us to cover the wide range of issues that this topic has generated. I'll begin with the first questions myself, seeking to explore issues around making the system less complex and easier to navigate from a service user perspective. So, what in your view are the main issues that make the system for care home commissioning across Wales complex and difficult to navigate? I don't know which of you might wish to go first. 

Shall I make a start, Dave? 

Fine, Maria, yes.

One of the issues is the differences in eligibility for funding for care home placements across health boards or in the NHS and local government. So, obviously, there are different types of placements—residential placements, nursing care placements and complex care placements. So, I think one of the issues is the differences in policy across that, and the eligibility judgment then is around the individuals, their needs, for funding of such placements, and the difficulties, under a period of austerity, of those statutory organisations agreeing who is responsible for funding. So, I think that's one of the elements. 

09:20

Thanks, Maria. I would agree. I think the other thing is that the majority of placements are actually funded via local authorities, there are some instances where people have to fund their own accommodation because of their resources, and of course we've got the added complexity for some people that they could be eligible for continuing healthcare funding from the local health board. So, it's a very complex funding pattern as well.

Thank you. You generally find in your experience—[Inaudible.] What sort of relationship do you find in practice you have between the local authorities and the health boards when it comes to working together on this?

I think generally it's very sound. Residential care is the responsibility of local authorities; there's very little input from health boards. Nursing care is clearly different, with the health boards responsible for funding nursing care. That genuinely doesn't cause any problems. I think where we do have difficulties on occasions is the whole continuing healthcare agenda, around whether people are eligible for community health council funding and the services that brings. I think that does bring a fair amount of discord between local authorities and health boards and, as I said earlier, a great deal of complexity for the people who use those services. 

If I may, Chair, I think there's also complexity where there are specific grants related to short-term care provision, so, whether it be a step down from hospital six-week rehabilitation, or around about that, discharge to recover and assess, where an individual's placement may be covered by a short-term grant, and then, obviously, if there's ongoing funding responsibility, determining whether that's the right placement, if somebody's in a nursing placement and it's deemed that they don't have nursing needs, or whether it's complex. I think that adds complexity into the system as well.

Okay. Thank you. Can you suggest any potential quick wins to simplify the process that could be done easily, or could be avoided or stopped? 

I think, from a CHC point of view, greater clarity for people, greater consistency around the application of eligibility, continuing healthcare, would be a great help. I think, as far as the rest of the process is concerned, certainly in my experience, people seem to navigate it very well.

The intention of the pooled funds was one single funding pot for placements in care homes, but I think the policy that underpins that, which is built on eligibility for different funding streams, is what causes the difficulties around pooled funds. So, I suppose a way, if you were designing a system from scratch, would be to have a single fund that is neither local authority or health board but both, with much more straightforward eligibility, potentially, for that funding. So, that may be an option. I guess you'd have to think about it, if you were designing the system from scratch, rather than trying to change the current system that we have, but I think there's potentially a disconnect between the policy and some of the aspirations around much clearer funding. 

Thank you. What do you believe are the underlying reasons and the cause of the very significant backlog in hospital discharges into care settings, including care homes, and whether public sector partners are doing enough to work collaboratively to resolve these pressures?

I'll come in there, Chair, if I may. I think the biggest issue that we have, really, is domiciliary care support. It's our inability to recruit and retain domiciliary care workers. As a consequence of that, our ability to keep people in or discharge people to their own home is affected and, by definition, that means that some people then get discharged to care homes. That's unfortunate. It's not the way the service should work; it's not the way the system is designed. But, as a director, I am far, far more worried about the state of the domiciliary care sector than I am around the residential care sector at the moment.

I would agree, Chair. Our data shows that there are a number of vacancies within the care home sector. Some care home operators are concerned about the level of vacancy and the sustainability of that, but, potentially, in some areas, in some services, we have an excess above our requirements for care home placements. The fundamental underpinning issue is the availability of workforce.

We do also have issues, or we certainly experienced issues during the period of the pandemic, where some care home placements are technically vacant, but actually can't be filled because of workforce shortages or other issues such as infections within the home. So, there may be embargoes on placements for various different reasons, but also qualitative issues where perhaps a home may be in an 'escalating concerns', and there is an agreement between the home and the commissioners that new placements won't be made. So, there's a range of different reasons, but, overall, the data suggests that there are vacancies available for people seeking care home placements. And we've also seen, over the winter period, because of the shortage of domiciliary care, that interim or short-term placements have been made in care homes, as a step down from hospital whilst individuals are waiting for care and support at home.

09:25

Okay, thank you. Can I bring Mike Hedges in to take up the questions?

Can I continue with pooled funding? The first question is: could better use of pooled funding arrangements for older people's care commissioning be made?

I don't think there's any question that that would be the case. I think the Audit Wales report reflects that, certainly, in Wales, perhaps the spirit of the pooled fund has been met, but opportunities haven't been made to maximise their benefit. I think there are two reasons for that. I think, at a local, political level, there was real concern around the prospect of some authorities cross-subsidising other authorities in a pooled fund. I think that made it very unattractive politically. I think, from an officer perspective, my main concern was, certainly in my experience, that local authority spend on residential care is reducing, and it's reducing because we are spending more and more money on domiciliary care because we're getting better and better at keeping people in their own home. 

My concern around pooled funds was that, if that money is in a pooled fund, and I want to utilise that for a different purpose in the future, could it be released from the pooled fund, or would it be there forever and a day? Personally, I wouldn't have started on pooled funds in care homes for older people; it's very high volume. I think there were other areas within social care and health where perhaps pooled funds would have had a more effective impact in a shorter period of time. 

I would tend to agree. I think the feeling within WLGA is that pooled funds may work better on a local level. We understand the difficulty that health boards with a number of local authorities in their areas have in operating a number of pooled funds. But, certainly, the feeling is that, if pooled budgets were the right thing, then they would be better to be at a local level, but also that it's almost the last thing that you would do in the chain of integrated working, that there are other things that we would do around collaboration, such as the joint contracts that we have in place in a number of regions, work on single fee methodologies. And so that's almost the end of the mature process of integration and collaboration, rather than one of the first activities that you would undertake, I think, because of the risk-sharing issues. The KPMG review really looked at the complexity around risk sharing. 

Twenty years ago, when the first idea of pooled funds came in—and I was on both the health board and leader of the council at the time—the problem was at that stage is that health thought, 'We've got some social services money to spend', and social services thought, 'We've got some health money to spend.' Have we moved on from there?

I think we've moved on to a degree. I wouldn't say those sorts of views have gone completely; they probably haven't. I think Maria has hit the nail on the head for me. I think one of the ways we could have overcome that was by pooled funds at a local level, as opposed to a regional level. I think that would have worked quite well. 

Okay. And just moving on to the most important people, the users and their families, and whether disagreements on commissioning and placements by the public sector partners, by which I probably mean health and social services in the main, cause any problems.

I don't think it causes significant problems. As I said, I think the process is very well established now. I think most people whose loved ones need to go in to residential care do a lot of work in advance, have lots of conversations in advance. I don't come across many difficulties or complaints in that sense. Maria, I don't know if you've got a view on that.

09:30

I think, again, as we've mentioned, the area of potential difficulty is that eligibility for CHC, particularly for people who have their own capital, obviously. Because if a placement is continuing healthcare funded, the individual doesn't make a contribution to that. Whereas, if somebody's care home placement isn't eligible for CHC, they will make contributions, and potentially pay for the whole cost of that placement. So, from that individual citizen's perspective, that could be an area of concern.

Moving on to another area, regional commissioning, I heard what you said earlier, Dave. But the reason for the regional partnership boards being developed was so that regional strategies could be developed that shaped the care home market to provide the range of facilities and services needed for current and future generations. And in a number of places—. I don't know Caerphilly particularly well, but I certainly know Swansea well, and Neath Port Talbot and Swansea run into each other—they are effectively one area, certainly on the borders. Is that working?

I think it is. Like you, obviously I'm very well sighted on the arrangement in Gwent—that's a big region, five local authorities. I can't quote in great detail about all the other areas. I think those relationships are strong, and getting stronger. I think things like the population needs assessment, market stability reports, they are now all coming into place. There's little doubt that losing two years to the pandemic affected progress in those particular areas, but in some ways, I think that going into the pandemic actually made those relationships closer. Clearly, we are still separate legal entities; I have my own legal responsibilities in this area. But there is very little that I do now in terms of anything around the market that I do on my own—I do that via the RPB. So, I think they are getting stronger and stronger.

And if I may add, I would agree. I think there are infrastructures underneath the RPBs, with commissioning groups, commissioning boards, which are working collectively and co-producing with individuals receiving services and providers—things like joint contracts, joint care fee methodologies, single monitoring arrangements—to try and increase consistency and standardisation of commissioning across regions.

Okay. Thank you. And, again, my knowledge is very much in a different area to where both of you come from, so could you tell me if it's normal across Wales? What we've seen in care homes in Swansea is the loss of a lot of relatively small ones and the growth of some large, and very large ones. Is that what you're seeing in the rest of Wales, and is that meeting the service needs of users? And we've got one excellent care home that has a dementia centre attached to it. Is that the direction we ought to be moving in?

If I answer your second question first, yes, I think it is. Certainly, I think there are quite a few examples in Wales of care homes that have got separate wings, separate extensions, for dementia. And you're absolutely right, it is the way to go, because, unfortunately, that is where the demand is going to be in the future. The market shape, yes, I can recognise that. Certainly, the newer homes that have come on stream, the fairly recent builds, tend to be of a larger size; I think that's purely economics, quite frankly. But equally, certainly, in the areas that I work, the majority of homes are still relatively small homes that are locally owned, and that brings both an opportunity and a risk.

