National Assembly for Wales

Albert, would you like to—?

Thank you, Minister. Good morning, committee. Albert Heaney, director of social services and integration.

Judith?

Good morning. Judith Cole, deputy director, workforce and local government finance.

I think the most significant, Chair—and thank you for the invitation, by the way, to meet with you—is the demographic change. It'll be no surprise to any members of the committee: in the submission of written evidence that you've had already, and the work that's been done, there are some stark reminders of the challenge ahead of us. So if you look at that over-65 population, by 2036 there's an increase of over 20 per cent in that population. But in the over-85 part of the population, there's a doubling of it, and of course what we know—and you can see it in the winter pressures that we face—is a number of people in the over-85 category are not only reliant on the NHS part of it, the hospitals and the accident and emergency, but also on the social care sector as well, with increasing complexity. So it isn't simply the age profile; it's that as the age profile increases and that bell curve shifts upwards, there's increasing complexity of care as well as health provision. So, that's the biggest driver of this.

What we don't have an absolute key knowledge on, an absolute certainty on—. And by the way, that's modelling as well, so, even with that, there's a level of uncertainty around that, but we can see what's coming towards us. What we don't have modelled—and in some ways it's difficult to do—is how we would actually respond to that, and what the impact of that would be on the financial situation of how we actually fund this. Because our responses to it, the way we collaborate, the way we innovate, the way we use technology, the way that we move towards a more prudential form of healthcare, and so on, how we do that differently in Wales could have a major impact on the way we actually fund our response to this as well. But we can see the scale; even if that modelling isn't precise, isn't exact, it's giving us a pretty good indicator of where we're heading and the scale of what we need to respond to in Wales and in the UK, and every other western nation.

Actually, the English longitudinal study—thank you, Chair—is quite helpful to us, because we can draw on some of the information of that. As you know, it looks at a sample of the English population aged 50 and over, it looks at health, disability, biological markers of disease, economic circumstances, social participation networks, when we look at things like the effect of isolation and loneliness on well-being, and so on. So, we can draw on that, but it's not as if we don't have other information. Before we came in I was talking about part of my previous career as a lecturer. I used to talk about longitudinal studies that were done on things such as bus conductors and bus drivers, back in the 1950s, looking at the health impacts. So, what we do in terms of responding, in terms of that: prudential care isn't just a slogan. It's about whether we can actually persuade people, Chair, to move towards a system where not only do they have support to look after their health, but there is an ownership of looking after health as well—that walking, cycling, active travel—all of those sorts of things as well. That can have a material difference, so it isn't only the demographics.

But we are also doing work here within Wales as well. Bangor University and Swansea University have done their own longitudinal cohort study looking at health and cognitive function in older people aged over 65, and that complements work that was done previously in the 1990s. So, it will look to address questions regarding later life and ageing in the twenty-first century. But we are scoping up more targeted research as well. I don't think we have to replicate what's being done in the England longitudinal study—we can actually draw on that—but more targeted research to produce a clearer picture of future demand and a more accurate base to model our costs that might come forward as well. But there are some unknowns around this as well, and part of that great unknown is how we respond to this. And if we do things differently in Wales, then the financial implications, let alone the health and well-being implications, could be quite different. 

I'm going to bring in Albert, my expert to my right here, to assist in this question, if I may, Chair. 

Thank you very much, Minister. Thank you, Chair, for the question. I think that some of the critical aspects of what we want to look at is we've got a lot of information around frailty, supporting older people, falls prevention, and crucially around loneliness and isolation in terms of reducing the potential for people to remain in isolated situations. So, the types of areas that we want to look at is what works well, and how does reablement work to enable people to be able to live healthier and longer.

What we're very keen to do is to understand the elements that will go towards assisting older people as they grow and develop, and we're seeing a much longer life expectancy now than we have in previous generations, which is fantastic news, but alongside that the important aspect for us is to focus on what keeps people in states of well-being longer, so that when they do have periods then in hospitals or need care and support, that those can be minimised and people can be enabled to live independent and healthy lives. 