I would agree with what Dave's saying. The work that Care Inspectorate Wales did in the lead-up to the implementation of the Regulation and Inspection of Social Care (Wales) Act 2016, they did a lot of engagement with individuals, and there were lots of discussions about the benefits of very small, local homes, which in some areas of Wales specifically deliver a Welsh language service, and the benefit of that. Some of the issues are that they tend to be converted rectories, converted country houses, so they don't necessarily meet the environmental standards we need for the future, and perhaps don't look as smart as the new-build, high-spec services. The feedback from communities was that they really valued those more small, local, very often family-owned services. So, I think, for me, the ideal would be a mix.

09:35

Can I come back to what you said there about the majority of them being small? I think you're absolutely right—the majority are. But the majority of places—again, I can only talk about Swansea—are in the larger ones. So, you have a lot of small ones, but you have some that are 70 or 80-bed and that's equivalent to five 15-bed properties. Do you see the same in the rest of Wales? You're on mute, are you?

Apologies. Yes, I think we do see that. As you said, I think certainly people coming in to the market for the first time are having to build to a certain size purely to make the economics work out. That's certainly been my experience. As I say, I don't think it's a question of small homes, good, big homes, bad—I think it's a lot more complicated than that—but I think there is a limit that you would want to see on those care homes. You wouldn't want them too big.

Are the regional partners working effectively and intervening earlier to reduce the demand for care home placements? Sometimes, people end up in a care home because they've reached a stage where they're unable to look after themselves at home. If, however, they'd been dealt with earlier, and had support earlier, they wouldn't have ended up in a care home.

Yes, I agree completely. As I touched on earlier, I think the biggest challenge we face in that area around prevention is the availability of domiciliary care services in people's own homes. And certainly, post pandemic, the recruitment and retention of domiciliary care staff is a real problem across Wales. And I think because of that, you're absolutely right, there are some people going into care homes who wouldn't have ordinarily done it, if those domiciliary care services were there. It's very sad; it's very unfortunate, but there are lots of people at the moment working very, very hard trying to overcome those recruitment difficulties.

If I may add, Chair, I think one of the other issues is the access to health services within the community for individuals: so, access to community nursing, access to allied therapists within communities. Those are also key areas of the workforce that could prevent people from going into care homes unnecessarily. I think very much the focus in the NHS is on the hospital system. There's a real need to look at—. And I think it's really positive that the strategic programme for primary care, and the six goals for urgent and emergency care, are really looking at the community infrastructure and that multiprofessional place-based working, which should hopefully, again, reduce that demand in the future and better serve people in their communities. 

Thank you for that answer. You bring up something I say fairly regularly. Too often we use the term 'for health, see hospitals'. If you follow any of our health questions and social services questions in the Senedd, there's more about hospitals and hospital treatment than everything else combined, by a substantial amount. So, I think we need to move some of these higher up the agenda.

But the final question from me is: we've talked about the regional partnership boards, should they be put on a statutory footing?

I suppose, to a degree, they're on a statutory footing anyway—they are a requirement of Part 9 of the Social Services and Well-being (Wales) Act 2014. I'm not sure what more would be gained by changing any legislative basis. I think that the boards are there. I think they are becoming more significant in their role. I'm not sure if any kind of legislation would significantly move that forward, would be my opinion.

Thank you, Mike. If I just ask a quick supplementary on regional partnership boards: two weeks ago, we took evidence for this inquiry from Age Cymru, and they said there was still more work to do for regional partnership boards in engaging with the voices of older people and older people's representative organisations. I'm wondering if you could comment on that.

I think there will always be more to be done. I don't think we'll ever get to a point where we reach the panacea. Again, I can't speak for the seven regional partnership boards—I only sit on one. That regional partnership board does have citizen representation on it and it has voluntary sector representation on it. I think part of the challenge we face with regional partnership boards—. The one in Gwent has got five local authorities and a health board attached to it. The regional partnership board meeting is now in excess of 40 people. So, there has to come a point where you can limit that. It's the work that's done beyond the regional partnership board, isn't it? And I think those challenges around hearing the voice of the older person and the older person's representatives are just as acute for individual local authorities and health boards as they are for regional partnership boards. So, I think that's about our day-to-day behaviour as opposed to doing anything specifically around the regional partnership board agenda.

09:40

If I may add, Chair, I think also, the team and the infrastructure that sit under the regional partnership board are really important. So, in the work for the population needs analysis, there would have been significant amounts of engagement ongoing with various different community groups. So, I think that's important, and that that is ongoing, and that that information is fed up to the regional partnership board to support that decision making. So, it's not always so much about a seat at the table, but the activity that goes on around the board as well. And I think a number of regional partnership boards have engagement offices or link into the engagement offices of the statutory organisations to make sure there is significant ongoing dialogue and co-production.

Well, quite. I think that was the point: in addition to the broader engagement you describe, it was the people around the table being involved in the design and delivery and monitoring of services and commissioning of services, and having parity of power and genuine co-production for non-statutory sector, third sector representatives, particularly in this case, well, we heard from Age Cymru, but older people's organisations and older people themselves. So, am I to take from your response that you acknowledge, from your comments, that not always being around the table, that there may be an issue there?

I—. Sorry, Dave, carry on.

No, sorry, Maria, carry on.

I think, from my experience of working with the partnership board, there are challenges, sometimes, with information being shared, so there is some information that's commercially sensitive that you wouldn't share in a wider partnership board, so it's striking that balance, really, and being aware that if you have a citizen representative, it's a citizen representative representing a particular community or themselves. So, it's the work of the board, but also recognising that the work of the board is really quite vast. There is a significant amount of grant fund schemes to oversee. Many of the boards, in my understanding, have regional commissioning groups as part of their governance structure with some delegated functions to those. So, a lot of the work of the board around commissioning goes on within those groups, and those groups are better served to engage with a number of different citizen representatives. So, I think it's—. The work of the regional partnership boards is really vast and complex, so it's how that infrastructure works in its entirety in addition to the board that sits itself.

Okay, thank you. Could I invite Natasha Asghar to take up the questions?

Thank you so much, Chair. Good morning, Maria, and good morning, Dave. Just to start with, I'd like to know—. You did kindly mention in, I believe, your first answer to our Chair when he asked you about some of the issues that have an impact on, obviously, costing, and you mentioned domiciliary care was one of them—[Inaudible.]—per unit, weekly, and those important placement costs across Wales.

I'm really sorry; certainly on my screen you froze for a few seconds there. I probably only heard the first 10 seconds. Maria, did you hear all of that or did you have the same problem?

No, I'm sorry. I wasn't sure if it was me, but I think on my screen Natasha did freeze too—sorry.

Would you mind re-asking us the question? Apologies.

Of course. No, I have an unstable IT connection, so my apologies, everybody, if I do freeze out again. Just to ask the question again: you did mention to our Chair in a previous answer that you both gave about domiciliary care being one of the reasons that costs were different, but I wanted to know, apart from the costing of domiciliary care, what do you find are some of the other reasons to have such a variation in costs for those in care homes across Wales?

09:45

I think, to be frank, up until relatively recently, we haven't had good methodologies to actually establish what the real costs of care were. Costs of care have been historic. In some instances, they've been based on the affordability, rather than the real costs of care. Certainly, I can remember several years ago where you would simply have whatever inflationary uplift the council had from Welsh Government for its budget—that is what you would pass on to the care homes concerned. I think that has changed over the last several years. Almost all areas and regions now have a formal methodology for trying to establish those fees. There are still big challenges around affordability; there's no question of that at all. Maria will touch on, in a second, some of the work the national commissioning board has done around the potential for a national methodology across Wales, which hopefully will—. I don't agree we'll ever reach a position where there is one fee for Wales, and I wouldn't want to necessarily be there, but I think that as long as we are consistent in how we establish the cost of care, then that would put us in a much stronger place than we are now. Maria, do you want to go into a bit more detail on that one?

I'm very happy to do so. In regard to the methodologies, the inputs that you put in are really quite important. Some of the key differences might be the local employment scenarios and the rates of pay required to attract and retain workers. So, that's a consideration, and that accounts for quite a considerable amount of the actual fees. Also, some of the variability there is the level of need or complexity of need of the individuals within that home, and the number of staff hours they may need per day or per week to meet those needs. So, that's one of the variables.

We've talked a little bit about the newer build homes, the larger newer build homes versus the much older smaller homes. There is quite a significant variability there in the capital employed to build and maintain those homes. You will have some homes that perhaps paid off their mortgage a very long time ago. There is then a debate about should there be a return, which is largely profit, then, for that particular home, whereas more newer build homes will have capital employed of anywhere perhaps between £120,000 and £200,000 per bed to actually build those. So, the build costs are really quite significant. There are loans or mortgages to be serviced for those homes. You can have a home that has very little loan or mortgage against it, versus one that has a very significant loan or mortgage against it. So, that return on capital employed is really quite a significant variability.

I think one of the difficulties we have is that the perception of that return on investment is that often, that's considered to be profit, rather than understanding that actually, it's paying the rent, the mortgage, the loans associated with that property. So, there are a number of factors. Also, the actual build of the property might have a significant difference on the energy costs. Older, less insulated buildings might cost more to heat and light, whereas other more new-build properties may be cheaper per room for that. So, there's a range of variable factors that go into that methodology.

The work of the national commissioning board is to link into all of the regions and the methodologies that they're developing, but also to work really closely with the national provider forum and care operators to get a really clear evidence base of their true costs that can be anonymised. Then we can look at that range, mean and median costs, to be able to share, without some of the concerns of commercial sensitivity, anonymised information to try and inform the local development.

You may be aware of the Welsh Government-recommended policy of 'Let's agree to agree'. There are some really clear principles there about understanding where we need to gather evidence of true costs, working together collaboratively—which is the role of the national commissioning board—to create that evidence base, and then share that out with the local commissioners.

I think one of the other issues that ideally, in the ideal world, we would address, is around the funded nursing care fee, albeit we've had significant amounts of court time and discussions about that. In my personal opinion, that fee focus is only on the nursing time and continence products. It doesn't actually include any of the additional equipment, medical devices, clinical consumables that are involved in the provision of nursing care. That is completely outside of that. So, I believe, then, that local authorities are potentially subsidising that element of that nursing cost. So, there are issues and tensions there, I think, as well.

09:50

Okay. Thank you for that. I know I've picked up on answers that you've given some of my colleagues already, and also how you responded to me, but how well do you feel that bodies are working together locally, as well as regionally and nationally, including providers, when determining charges, as well as fees, being given to those who need care, and their families as well? Dave, you're on mute.

Apologies. I have to stop doing that. I think locally that work will always be there in the short term; it will vary between local authorities. I think the big progress we are seeing is at a regional level. I think that, increasingly, the whole issue of affordability, fee levels and sustainability in care homes isn't being considered locally anymore, it's being considered regionally. Nationally is more difficult. I think Maria is right; there is room for things like those national methodologies and national toolkits. But to try and look at an area that's as diverse as Wales, and that's as large as Wales, and suggest that, perhaps, one formula and one fee would work—it isn't the case. She's absolutely right. It's down to the type of care homes we've got, the age of those care homes, and also some very tricky decisions around how much profit should an independent or private provider make. I'm sure if I went around the room now and asked everyone for a percentage figure around how much profit should a private provider make out of care, there would be different answers. So, 22 ways of doing that isn't good enough. I think one way is unrealistic. But I think that going with the seven regional approaches to this is a distinct possibility, and there's an awful lot of work going on in that direction.

Yes. Just an observation, really. I think it's really interesting that the residential element of fees, generally, is negotiated and set at a local level, the funded nursing care fee is generally set at a national level, and continuing healthcare is set at a regional level. Whether we would set a system up—. We talked earlier on about some of the complexities. I think that's a really interesting system observation. I think the work at a local level is, generally, very collaborative. I think, as Dave said, there's a lot of really positive working between providers, citizens and commissioning, planning and contracting offices. The difficulty then comes within the decisions around the affordability of the evidence that's being provided, then, of the true cost of that, and some of the judgments, as Dave mentioned, around what element of that is profit and how do we feel about private providers' profitability. 

Okay. Thank you so much. I've got two more questions for you, and then I'll pass you on to the Chair again. Towards the end of the year, England is going to be introducing an £86,000 cap. It's a concept that I think the UK Government has actually brought out. And it's also going to be proposing some changes to the means-tested threshold to support those who require care in England. Obviously, that's not the case here in Wales, and I'd like to ask you what your personal and professional views are on having such a cap set here in Wales that is much lower than what we have in place at the moment.

The charging methodology that we use for care homes at the moment has been in place since around 1993. As you say, there is a threshold. There is a point below which we don't take people's savings or capital assets into account. It is a different approach to England. I'm not quite sure quite what the English approach is going to achieve and whether it will work out in the way that they envisage. Personally, I think that the system that we've got at the moment has done its job extremely well, and I would probably be reluctant to have change for change's sake, really. I think the threshold at the moment sits at around £50,000, so if someone has capital assets more than £50,000, then the difference between the £50,000 and that capital asset is taken into account for charging purposes. If the capital assets are £50,000 or below, then they're ignored for charging purposes. Personally, I think that that works really well.

09:55

I would acknowledge that it's a really emotive issue. I think that there are a number of different views around it. I guess I'm interested in the report from the expert group around the national care service and the Government aspirations around a national care service that's free at the point of delivery. What that means is that free personal care—. Will that make a change to some of that? I think the issue of changing thresholds is how the public purse meets that. It goes back to some of the early work that was done in the UK around, 'Are we prepared to pay additional tax and additional national insurance to be able to meet that cost of changing thresholds?' Again, that becomes a very emotive issue around do we ask younger people to pay for the care of older people. So, there are a number of different perspectives around that agenda, I think.

Okay. Thank you for that. My final question: we've all heard in the news at the moment about the cost of living—that sentence, I think, is the bane of a lot of people's lives at the moment. But I do want to ask you, in relation to care, going forward, for the elderly, what implications could the cost of living and the increase in the cost of living, I should say, more importantly, have on those who have contracts, for example, and who are paying for their own care? I'd love for you to explain to me how that's going to impact on them, because when it comes to their contracts, they're normally set, and I believe that they, or their family members, agree to it. So, going forward, is it going to lead to an immediate increase, is it going to be a slow and steady increase, or is it something that's just going to stay the same, regardless of what happens?

This is a personal perception. I don't think it will stay the same, I think it will go up and I think that that's inevitable. I think whether it goes up incrementally or in one large sum is going to come down to the provider concerned. I've got first-hand knowledge of this. We're currently dealing with the situation of a private provider in my own authority who is basically going to put his fees up by £150 a week. That's to the local authority and the private providers as well, and that's to mirror those costs-of-living increases.

There is nothing wrong with providers reflecting those cost-of-living increases, but it has to be affordable. If they're not affordable, it's got a potential knock-on impact on the local authority. And if those increases are unrealistic in any extreme, it can have an impact on people and on their ability to actually stay in their homes. We know about things like fuel costs, we know about food costs, but I think one of the things that has taken us aback, at a local level, is insurance costs. A lot of providers have given us evidence that their insurance costs have more than doubled since the pandemic. So, it's not just the typical cost-of-living increases that we're all seeing, there are some things that are specific to this sector that are bringing pressures.

I think most authorities have responded to that in the current settlements. I think the settlements, with Welsh Government's help, to be fair, have been higher this year than certainly in my time as director, which is quite significant. But obviously, what is worrying is that we don't know where this is going to stop or when it's going to stop. The costs are significantly higher now; what are they going to be like in a year's time? So, I think those pressures on self-funding residents and private fee payers are inevitably going to become more significant.

Just one final sub-question, please, Chair, and I promise that then I'm done. I'll be the hope and positivity; let's hope, in a year's time, that the situation improves and things resume back to pre-COVID days, with a little bit of normality and stability in the world. Let's go with that hypothetical situation. If the prices are set to increase now, at what rate and how quickly will those rates be able to decrease and come back to a rate of so-called normality once that heavy period is over?

We simply don't know. Certainly, in my experience, if you look at things like fuel companies, they seem to be very quick to put costs up and not so quick in bringing them back down when the market changes. That is what it is. I suppose we can bring some pressure on providers, as commissioners, in terms of their fee levels being realistic and reflecting those societal pressures. I don't think, in essence, what local authorities pay providers will ever go down, but what we may well do is give lesser increases because the cost of living is, hopefully, reverting to something a little bit more sensible than it is at the moment. But that will be a very complex and detailed piece of work.

Thank you, Dave. Thank you very, very much. Thank you, Chair.

Thank you. Mike Hedges, I think you're going to take up the next question.

Yes. It's very straightforward: are you happy with the performance information that you're receiving from the care home service and are there good arrangements with independent care providers to supply the necessary performance information?

10:00

In terms of quality—. When you talk about performance, do you mean quality?

I'm talking about the whole range of performance, not just quality, but how happy the residents are, how well they work with families, how good they are at discharging people from the care homes, after a certain period of time, into more suitable domiciliary care, if that becomes more suitable—after somebody recovers, for example, after an operation. Those sorts of areas.

I think there will be local arrangements in terms of contract management performance monitoring, and in some areas, there will be regional arrangements. So, I think it will differ. Again, we don't have a national oversight perspective; that's something that the Welsh Government is looking at in terms of what a national oversight scheme may be. So, I think it will very much depend on local surveys and capacity within contracts and commissioning teams, which do vary significantly across local authorities—how many workers they have to go out and undertake that activity. I think the trick for us, or what we really should be aiming to work towards is really good information sharing, so the information that's supplied by care homes and care providers to Social Care Wales, to CIW, to health boards, to local authorities—that we bring all that together into high-level oversight information that helps us to make some of those judgments.

Yes, could I just come in on that? Talking to nursing homes in the Gwent area, talking about the communications between hospitals and nursing homes and care homes, how well do you think that is happening, when it comes to moving people out of hospital beds into nursing care and that sort of element?

I think it's a challenge, and I think, clearly, the pressures on the hospitals at the moment don't help in that sense. The pressure to physically discharge people I think does impinge on that communication at times. Certainly, as local authorities, we've experienced that to a degree, where we are told, 'Can you get a placement ready? Someone's fit for discharge.' You do the work behind the scenes, you work with the nursing home, and then, for whatever reason, that person isn't fit for discharge. So, I think the pressure that is in the system at the moment and is likely to be there for a while yet is definitely having an adverse effect on that communication.

Do you think there's a parity of esteem between the nursing home staff and the NHS staff? From my personal experience of talking to nursing care homes, it's one way and it's not the other. The NHS want all the information, but they won't share back, and that impinges on that good working relationship.

I don't think there is parity of esteem. I don't think there's parity of esteem between NHS workers and social care workers in a whole variety of ways. I still think that the nursing homes are viewed as perhaps the poor relations in that relationship, and perhaps that is understandable in terms of that they are not part of the NHS. But, yes, it clearly does impact on their ability to meet needs on occasions.

And I believe the Care Inspectorate Wales-Healthcare Inspectorate Wales review in north Wales bore that out as well. So, definitely a lack of parity, and I think there's also a lack of understanding of the role of care homes. The regulations at care homes have to be met within the acute sector as well. So, some nurses don't understand that not all care homes have nurses. Some of them are residential homes and try to discharge people with nursing needs that can't be met. So, there's definitely a lack of understanding as well as a lack of parity. So, things like not wishing to share nursing assessments with the nurses of a care home. So, there are definitely systemic issues for us to address.

Thank you. Mike Hedges, have you finished your questions?

Thank you. Natasha. Natasha Asghar has got a further question.

10:05

Thank you so much, Chair. Myself, I'm back again. Just a quick one, I'd like to ask you: what's your overall assessment of the state of the care homes market for older people across Wales, its overall sustainability, as well as the quality of care going forward now? 