Mike Hedges on that. 

A quick point there. Every time people talk about predictions for the future, I always remember how they predicted that by 1950 the streets of London would be covered in manure from the horses, because you don't know what's going to happen. But the point I was going to make is that according to the actuaries, of course, life expectancy has reduced in the last few years. Their expectation for you and the rest of us in here was 92.3; now it's gone down to 91 point something. There has been this change, and I think this may well have a lot to do with people's current lifestyles. We're talking about, sort of—. You can't keep on saying, 'People keep on getting older: it used to be 70, then it became 80, now it's 90, and it's going to be 150 in 100 years' time', because it seems to have equalled out and started to reduce slightly. Are those figures that you recognise and does that fit in with your planning?

Yes, and we have to incorporate in a very dynamic way the latest projections, including those around lifestyle, because one of the factors of a modern affluent western lifestyle is that that has health implications itself. Curiously, as we were chatting about this, I was saying that one of the biggest downsides of sometimes working in the jobs that we do is finding the opportunity to mix a healthy lifestyle with a busy form of work, and it's not exclusive to us—there are many forms of this. So, that needs to be factored in. 

I wouldn't want the committee to think, however—. I touched on the issue of how we respond to this. I wouldn't want you to think that we are footloose without any ideas of how we do it; in fact, some of the stuff prior to me coming to this Assembly that you put in place—I think all the Members around here were here before I was here—. The Social Services and Well-being (Wales) Act 2014 placed that idea of saying, 'We move towards this more preventative and prudential approach to healthcare', so we're well on train to that. How does Government underpin that? We put money into things like intermediate care funding, so we deal with complex needs, complex issues, joint working across health and social care. There are a number of ways that we can do this. We bring together regional partnership boards. We break down the boundaries between health and individual local authorities, or multiples of local authorities, and say, 'Work together on the outcomes that we've put on a statutory footing'. 

All of that is starting to change the whole paradigm about how we provide health and social care, and move towards prevention and prudential healthcare. It's starting to have an impact now. What is interesting in terms of these projections and the scale of challenge facing us is how much that re-gearing can transform the way in which people live their lives, the way in which support is provided close to home, closer to the places that they live, and keeping them alive longer and fitter. Whether we all turn out to be Methuselahs, or whether we turn out to be living into our 70s or 80s, I don't think we'll get to the 300s or 400s, but you're right—.

We do know, of course, that the oldest person in the world, apart from when they've had people who've cheated because they tried to avoid armed service, have always been in the 114 to 118—a very narrow number. That seems to be the extent to which the human body will keep on going.

Indeed, indeed, but part of this fiscal challenge is this: if we can devise the sort of measures that anticipate, based on our current projections and the best modelling available, that we are heading towards a much older population—. That projection of 2036 with a doubling of the over-85s—we're starting to see it now. This is what's now happening in our surgeries and our general practice clusters, in our accident and emergency units and in social care.

Now, on that basis, as to the sort of things, for example, that they're doing—and they're doing them across the country, but if I take one example—in the regional partnership board with Rhondda Cynon Taf, stretching all the way from Merthyr down to Llanharan and so on, bringing those local authorities together with the health board, there they have this approach of stay well at home, stay well closer to home, et cetera. It's all geared towards that. Now, that's having a transformative impact already, because the support is shifting out. It's not being taken away from the A&Es, but what they're doing is refocusing on to saying, 'If we can get you much more rapidly the support you need in your home environment or closer to home so you don't have to wait months and months for it—'. There's a team of people who say, 'Right, we know what you need, and you need it quickly, because if we don't get it to you quickly, you'll have the slips and falls, you'll end up coming in.' This has an impact on the fiscal situation. If we can make what looks good in those sorts of situations, pump primed by ICF funding, then we can move to a situation where we avoid hitting a tsunami of costs and we turn it into a manageable amount. Now, that's a huge challenge, I know.

We'll move on, with David.