In terms of the sustainability of the care homes, I think it is still a very challenging situation. We haven't got back to normal post COVID. Probably the only reason we're in as good a position now as we are is the Welsh Government hardship fund, which really kept a lot of those care homes going through the pandemic. As we come out of the pandemic, certainly my experience is we don't necessarily have the right number or the right types of homes. We've probably got a surplus of general residential homes. Elderly mentally infirm provision is always under pressure, and we could do a little bit more, we need a little bit more, and then we always have a dearth of provision in nursing homes. We can never get enough nursing home places. That principally settles around their inability to recruit registered nurses. You will know the pressures in the NHS in terms of recruiting nurses, and if the NHS can't recruit, then the private sector are going to find it even more challenging.

As far as the quality is concerned, I think generally, the quality is good. There are way more good homes than bad homes, but as Maria touched on in her answer to an earlier question, really, the trick for us as commissioners is making sure that this isn't just about the fees we pay, it's about the work that we're doing in those homes to make sure that they provide the quality that we want. There's been great progress on regional service specifications, so the requirements of local authorities and providers are becoming more and more consistent. But the work that we have to do to make sure that they are providing us with with what we want is a crucial part of the activity. 

If I may speak on behalf of the national provider forum, they've certainly raised concerns around sustainability, particularly around the costs and increasing costs and particularly workforce, so workforce availability. We touched earlier on the cost of living—you know, even the real living wage of £9.50 an hour is a real challenge for workers trying to meet all of those food and energy inflations.

I think one thing of particular note—the not-for-profit sector of housing associations are really considering whether they can continue to operate in the social care arena, particularly around care homes, because they can't make it sustainable. So, as a not-for-profit sector, they can't keep it sustainable. So, I think there are real risks and challenges ahead, albeit that we also need to manage some of that shaping, as we do potentially need a different pattern of services in the future.

As my lovely, esteemed colleague Peredur mentioned in his question earlier, I've had the privilege of meeting a lot of people who have private nursing homes, as well as meeting those who are residents in, I should say, local authority-run care homes as well. Having spoken to those in the homes run by local authorities, the one message that those carers have had is not just the pay discrepancy between those who are working in their particular homes and those working in the private sector, but it's also about time off, and time off not just to have a weekend with your family, but time off for holidays et cetera. They've genuinely felt so overworked and genuinely tired that they feel that that burden has been something that has been completely ignored by everyone. So, my question is, going forward—and I'm sure both of you have spoken to many people who have been in that position, as well—obviously, the private sector is going to have an impact, and a lot of people in the care sector will be more inclined to go towards the private sector, perhaps for the pay, for the benefits, for everything, but what are you doing specifically to help those who are working in those homes that are being run by the local authorities et cetera? How are you making sure that those all-important carers are getting the relief and the respite that they need to be able to do the job that they're doing to the best of their ability?

I'm not 100 per cent—[Interruption.] Sorry, Dave.

I'm not 100 per cent sure if I've quite understood that question. So, my understanding of both the feedback to myself and the evidence from research is that the private sector receive far lower pay and far, far lower terms and conditions. Am I understanding—? Or were you saying it was the opposite way around?

My understanding is slightly different, that if a carer is working in the private sector, they are on more money than someone working in local—

Absolutely not. Absolutely 100 per cent not. There's plenty of evidence of that. Very significantly different, and I think that in the work that we do around the care fee methodologies, there's quite a lot of—. When we base care fees, generally we base it on the real living wage of £9.50. Many local authority staff would be paid more than that. In terms of pension contributions, our fees are based on 3 per cent employer pension contributions. Local authorities are likely to pay 20 to 24 per cent towards contributions. There's statutory sick pay only in the independent sector, whereas there's occupational sick pay in the local authority sector. In terms of leave, you're likely to get a much more generous maternity leave and carer's leave in the local authority, because there are tied national terms and conditions, rather than in the private sector. So, it all relates to the fees that we pay. So, the affordability and the fees that we pay to the private sector then have to balance—balancing those books, meeting all of their costs—and it generally tends to be workers' terms and conditions that suffer if there is a lower fee than the actual cost, but, generally, our methodologies are based on much lower terms and conditions. 

10:10

And if I could, Chair, I think one of the reasons that we're seeing some of the, certainly, retention difficulties in care homes is because carers are burnt out. They've had a hugely challenging two years. And, actually, are you going to stay in that environment and earn the £9.90 real living wage when probably in every high street in Wales at the moment there are cafes, there are supermarkets, there are all kinds of people recruiting at significantly higher hourly rates? So, you don't have the challenge, you don't have the burn-out, and, actually, you take more money home at the end of the week. There's a real societal issue here in terms of how we value carers. 

Okay. The first of June, I believe, is quite an important day for you all because it's the time whereby a local authority is going to be hopefully submitting their stability reports. Are they all on track in Wales at the moment to be able to provide those reports? To what extent have they all been working together to make sure that this approach is viable and it's something that's going to provide positive results?

They are on track. Certainly, the several regional partnership boards and directors I've spoken to, they're all on track. And I think your second point's an important one. There's been great dialogue between those regional partnership boards in comparing approaches. So, they won't be identical, and they shouldn't be identical, but there will certainly be a lot of commonality in terms of the approach that's been taken on those stability reports. So, this isn't seven people who have locked themselves in seven dark rooms and come up with their own approach, there's been really good dialogue between the regions to just understand the various approaches that have been taken. 

And the role of the national commissioning board has been to support good practice sharing, support learning, practice sharing and support templates and tools so that we reduce some of the overall effort and improve the quality of those. So, we did have five, I think it was, peer-support meetings to support those individuals working on that, bringing in Social Care Wales and other data providers and the national provider forum to work with the Welsh Government to run some workshops for that as well.

Thank you so much, Maria. Maria, in one of your previous answers to me, you mentioned the 'Let's agree to agree' toolkit. I just wanted to ask you, what are some of the positives and negatives of this? 

Of the toolkit? I think the principles are really sound; they build on the co-production principles of the Social Services and Well-being (Wales) Act 2014 that we need to determine the evidence that we need to collate together, that it's very much a partnership approach rather than the more traditional contractor/contractee. And the principles are the direction for us, really. We need to see our care home providers and our domiciliary care providers as partners rather than contractors and improve those relationships. So, I think the principles are really sound. Some of the difficulties we've discussed today because also people come with their different roles—funder, with all the political and governance areas of that, and a commercial operator. So, competition and collaboration all together in the mix is a challenge, but I think that, as I say, there are the principles of collaboration and working together, recognising that there are things we won't agree on, but that, actually, there are things that we need to agree on and can agree on together, and that joint working is a really positive approach.

Fantastic, thank you. My final question is: do you believe, at present, the balance in the market between the public sector supply and the independent provision provides value for money?

It probably provides value for money in the sense that if that balance changed and it changed back towards the public sector it would cost more. Personally, I would still like to see a little bit of a better balance. I probably would like to see more public sector provision. It doesn't mean that I would lose the private sector provision that we've got, but in terms of certainly any new provision and any capital, I would like to see local authorities building care homes again. I think that the way that we've looked at it, as directors of social services, is that Welsh Government has run a very, very successful twenty-first century schools programme. Could we run a very, very successful care home building programme along those lines? If we were to do that, I think that's where the public sector could step in, with perhaps more of a balance than we've got at the moment. I think, very roughly, around 70 per cent of provision in Wales at the moment is private sector, the other 30 per cent public sector. Personally, I think if we took it to 50:50, that would be a nice place to be.

10:15

For me, I would like to see an increase in social value so that the pay for the workers and better terms and conditions for the workers would increase that social value, irrespective of who the providers are.

Thank you. Time is short and nearly over, but, Peredur Owen Griffiths, can I bring you in for the next set of questions?

Yes. Thank you. I think we've touched on some of the points that I was going to raise, so there's only probably a couple of questions, looking at workforce and going on from what Maria was just saying there. We've talked about parity of esteem and parity of pay. How are partners, including providers, working together to get a sustainable workforce to meet the current and future demand? How do you balance the demand across the sector with staff from health and social care? How do you work that? Have you got any insight into what we need to do to make it better?

There's a whole range of work going on at the moment trying to overcome the current challenges. Social Care Wales have got a national programme going on in terms of trying to make care more attractive as it is. I know, at local levels, we're doing an awful lot of work. We've had people out in supermarkets, we've had people out in town centres trying to sell the whole message of a carer. I must admit, when we were in the midst of the pandemic and we had everyone out on a Thursday evening clapping, I thought this would be the pivotal moment—after the pandemic, we will have people who want to be carers. And that simply hasn't panned out. In fact, I think the demands that people went through in that period meant we've lost some people that perhaps we wouldn't have otherwise. It's a really tricky issue.

Ultimately, it does come down to terms and conditions, and it does then come down to parity of esteem. Carers are not viewed in the same way as NHS employees, and some people may think that's right, some people won't. But it's a really tricky issue. I'm not in any way being critical of the move to the real living wage. I think anything that increases pay rates for carers is fine, but, quite frankly, £9.90 isn't going to cut it. The view of directors of social services in Wales is that an hourly rate somewhere akin to £12 an hour will mean that we could start being competitive with the tourism and hospitality sector.

There's work that we can do around career paths. So, people coming in to care for the first time—where can they go in the future? Could they stay in care? Could they actually go and work in the NHS? Is there an opportunity for some staff from the NHS to come across, particularly into the independent sector, and understand those services a little bit more? So, there are things that we can do to make the jobs more attractive, but, personally, the elephant in the room is the terms and conditions that these people enjoy.

Just following on from that, Dave, with regard to interchangeability, potentially, between NHS and social care, would there be a way of supporting professional development to make sure that they align, so that at least there is that opportunity to interact?

Yes, absolutely. I think it's a really, really important point. Clearly, the roles are slightly different, and whatever you do will need to reflect that, but I see no reason why that sort of interoperability, for want of a better word, can't happen. There are some professional challenges that we've got to overcome, but perhaps if people saw this as an opportunity to work in care, but as part of that they would be exposed to the NHS, and vice versa, that might mean that we've got people on career paths that we haven't had in the past.