Thank you, Chair. Well, since we're on the social services and well-being Act, because I think—. I remember it going through the Assembly and one of the concerns of many Members was the 'can' and 'can only be met by the local authority social services'. I was aware that that might be used by local authorities as an excuse not to deliver on some of the needs of individuals, and there has been evidence received by this committee that those eligibility criteria may be getting tighter and tighter in areas over the years, which is as a consequence of the financial pressures—let's be blunt about this—the financial pressures placed upon them. Obviously, as you would expect, the Welsh Local Government Association and the Association of Directors of Social Services have said, 'No, that's not the case,' and I wouldn't expect them to say anything else; it's perception. But what are you doing as a Government to monitor these eligibility criteria to ensure they are consistent across Wales and to ensure that the needs of those individuals are being met and so are not being left simply because of financial constraints upon local authorities?

Thank you, David. The first thing to say is that, regardless of where we are with financial constraints—and you are right that the context of this is exactly where we are with the budgets that we have, even though we've done our very best, and we have, compared to England, protected particularly the social services aspect of local government funding and partnership funding with health boards as well in that joined-up way—there is a reality that that is a backdrop to all the decisions that we take. However, let me make it absolutely clear—and you're right, we are being told by ADSS, we are being told by WLGA, we are being told by all the stakeholders we're involved with that this is not the case, but there is, sometimes, a perception that's reported because of that backdrop that eligibility criteria and so on are being altered because of the context of austerity—we as Welsh Government would not expect that to be happening. We are told it is not actually happening on the ground. We would not want to see that happening, come what may. There are duties within the statutory framework we have that say that people have the right to have that co-determination of packages under social care support, they have the right to advocacy. This is not some lame wish from Welsh Government; we, as Assembly Members, put this on a statutory footing.

What are we doing to monitor it? One of the biggest challenges of that social care and well-being Act, as you rightly say is, if we give the flexibility not only for local authorities but local partners in the third sector on the ground then to deliver the outcomes that we want to see for individuals, how do we make sure that's happening without micromanaging it? Well, part of what we've done is we commissioned work around monitoring now. We've just done phase 1 and we're moving into phase 2 of monitoring the outcomes in the process: how do people feel this is happening for them on the ground? Whether you're a carer, whether you are somebody who's receiving services directly yourself, how does it feel for you and how do you feel about the outcomes? Albert, I don't know if you want to expand a little bit on that, because that's quite a major piece of evaluation that we are doing, and it will be ongoing, because I know the thing that people will say is, 'Without micromanaging it, how can you be assured, as Welsh Government, that we know that this is working well on the ground and that providers are not using the background of the constraints of funding to say, "Well, we're going to have to tweak things—you can't have this, you can't have that?"' 

Thank you, Minister. We have a formal evaluation process on this. Crucially, as part of that, eligibility, the process around eligibility and the process around the 'what matters' conversation will be formally evaluated and considered. Alongside that, we have, as part of that process, what we're calling the Measuring the Mountain exercise, which is where citizens—people themselves—are formally involved in the evaluation process. So, it won't just be a professional lens; it will also have a person-citizen direct input into the evaluation in terms of going forward. 

We've also had regular conversations with our colleagues in local government around this, because it is absolutely crucial. The Act doesn't just place duties about care and support by local authorities. It places duties on local authorities around prevention and earlier intervention, and those conversations have continued and focused upon the range of services. So, we are seeing that the information, advice and assistance services that have been put in place under the Act are beginning to help have different types of conversations with people, and that sometimes—and this is part of the intention behind the Act—people's needs can be met within their communities. On other occasions, they need, quite rightly, complex care and support packages provided by the local authority. But it's making sure that a 'what matters to them' conversation takes place to enable them to get the right level of care and support, whether that be community focused or whether that be through the provision directly provided by local authorities. 

I accept that, and I accept your arguments about the funding going to social services compared to England, and I won't argue about that. But we are now talking about delivering our big policy and an Act, which this Government has processed and completed, to which, at the time, local authorities always indicated that there was an additional cost and it was not cost neutral, as claimed in the Bill.