The £12 an hour links much closer to the 'Agenda for Change' pay scales. I think that would be a really important development. An individual is an individual with social care needs and healthcare needs, so those blended roles and closer competence frameworks are really important. There's a lot of work going on in how we establish that, both within domiciliary care and care homes, with a multiprofessional framework just starting to be worked on within the strategic programme for primary care. So, I think there's lots of opportunity there, the issue being the cost of that, the affordability of that.

10:20

As part of that I'd imagine that streamlining paperwork across those—. Because if one person's paying for this and that and the other, then you've got different questions being asked of different aspects of different money pots, and having a clearer, easier way of navigating that element should be considered as well, I'd imagine.

Yes. It creates more seamless care for individuals. They don't care whether you're a social care worker or a healthcare worker when they have a dressing and they need support to get dressed. Ideally, one individual could undertake those tasks.

And then there would be efficiencies, obviously, because it would be one form rather than seven, or whatever it might be.

Yes. Right person, right time, right place.

Going on from what Dave was saying just a little bit earlier about people clapping on doorsteps and that was excellent, the WeCare Wales programme for trying to get people to be employed and recruitment into social care hasn't happened, then, or hasn't worked.

It is happening. Certainly at a local level, what I'm seeing is an encouraging number of new people coming in. Unfortunately, what we're also seeing at the moment is a lot of people retiring. We have carers in their late 60s, early 70s, and I think the whole experience of the last two years has just made some people decide, 'Well, I'm going to call it a day.' So, at the moment, we're keeping our head above water. We're not losing staff, but we're not seeing that increase in workforce, which is what we need. Hopefully, in the next few months, that could begin to change.

I think one of the other issues is that people come into the sector, work in social care for a short period of time, then have to complete qualifications to register, or they could move into the health sector, where they don't need to be registered and meet all the requirements of registration, and get more money. That's another element of the flow of the workforce. They come into the independent sector and then move out into the statutory sector, often, so you've got to keep that churn of new people coming in.

Okay. Just your indulgence, Chair, for one more question, and then I'm done. What do you think is the role of volunteers in care home settings? Are there any concerns or challenges, especially in light of some of the things you were saying earlier around assessing the real cost of care? If it's a volunteer, you're not necessarily adding to that cost, but assessing the overall real cost of it is going to be very difficult. So, do you think there's a place for volunteers in care home settings? How do you balance it?

I think there's been a lot of innovation. I think there's some really positive work through WCVA with Helpforce, and I think lots of the grants available during the pandemic have supported at a local level, with their community voluntary councils, the establishment of volunteers in care homes. I think it really adds quality, particularly to individuals that either don't have family or don't have family nearby. So, I think there's a significant opportunity for volunteers, but they're almost an additional service element, or additional quality element. We still need to have suitable numbers of workforce that are registered, that need to have all the training and induction, et cetera, which you wouldn't necessarily expect of a volunteer, to meet all of those competences. So, I think that they're really positive and add a layer of quality, but we still need that main baseline service as well.

Thank you. We're massively over time, so I'd be grateful if you could keep your reply to my final question now extremely succinct. Overall, how confident are you that the Welsh Government is moving in the right direction and quickly enough with its policy reform to address the issues affecting care home commissioning that the auditor general has highlighted, and what if any observations would you wish to raise about the auditor general's recent report on direct payments for adult social care, including around the interface between direct payments and access to NHS continuing healthcare? 

10:25

I think, in terms of the policy reform, it's difficult to say whether it's moving ahead at the right pace. It is certainly moving ahead at a pace, we can see that, but it's tricky to see where the endgame is there. I still think there are things like the national care service where we're not 100 per cent clear, certainly within the sector, what that references, what that means, what that would look like. In terms of direct payments, I think there are opportunities with direct payments, but one of the barriers we have faced is that continuing healthcare, and it's disappointing that we haven't been more able to overcome that. Most people would want someone to care for them who they know, and if that is practically possible, then we should be doing all we can to make that happen. There are some burdens that come with direct payments that not everyone wants to take on, because effectively you're taking on the role of an employer, but I think the Audit Wales report is accurate in the sense that there is more to be done. There are opportunities that have yet to be fulfilled. 

And if I may add, I think the national framework is a really positive development, and I'm delighted that the Welsh Government has asked the national commissioning board to lead on the development of national commissioning standards that will hopefully support greater consistency. 

Okay. Thank you. That brings us to the end of this session. I thank both witnesses, Maria Bell and Dave Street, for being with us and for your answers and contributions this morning. A transcript of today's meeting will be published in draft form and sent to you for you to check for accuracy before the final version is published. So, again, thanks very much indeed. You can go back to your day jobs and start dealing with some of those practical issues you've explained and shared with us. So, thank you again. Members, we were due to have a 10-minute break, 10 minutes ago. But, do you want to take a five-minute break? Thank you, all. 

Gohiriwyd y cyfarfod rhwng 10:27 a 10:35.

The meeting adjourned between 10:27 and 10:35.

10:35
3. Comisiynu Cartrefi Gofal i Bobl Hŷn: Sesiwn Dystiolaeth 4
3. Care Home Commissioning for Older People: Evidence Session 4

Croeso. Welcome back to this morning's meeting of the Public Accounts and Public Administration Committee, and I welcome our new witness to the meeting. I'd be grateful if you could state your name and role for the record.

Heléna Herklots, Older People's Commissioner for Wales.

Thank you very much indeed. As you might expect, we have a number of questions and, again, I ask Members and yourself as a witness to be as succinct as possible so that we can cover the wide range of issues this topic has generated. I'll begin with the first question, seeking to explore issues around making the system less complex and easier to navigate. So, what, in your view, are the main issues that make the system for care home commissioning across Wales complex and difficult to navigate? 

From older people's perspective, the system is very complex and very difficult to navigate, and, in particular, it's very difficult with the current system for older people to know what their rights are and to feel that those rights can be upheld. So, the funding system is complex, the assessment system also complex, and the interface between health and care and different funding regimes also creates difficulty for older people. So, for example, older people might find it very difficult to be assessed for a care home place, and often, of course, you're looking to move into a care home because you've had a sudden deterioration in your condition where you're at a point of crisis, where things need to move quickly for you. But, sometimes, you're actually finding that the assessment process is taking too long.

There are particular issues around moving from hospital to care homes as well. So, there are problems about the communication between the hospital staff and the social worker and the care home. So, there again, the system can get complex and difficult for an individual. And also it can be very difficult just to identify and choose an appropriate care home. Most older people will want to stay in their local area or near family, and quite often it can be very difficult to find the right home in the right place. 

Thank you. How does the experience of accessing care, including issues arising from out-of-area placements or Welsh language provision, impact on older people, service users and their families? 

So, it has very distressing impacts, and it's important, as you did in your question, actually, to remember this is not just about individual people; it's about families and loved ones. We all want to do our best for our loved ones, and often families are put in a position where they feel they can't do that because of the complexity of the system, or the fact that there isn't a good care home there. I think there's also a major issue around how in control older people can feel about the decisions that are being taken. Moving into a care home is a major decision for yourself, for family and loved ones, and you need support at that time. You also might need access to independent advocacy if you feel your voice isn't being heard; if, for example, you feel you're being really directed to a particular home, or you don't have any choice, or you want an alternative form of care. So, we do need to increase the provision of independent advocacy for people at these points as well.  

And then, once somebody moves into a care home, issues can be very difficult for families as well. We all know over the last two years how difficult it has been for people living in care homes, people who've had loved ones in care homes and, indeed, people working in care homes. But some of those issues around the restrictions on visiting, restrictions on being able to get out and about, are at risk of changing the culture of care homes, and we need to move very quickly, I think, back to a position where, fundamentally, these are people's own homes where you can come and go and have visitors and live your life in your own home. And I think there is a risk that we've moved away from that—well, we have moved away from that during the pandemic—and we need to make sure that older people's rights come much more to the fore, both in accessing care homes and then living their lives well in care homes.

Thank you. How have you engaged as commissioner with public bodies and providers to tackle the problems raised with you by service users?

10:40

We get individual older people and their families coming to us and they are helped by my advice assistance team. So, we deal with a lot of issues around care homes, particularly at the moment, actually, and what we seek to do is to enable the older person or their family to find a solution. Sometimes, that's about giving them clarity about what the law says or about what guidance says, because it's really complicated. Sometimes, it's about advocating or working on their behalf. So, they may have found that they've got a complaint, for example, that hasn't been dealt with well and they need me and my team to come alongside to make sure that that can be dealt with in the way that it should be.

A lot of my focus as commissioner is on the rights issue. So, I'm taking action in a number of areas and I've set up a group, including key organisations in Wales and across the UK, and we're focused on how to improve the rights of older people living in care homes. Part of that is about good information and provision, which we need much more of. We've been consulting and working on a new rights leaflet for older people and their families to try and demystify and make it much more easy to understand and, therefore, uphold your rights, but also looking at some fundamental issues, for example, the contract that you have as a resident in a care home. You don't have security of tenure in a care home. You don't necessarily have your rights upheld as they should be. So, we're looking at whether, actually, contracts can change so they're much more focused on upholding people's rights in care homes and rebalancing, if you like, the power between the commissioner, the care home provider and the individual older people.

I also, on a regular basis, make representations on behalf of older people to Welsh Government both at ministerial and official level in terms of the issues that I'm hearing from older people, so that I can raise key issues of concern with them and follow those up and hold Welsh Government to account on the action that it takes.

Thank you. My final question at this stage: what, if any, potential quick wins can you suggest to simplify the system for older people? Things that could be done easily, or things that could be stopped or avoided.

Sadly, the complexity of the system is not something that's going to be dealt with by a quick win. We need some fundamental changes there. So, I think the way in which to improve it right now is to focus on how we can give increased control and an understanding of rights to older people and their families, and to look at those points where there are particular problems. So, I think a focus on hospital discharge, for example, where actually issues of communication could be improved—and this is an area where I think a quick win could happen. Quite often, a difficult situation is made worse by poor communication. Families and older people need those regular updates of what's happening. We need to get rid of some of the jargon that's used. The language around this is not very user friendly, if I can put it that way: the notion of, 'What is an assessment? What am I being assessed for? What does that mean? What does eligibility criteria mean?' So, I think we could do more, really, to look at the language and simplify that. And then also actually making it easier to question, to comment and to complain and to seek redress. That can be quite difficult at the moment. Particularly if you're living in a care home, for example, then you might be worried about the repercussions if you raise an issue or concern or if you have some fundamental issues around the contract. The place that you can go is somewhere like the Trading Standards authority, and they may not have the expertise to actually help you on some of those issues. So, I would strengthen rights, improve communication and focus in on those areas in particular where there are problems, which tend to be moving between different services, both health and social care.

Penodi Cadeirydd dros Dro
Election of Temporary Chair

My colleague Natasha Asghar will now temporarily take over chairing of the meeting. So, could I hand over to the clerking team, who need to facilitate that?

Sorry, Natasha, I just need to conduct the formal appointment, if that's okay. The Chair has had to temporarily depart the meeting. Therefore, in accordance with Standing Order 17.22, I call for nominations for a temporary Chair.

10:45

Great. I therefore declare that Natasha Asghar has been declared temporary Chair, and I invite her to assume the role of Chair until Mark Isherwood is able to return to the meeting. Natasha.

Penodwyd Natahsa Asghar yn Gadeirydd dros dro.

Natasha Asghar was appointed temporary Chair.

Thank you very much, Owain. Heléna, welcome to the committee. I'm Natasha; it's a pleasure to have you here. I know our Chair has begun by asking you the first question, so I'd now like to pass over to Mike Hedges with his follow-up questions. 

Diolch. Can public sector funding approaches be simplified?

Yes, and they need to be. So, from the older person's perspective, I don't think that older people should be bearing the brunt of difficulties in terms of public sector funding and perhaps disagreements over that. So, one of the key areas is in relation to continuing healthcare funding and whether or not someone gets continuing healthcare funding or not. And the process of that can be quite complex, it can involve some disagreements between health and social services, and it can lead to uncertainty and anxiety about whether your care is going to be paid for. And when you need care and support to live day to day, you shouldn't also have the anxiety about whether that's going to be paid for. 

So, I think, in particular, we need to move to much more seamless funding, where there isn't this division between continuing healthcare funding and social care funding. Fundamentally, I think that's going to be by moving over time to a system where social care is free at the point of need, but looking at what can be done in the meantime to simplify the arrangements. 

Can I just ask you to expand on part of the answer you gave, on the impact on service users and their families when the public sector partners don't agree?

It's distressing. It's frustrating. It's incredibly worrying. It can lead to deterioration in someone's physical and mental health, and it can feel as if you're a very insignificant person in a large and complex system that doesn't really focus on you. I think it's also, quite often, really difficult for the people working in it as well, who are trying to do their utmost and trying to provide a good service. And I know from social workers that have been contacting my advice and assistance team that, often, they are also facing distress because they're not able to do what they want to do for a person.

So, this has real consequences for the health and well-being of older people, and also it creates anxieties amongst older people who have not yet needed to access that care, but know from friends and relatives and others that it can be a really difficult process to go through. So, in my view, it's urgent that these areas are improved. It seems to me we've been saying for years that the system is too complex for older people, and, frankly, not enough yet has changed to improve it. 

I would agree with all of that. Moving on to regional commissioning, we've got regional partnership boards; they're meant to be developing regional strategies that help partners shape the care home market. Do you think that's working?

Well, regional partnership boards have just completed publishing their population needs assessments and are working on these market strategies. So, it's too soon for me to be able to say whether those are going to be working. My concern is that the data on which they're based is, in quite a lot of cases, not adequate, and the regional partnership boards population needs assessment reports actually highlight the deficiencies that are there. So, just to give you a couple of examples, they're using the census data from 2011 because the 2021 census data is not yet out. So, immediately, you can see an issue there in terms of accurate data on population. But also, because of the pandemic, some of that work that is needed to really understand not just population levels and making assumptions about that in terms of what's needed, but issues around what older people want and need—that face-to-face engagement—hasn't been able to happen. Some of the data collection was paused because of the pandemic, or some of the data types have changed, so, actually, it's very difficult to then compare. 

So, I think what's going to need to happen, as soon as those market strategies come out, is there's going to need to be an ongoing process of review and improving the data and improving the strategies, including looking at what we mean by the market. So, there's not just one care home market in Wales, there's not even just 22, because, for an older person, the market that matters is the local market. So, in fact, there are lots of different care home markets across the country, and we need to find a way of understanding both the national and regional and local perspective, but also looking at a much more granular level, and really looking at it, in market terms, through a consumer lens, not just from a purchaser lens.

10:50

Yes, I think that the local market often depends on where relatives live rather than where the person lived before they move into a home. Talking about homes and home infrastructure, I can only talk about Swansea—Swansea East in particular—where we've had a movement to a lot of very large homes, with specialist centres for dementia, which has worked incredibly well in one of the homes in Swansea East. We've also seen some of the smaller homes, over a period of time, disappear, and go back to being either houses or flats. Is this happening across Wales, and is it having an effect on the availability of places where people want them?

So, my sense is, if you're looking at Wales as a whole, the care home market is quite fragile at the moment, and we're starting—. It was kind of an accidental market, so it doesn't necessarily mean that where you've got homes is where you most need them, and there are areas where you need care home places and they aren't there, which is why we need this market-shaping work to happen. You touched on dementia there, and, certainly, one of the areas of need is to improve and increase the number of care home places for older people living with dementia, and also to make sure that there is enough respite provision as well. So, if you're caring for someone at home with dementia, and you want to be able to access respite, that that is there as well. And we're also in a situation, I think, where care homes have had financial support from Welsh Government during the pandemic, which has been really important. As that stops now, I think we are—and we've got issues of rising costs and inflation—in a volatile situation, actually, in terms of the care home market.

Of course, developing the sites, you have to go through the planning system, which doesn't treat the need for dementia care as a part of the planning process, does it? It's based on planning rules rather than community need.

And it is about community, isn't it? Because, sometimes, these debates are characterised in a very narrow way, but, actually, we all need good care homes—we need it for our loved ones, we need it for our neighbours, we need it for people that we care about. And good care homes are part of the community: they're a community resource, they're a place where schoolchildren can go in and visit and get to know older people, they're a place where you can really have a good quality of life in later age. So, we do need, I think, to find a way of encouraging investment in care homes, in the right places, and with the right support. And of course, staffing is a crucial element of that.

Finally from me, a question about regional partnership boards: should they be on a statutory footing? And do you have a view on the impact of regional accountability to the regional partnership boards, and is it helping?

I think, on balance, there's an argument to say they should be on a statutory footing, but I don't think that, in and of itself, necessarily deals with the issues that we have now. So, I think the issue for me is about a clarity of accountability and responsibility, in terms of what the regional partnerships ought to do and what they're about. If you asked a member of the public, they would never have heard of a regional partnership board, or what it does, but they would know about the local council and what its responsibilities are, and the health boards. So, there's something there about having clear accountabilities and transparency in terms of what the bodies do. And then, joint working is so much more than just bringing people together, isn't it? It's about culture, it's about trust, and those things do take time to develop.

Thank you so much, Mike. Heléna, the next part is my section, which is going to be revolving around expenditure. So, I'd like to ask you: what do you see as some of the reasons for the variations in unit costs—for example, weekly placement costs—across Wales and whether you think this is actually justified?

10:55

So, you might expect some variation in terms of wage levels and those sorts of things, land costs potentially in terms of initial investment into a care home. But actually I think, too often, there isn't good reason for variations in those costs. And actually, I think we need a much more consistent approach to determining fee rates, for example, and what you need to pay.

We also know that, for older people, quite often, it's not clear what costs you are going to have to pay. So, for example, it might not be clear if you need to pay some top-up fees in addition to the stated cost. So, the information that care homes provide on their costs needs to be very clear, particularly around what the fee covers and what any additional costs might be, because otherwise, you don't really know the true cost of the care home. And we've certainly had families come to us where they've had very unexpected, sudden bills for top-up fees, quite often for things that you would expect should be in the standard fee.

We've also worryingly had instances of care home providers asking for top-ups on continuing healthcare funding, which actually goes against the guidance and shouldn't happen, and sometimes for the things that you really wouldn't think would be an extra, for example, access to the garden. You wouldn't expect that to be seen as an add-on or a luxury. So, the expenditure and the costs need to be much more clearly explained and itemised so that you know what you're paying for. And I think we need a much more consistent and standardised approach to what those fees are that are paid as well, so that if you're looking to move into a care home, you have an idea about what the care home is charging and whether that looks right in terms of what the national levels are.

Okay, thank you very much for that. I'm going to reiterate a question that I asked our previous attendees here in the meeting: with the cost of living on the rise, it's evident that everything in cost, whether that be gas, electric—you know, it's all going to go up eventually. But what implications do you foresee that having, particularly when it comes to old-age homes, particularly within Wales and across the board?

So, cost of living is one of the two or three issues that people are raising with me most at the moment. So, they are incredibly anxious, and I've used the word 'terrified' about the impact of the cost of living on their own income. So, the first thing I would say is that it is adding to the challenges that many older people are facing.

In relation to care homes, you'd expect to see that work through in terms of increased costs for them—anything from energy and food to staffing. So, I would expect to see the cost of good-quality care increasing as a result. So, the issue there is: will the rates that local authorities pay increase to recognise that? Will there be a greater unfairness in the gap between what some local authorities pay and what the actual cost of care is, which means that older people who pay all the cost—who self-fund—end up subsidising that? And there is an unfairness in the system at the moment, where you can end up paying more if you're a self-funder than the local authority will fund. And it shouldn't be the case that those issues end up being borne by people who are needing to move into care and using all their savings up to pay for care.