I'm sure you get casework, as I get casework, about individuals who feel that they are not getting their needs assessed and there are others who are not even aware of their right to have their needs assessed. So, there's a huge gap still there, and that's not perception; that's experience. I suppose what we're trying to make sure is—because we are talking about the fiscal side of things—how you are looking at this, with a view of the fiscal aspects, to ensure that, in fact, there is sufficient funding to deliver on this Act in the longer term. As local authorities find themselves in tighter constraints because of austerity coming down the line—and it's still there—how are you going to ensure that this Act can be delivered and the people who this Act is for will get the services they want?

Well, we've put the money into local authorities to make sure that they can carry out the legislation effectively. So, we haven't stood back and said, 'It's all over to you'. We've put the funding support in there to do it. But we are also, as Albert has explained, making sure that we are evaluating the outcomes, and we will, whilst working in partnership with local authorities and other providers—and it's beyond the local authorities; it is the wider providers, the network of providers in the third sector and so on—also hold them accountable for making sure that the individual assessments are working effectively.

And that's part of what we do with not only the formal assessment part—. By the way, within that, the representatives of older community organisations are formally part of the formal evaluation. So, they put their feedback into it, and they can happily feed in then whether they think that, as individuals or collectively as a cohort, they're not being adequately listened to. Secondly, that deep dive that we're doing with Measuring the Mountain is, in a sense, ground-breaking, as the legislation was, because this is deep, qualitative research—sitting down with a lot of individuals in the hundreds upon hundreds to say, 'What do you feel of it?'

I think, David, you are right in that saying that we will have individuals—and we would, regardless of the legislation, but particularly now—saying, 'Look, they've sat me down and co-produced it'. But I've had individuals say to me, and I think this is partly to do with the newness of the Act as well—2014, it was passed; 2016 implemented, and we're still rolling it through—'Are people aware of the fact that they have a statutory right to advocacy—informal or formal advocacy? Are they aware that there should be a co-produced package? Do they know what we mean by that? Do they know that that means sitting down with a representative, saying, "Within the constraints in Carmarthenshire and within the constraints in Bridgend, here's what we can determine with you and not to you"'.

So, I think there's an issue over awareness, which we are keeping an eye on in the evaluation. There's an issue around working with all local authorities to make sure that all of their front-line officers, as well, are equally focused on what this Act means to them in the way that they deliver it. But the funding has been put in place to help them deliver this—we have no doubt about that. And we're not picking up from the Association of Directors of Social Services, the Welsh Local Government Association or others that they doubt that the funding has been put in place to enable this transition to a very different way of working, focused on individual outcomes. But you and I, and others, will still have individuals who are unhappy with what's been co-determined with them and for them, because it happens in the nature of things; there will be people who aren't happy. We want to minimise that. I'd love to say that we could get to a position when we don't have anybody, but—

I question your term 'unhappy', because 'unhappy' implies that they may be entitled to something but they're not happy about what they're entitled to. There are people who are entitled to something and are not getting what they're entitled to, and there's a difference. So, it's not just 'unhappy'.

In a sense—and you highlighted this—this also links to carers, because carers also have the ability to have their needs assessed. We've got evidence to say that there are around 370,000 informal carers, of whom only 6,200 have been assessed, so that's a huge proportion not assessed. Of those who have been, less than 20 per cent have been identified as having needs, but that's 20 per cent of the 370,000—that's a huge number. Again, the question that we have on the financial aspects: is the Government in a position to ensure that the financial support for those individuals who are yet to be identified is available? Because 20 per cent—we're talking about 60,000, and that's a huge number.

Yes, indeed. As part of the integrated care fund, which we've committed to for the length of this Government—I think it was £60 million that we put in last year, and £50 million this year and £50 million the next year; we're committed to that—we've identified a tranche now specifically for carers. That's in line with the carers policy that we announced back in last—was that November?

In the autumn.