What do you think would be a good solution to create more equality in the system to stop that happening in future?

So, I think the work that's under way—the national commissioning framework—to set a clear rate—.  And it needs to be a fair rate. So, it needs to be a rate that enables care homes to recruit and retain quality staff and pay their staff well and have good terms and conditions and provide quality care. So, that should be the rate. You shouldn't then have a situation where, if you're paying for yourself, you have to pay a higher rate than that, unless you're paying for some additional things, or, for example, there might be a difference in that you're having a much larger room or something, or an actual difference in the accommodation in particular. So, if we have a rate that is understood, that is across Wales, where you know that's the rate that the local authority will pay, and that's the rate that you'll pay if you're funding yourself, you get rid of that inequity.

11:00

Thank you so much. Commissioner, you kindly provided us with a lot of information, which I know my colleagues and I have all gone through prior to this meeting, and I just wanted to know—. There were issues relating to funding, cross-subsidisation and top-up fees. Are there any points that you would like to elaborate on, particularly in relation to the information that you've kindly provided to us prior to this meeting?

Yes, I think, on top-up fees. This is a very worrying area, and it's where, as an older person or a family, you feel you're slightly at the mercy of the care home provider. So, if you've moved into a care home, it's not like you can easily shop around and say, 'Well, I'm going to move somewhere else if I think I'm being asked to top up my fees inappropriately.' So, that needs much stronger attention. The issue of continuing healthcare and top-up fees shouldn't be happening at all. And as I've explained already, that issue of cross-subsidisation. At the moment, a lot of the complexity and difficulties of funding are being felt and experienced by older people and their families in a way that is very, very difficult for them to manage. And if you think about living in a care home or having your loved one in a care home, and that sense that you can manage, but actually with the top-up fees you're getting to the point where you're thinking, 'I can't afford to stay', that is just a terrible position to be in towards the end of your life. It's completely unacceptable and we need to get to a point where those things just don't happen.

Thank you for that. What are your views on the fairness of the funding model in Wales, relative to what has been proposed in England?

Well, I certainly wouldn't advocate what's being proposed in England. So, here in Wales I think there are a couple of good things in terms of the funding system. So, the fact that there is a cap on how much you have to pay per week for domiciliary care, I think that is positive. So, you know that you might be contributing, but you're not going to be asked to pay more than £100 a week. The asset threshold in Wales is also, at the moment, better than in England. I think the problem with the proposals in England is that they only deal with one very narrow element, actually, of care home funding, and the most recent amendments to what's being proposed around the £86,000 cap actually mean that, according to analysis by Age UK, more than four in five older people will not see any benefit from the cap at all, and it will particularly just help those wealthier older people who might reach the cap, say, in a couple of years, whereas someone with fewer assets could potentially have a decade or more of paying fees and will never reach the cap at all. So, it isn't an approach that I would advocate here by any means.

Okay. My final question to you, commissioner, before we go on to Mike Hedges with his next set of questions is that there's no denying, and I'm sure my colleagues here will agree, that the population here in Wales is ageing. It's ageing across the United Kingdom and health conditions are changing—they're evolving at an exponential rate. What can we as politicians here in the Senedd do, and where can we drive the Welsh Government to put their funds in order to ensure that the needs of the elderly population here in Wales are met adequately going forwards?

So, I very much welcome that question and the committee's attention on that. I think we need to be better at planning for our ageing society and to do that on the basis that this involves all of us; we are all ageing, and actually we should celebrate the fact that we're living longer, but we need to prepare for it much better. So, more investment in social care, particularly at the preventative side of things. Too many times now we're seeing older people who could be living well, volunteering in our communities, caring for others, who, because they are not able to access decent social care or get the preventative healthcare support that they need, are deteriorating more quickly. And there are some issues, I think, where older people just do not get the access to services that they should, and sometimes I think that's because of ageism, actually.

So, I'll give you an example. In terms of mental health support, the Royal College of Psychiatrists has identified ageism across the UK, actually, in terms of access to and provision of mental health services. So, better planning, more engagement with older people about what is needed and the services and support that we all need as we get older, more investment in social care, including in terms of the workforce. And then making sure that, in the work of Welsh Government, the issues of an ageing society are taken better into account across its areas of work. To give one example, we are an ageing workforce as well, so if we're going to improve recruitment and retention in social care, we need to be better at supporting us as we age in the workforce as well.

11:05

Thank you very much, commissioner. I'm now going to move over to Mike Hedges, and he'll be asking you some questions in relation to improving performance information. Mike, over to you.

My first question is: should we have more collaboration between purchasers and providers, rather than this almost two-side, 'We're buying, you're selling, and we'll negotiate from there'? Is there a role for more collaboration between the two, because at the end of the day, the person in the middle, who's the person in these homes, seems to be the one person who is left out of that discussion?

Yes, I agree. We need a collaborative approach, ideally based on trust. Providers know a lot about what good-quality care is and the challenges in providing it. And good commissioners listen and work very closely with providers, and providers have got a lot of knowledge and insight, actually, about what good-quality care is, what older people are looking for and need. At the same time, I think both commissioners and providers need to stay close to older people, in terms of listening, listening to feedback, listening to positive feedback—[Inaudible.]—as well as the negative. I think too often, it seems there's a long—. There's a big gap between the older person and this kind of machinery of commissioning and procurement, and these things need to be closer together and, as you were saying, included in a closeness of working between providers and purchasers.

Thank you for that. Again, round by where I live, of the big care home providers in Swansea East, three of them I think are very good. They invite me to things and they want to show off the quality of what they're providing. Others are less keen on having any visitors, and it always makes me feel a little worried.

I want to ask you about the quality and suitability of care homes, and are you happy—? We've had some relatively poor care homes that have been picked up by inspections, but are we moving in the right direction in that all care homes are improving and getting better?

I think we still have quite a variable picture. We have many, many really, really good care homes and huge numbers of staff working incredibly hard, particularly over the last two years, going above and beyond to protect people in their care homes. The issues about good-quality care in care homes are a lot about leadership, so the leadership in the care home, and a lot about recruitment and retention of staff and managing staff. I think there's more that can be done to build on some of the things that happened during the pandemic to support staff. So, for example, Age Cymru, Care Inspectorate Wales and Public Health Wales brought together a—it's sort of called the 'care home cwtch', which is a peer-support group for people working in care homes during the pandemic, which I thought was a really good example of the need support staff and get alongside, to understand the stresses and strains, and to enable people to share good practice across care homes. So, I think one way of improving quality is that peer learning and peer support. We need also to make sure, however, that if there are problems in care homes, all the people feel they can complain without fear of repercussions or without the threat of eviction, for example, and that if they do complain, it's a straightforward process and a process from which both the care home and the regulator, actually, can learn, because you can learn a lot from complaints. So, again, I think it's about improving people's rights in the care homes, so that they feel able to complain, or their families feel able to, as well as supporting staff to continue to develop their professional expertise in what can be a very challenging role. 

11:10

Thank you for that. It's not just care homes, I've got one doctor's surgery that is very unhappy to have any complaints, and the first thing they say to somebody who complains is, 'All right, we'll kick you off our register. You can go and find yourself another GP.' Do you see that happening in care homes?

We've had some cases where people have been seen as making a fuss and have been threatened with eviction. The only reason, really, why someone should have to leave a care home is if the care home is unable to provide the level of care that they need. That's why, actually, we need care homes to be in a position where they can care, as far as possible, for someone to the end of their life, because it's very distressing to move care home. So, we do know that, sometimes, raising complaints can lead to repercussions or the threat of eviction, and again I come back to the point about needing to improve older people's rights and give people security of tenure so you can't have that eviction threat.

And, of course, we know that moving care homes can have a serious effect on life expectancy as well. Moving on to the role of the care home inspectors—is that working in helping to drive up care quality, or is it, like a lot of inspections in different places, that everybody performs doing what they think the inspector wants to see, not how they perform normally?

So, I think—. It's obviously been a very different couple of years, really, in that inspectors haven't, on the whole, been able to go into care homes, and you learn a lot from walking into the care home and experiencing that. I think, now that inspectors are going back into care homes, that's really important, and for them also to identify what's working well, as well as the areas that need improvement. So, the regulator is crucial in terms of giving assurance around safety, good care and provision. They do have a role also, I think, in spreading good practice, in supporting improvements in quality, but other organisations do as well—so Social Care Wales, for example, Care Forum Wales, as well as the umbrella group for care homes. And a lot of the issues around quality, of course, are driven directly by the provider, by the manager of the care home, of the organisation that runs the care home. Where it works well, I would agree with your point, absolutely. Care homes want people to visit and come in, of course, in a safe way, in terms of the COVID experience. I'm sure we've all been in those care homes that are very welcoming and that are encouraging people in from the local community, and that helps quality. If people have got eyes in the care home, if you like, different people coming in, relatives able, also, to visit and keeping an eye on their loved ones, so they are not closed settings, they are open settings, that really helps quality as well. 

And the final question from me: should Care Inspectorate Wales and Healthcare Inspectorate Wales be merged?

I think there's an argument for that, yes. We talk a lot, don't we, about the integration of health and care, and yet we have two different regulators? I think we just need to be careful that we're very clear about the reasons why, and that we don't just assume things, then, work immediately better if we have a merged body; that doesn't always hold true. But at a point where we're looking at trying to remove divisions between NHS and social care, and working seamlessly, it would seem logical to have a single regulator.

Thank you. I'll just finish with a comment that mergers sometimes mean you have somebody in charge of both, and then you go to the next layer down and they separate back out again. 

It's not a panacea. I was involved in one of the largest ever charity mergers, so these things are not easy to live through either.

Thank you so much, Mike, for that. I do appreciate it. The final comment you made was something I was going to say, which is that none of us like layers, layers and layers of bureaucracy at the end of the day. I'll move on to our next Member—Peredur Griffiths, I'll pass over to you. I know you're going to be asking about stability and quality of care home provision.

Thank you, Chair, and morning, Heléna, it's lovely to see you. As Natasha said, looking at the stability and the quality of care, what's your overall assessment of the state of the care homes market for older people in Wales, its overall sustainability and the overall care quality?

11:15

I think we're in quite a fragile position, not least because of the last two years, but also because of the issues that this committee is looking at in terms of funding and the difficulties of funding. To reiterate my earlier point, it's not just one market and I think that's the complexity as well. If it's to work for older people, it's about local markets as much as anything, and too often, older people are not able to access the care homes in the places that they want to. So, my worries about stability of the market are not just on the macro scale, but also on that local scale as well.

I worry about potential care home closures as well, because of funding issues. So, the fact that that Welsh Government financial support during the pandemic has stopped, for understandable reasons, that could create some further problems. And when care homes close, that can be a devastating experience for older people to move. People, when they've got to know friends in the care home and their relationship with care staff—all of that can go in a matter of days and that can be very distressing. I think, also, the care home market doesn't have some of the provision we need, particularly for people with dementia, which is not just about specialist homes, actually, it's about recognising that, in pretty much every care home, there will be people living with dementia, so how do we make it the case that you don't have to necessarily move to a different home as your needs change? 

I think the other issue related to quality is that issue about getting back to the culture of care homes being open and part of the community and not closed. So, I worry about care homes where they still have restrictions on visiting that seem above and beyond what is needed now. So, those will be some of the issues, I think, at the moment.

Okay. So, what expectations do you have for the work being carried out by the local authorities on market stability reports and their potential to change the shape of care home capacity and services?

Well, we need that work. We need the kind of market-shaping work. We actually need it on a number of levels; we need a kind of national plan, really, in terms of what provision do we need—[Inaudible.]—age and what does that mean in terms of provision of care home places? That can't be done well without thinking about the overall kind of care provision. So, the number of places we need in care homes is also a factor of what we need in terms of home care, what we need in terms of housing. So, if we have housing where you can live well into your later years, even if you need a significant amount of care, that reduces the need for moving into a care home. So, we need that plan across care provision for older people.

We also need it to be based on better data than we have at the moment, and I indicated earlier some of the problems with population needs assessments, and I think it would be a good exercise to look at the population needs assessments that are being published right now, and in particular to look at the sections that indicate where there are gaps in data and where there are gaps in insight and knowledge, and, actually, for Welsh Government and regional partnership boards to look seriously at how to meet those gaps. In some other countries, they have what's called a longitudinal study of ageing, which is a really valuable data set, which, effectively, looks at the ageing population over time in terms of how it changes, the levels of need, the levels of the contribution we make as we age, and provides a really rich data set for all sorts of areas of activity of the Government, from care planning to economic development. We don't have that in Wales, actually, and it would improve a huge number of areas in terms of our planning if we had something like that. 

Okay, thank you. Recognising the increasing costs in the sector, how do you think the Welsh Government and commissioners should respond to manage those impacts on service users?

Cost-of-living impacts are affecting all of us. We know for older people the impacts are hugely significant, actually. Many are struggling to manage even now, and that's before the next energy hike, before the winter. The state pension hasn't gone up as much as inflation, and nor have other key benefits. So, I think there's more work that Welsh Government can do, actually, in supporting older people on the cost-of-living crisis, first of all. There's more action that could be taken there, and I've highlighted to Welsh Government what I think it needs to do on that.

In relation to access to care, we need to make sure, I think, that you're not disadvantaged if you need care. It shouldn't be that the people who bear the brunt of the cost-of-living crisis are those who are in particular need of care and support. I wouldn't, for example, want to see an increase in care charges on older people; I think that would be a pretty outrageous thing. There's no sense that that's going to happen, by the way, but we certainly shouldn't be looking at that. We should instead be looking at how can we maybe mitigate more of those costs that older people might be facing, if they're having to pay towards the cost of their care.

11:20

Going on from your comments earlier that a care home is people's home and, obviously, the workforce are there to support people in their home, because they're in a care home, how well do you think that partners are working to develop a sustainable workforce for the care home sector and support professional development?

There's a huge amount of hard work going on, which I can see across all bodies. It's the thing that people raise with me a lot around workforce, and it's not just a challenge here in Wales. I think, fundamentally, actually, part of the challenge is that we don't value, as a society, care. We don't value the people who do it unpaid, we don't value the people who are paid to do it in terms of what we do to support them. Actions are louder than words on this. I very much welcome the fact that the Welsh Government is introducing the real living wage. I see that as a first step only; we need to go further on that. We need to provide more support for unpaid carers, which includes easier access to care for the people who they are caring for. And also, I think ageism is at the root of this a bit as well, that people have a very negative view, often, of older people, of growing older or of working with older people, even, and I think that's part of it as well. Some of the change is about cultural and attitudinal change. It's why one of the things I'm working on is how we can combat ageism, how we can get rid of those stereotypes, how we can get rid of the notion that, somehow, older people are a burden, and actually put much more value—and value all of us who need care. Most of us are going to need some care and support through our lives, either for us or our loved ones, so we should value that as a society, and that should be reflected in the budgets that go to social care, for example, the rights that people have. There are ways to reflect better the importance of social care to all of us.

And just finally from me, Chair, if I may, what role do you think that volunteers have in care home settings on an ongoing basis? Are they there to enhance people's lives or are they there to perform the basic functions? What are your thoughts around volunteers in that setting?

I have a positive view of volunteering, not least because my first experience of working with older people was volunteering in a care home, so it's something quite close to my heart. I think volunteers do have a really positive role to play. Importantly, they have a lot to gain as well. This is not just about people doing good for older people in care homes; it's much more, actually, about the mutual benefit for the person who gets to know an older person. They might not have an older person in their lives, but get to have a different friendship. I'm really supportive of, for example, intergenerational contacts between older people in care homes and elsewhere. There have been some lovely examples, during the pandemic, of people developing pen-pal relationships with people in care homes, because they couldn't go in, so they became pen pals. I think where volunteering is at its best is shared interests, shared activity; I think it's wholly positive. I think it needs to be supported, so volunteers need to be supported, and, obviously, care homes need to have the capacity to manage that well and to support volunteers well. What we don't want to see is where volunteers are being brought in to do basic essentials that should be done by paid staff. So, as long as that doesn't happen, I'm very supportive of volunteers in care homes.

11:25

Thank you so much, Peredur. Commissioner, I'd just like to ask you a couple of points, please, before we wind up the session. Firstly, I just wanted to ask if there are any observations that you had, particularly, that you may want to raise about the auditor general's recent reports on direct payments for adult social care, including issues that may be causing you concern around the interface between direct payments and access to NHS continuing healthcare.

It was an important report and, I think, reflected quite a bit of what we've heard through our advice and assistance team over the years. The take-up of direct payments amongst older people is low. I think that's for a number of reasons. The system can be quite complex to navigate, it puts a lot of responsibilities on the individual, for example to directly employ staff, which you might not want, and, sometimes, people who are working with older people in social services assume they're not going to want a direct payment when, actually, sometimes they might. Occasionally, more recently, we've seen where a local authority hasn't been able to provide the care and support for an older person, because of all the issues around staffing, and they've offered them a direct payment as a last resort, in a 'try and sort it out yourself' way.

We've also heard, worryingly, to your point about the relationship with continuing healthcare, that because you can't use your direct payment if you then get continuing healthcare, some people are stuck in a situation. I'll give you an example of someone who's getting direct payment and maybe they're employing a personal assistant, they've managed their package of care and support, they've got it working well for them, but their health needs are increasing, so they're eligible for continuing healthcare funding, but if they go to continuing healthcare funding, they can no longer have their direct payments, and they lose that choice and control over this package of care and support that they've arranged. That's a ludicrous situation, isn't it, that because you're now eligible for a different form of funding, you can't continue with the type of support that you had. I think that's a particular interface between continuing healthcare funding and social care funding that needs sorting out. You should be able to continue to be able to have that choice and control. We know that some people have rejected continuing healthcare funding because they couldn't maintain that choice and control over their care.

Thank you for that. Commissioner, in many of the answers you've given, you've spoken about ageism. I personally hate it, I know my colleagues do as well. Racism, sexism, we're not fans of any isms here. But I just wanted to ask you whether, overall, you're actually confident that the Welsh Government, as a whole, is moving in the right direction and quickly enough with its policy reforms to address the long-standing issues affecting care homes across Wales.

I think some of the direction is good, particularly in relation to care homes, looking at having national commissioning frameworks and more consistency over those areas. I think that's good. Implementation is the key, and speed. Older people quite often will say to me, 'We haven't got time to wait', so it matters that this stuff is done quickly, it matters that implementation is done well. We know, potentially, there's some radical reform that might be proposed in relation to the Welsh Government and Plaid Cymru agreement on the future funding of care. I think we just need to make sure that the improvements that can be made now are not delayed because of working on this new funding system or this new bigger reform. We need to improve matters right now for older people, and that's through some of the things that I've suggested. So, look at those pressure points in the system, particularly between hospital discharge and care homes. Improve rights, improve communication. Sort out the interface on continuing healthcare. That needs to have a really clear focus on it. Get that clarity about care home fees and improve people's rights as well as looking at, longer term, how we can move to a system that's much more about care being free at the point of need, and a much simpler system to access. I think a lot of time and money goes on complex assessment and eligibility systems. We need to trust people who need care and support more, we need to simplify the process, and we need to make sure that we don't just increase layers of work on this, that we actually look to how we can do away with some of that as we move forward.

11:30

Okay. Thank you so much. I just want to give Mike and Peredur the opportunity now if there's anything they wanted to add. No. Okay. Thank you so much, Heléna. Just one last remark for you: if there's anything you wish to add to any of the comments or questions that you've made today and responded to. Is there anything you'd like to add?

Heléna Herklots 11:31:09