It was in the autumn last year—the carers policy, around those priorities, including, crucially, identification of carers, because we know that one of the challenges we face is that many carers do not self-identify as carers. What they say is, 'Well, yes, I'm looking after my child', or 'my mother'—in the case of young people who are looking after older people—'but I'm not a carer'. So, we're doing a lot of work, by the way, around the identification of carers, because we've got a feel for how big it is—the numbers you mentioned—but a lot of them don't identify. So, identifying carers and so on—.

Of that £50 million funding with ICF, a tranche of that—£3 million—is specifically for the support of carers and rolling out all the work we're doing around the policy and the three priorities within the policy. Those three priorities are: supporting life alongside caring, identifying and recognising carers, and providing information, advice and support. Those are the drivers now, and we've put, as I say, the £3 million alongside that, for it. I think you're right in that we're probably only scraping the surface at the moment in terms of getting to those carers. But it is interesting—those figures that you were talking about: just over 6,000 informal carers assessments and just short of 2,000 assessments leading to a formal support plan as a result. That's not inconsistent with the wider population assessments in terms of support packages. They don't all end up in formal support packages. Those are, sort of, the ballpark figures that we probably expect, once you've had an assessment done.

But we are likely to see an increase in carers over 60, as a consequence of this as well.

Yes, indeed.

As has been pointed out, carers are also becoming older and so there's going to be a huge impact on the older generation.

And, fiscally, one of the things we're going to have to look at going forward, not just with the ICF—but it's interesting how the ICF has morphed over the years. Originally, it was focused entirely on older people. We've morphed it because of some of our population needs assessments, which were part of the legislation that you took through. That population needs assessment showed new groups that we need to focus on—for example children with complex needs, adults with learning difficulties and so on. So, we've started to morph the ICF. One of the—is 'morph' a committee term? I don't know. 

It seems to be now, anyway. 

One of the changes, one of the modifications we've made—

It was Tony Hart, wasn't it?

It was, it was—is to actually identify carers as a specific group with identifiable funding as part of the ICF. If, as time goes by—. We've been quite clear that we are open to flexing the ICF funding to identify and meet the needs of particular groups there, but it shouldn't only be the ICF. This should also be the way in which the existing core funding that is out there with local government, health boards, education—because in terms of identifying carers and then providing support, some of this is how we respond in school settings or in college settings. So, there are ways in which we can lever in money to support carers that is not only ICF. There are a number of ways, and this is a proper cross-Government approach. 

That's important, because you've talked also of the preventative agenda—you've mentioned it, which is important—because you may find many carers don't need that support, they've been assessed and they don't need that support, or they may not even have been assessed so they don't think they need that support. But, as a consequence of something being a preventative agenda, we need to look at what we can put in place so that we can prevent a problem arising. There's been evidence to us that a carer may not have any extra surgery or operations because they didn't want to give up the time to actually lose their caring facility. That's the type of support that is preventative, which means that down the line we won't end up with more problems.

You're absolutely right, and similarly with mental health issues as well for carers—mental health and well-being. That's why part of the work we've done—. So, for example, with education, there's been funding for the development of a toolkit for schools to identify carers, because we know that otherwise you impact on not just the physical well-being but the mental health and well-being of young carers who often care for their parents or elderly relatives. We need to do more in terms of GPs, working with GPs in collaboration so that when you have somebody present to the GP with a medical condition, there should be a way of also, in a sensitive way, presenting to that potential carer, 'Look, if and when you need support, just to let you know, it is available.' And they might say, 'I'm not a carer', Chair. They might say, 'I'm not interested.' But, at least you're making them aware that there is support available, whether that is respite or whether it's more informal support in a network of carers. What we often face is that carers are not aware of what's available within an area for them. Albert, sorry, you wanted to come in.

Thank you, Minister. Just two very quick comments. One is I attended a carers group in Flintshire and they had co-produced their approach with the professionals. What was interesting was they'd transformed the way they were setting up the support and they were getting more and costing less. So, again, it's about looking at how, together, you get that voice in meeting the needs in a different way and a more responsive way. Sometimes, that isn't always about costing more, it's sometimes about being more effective, more efficient, and actually responding to the true needs of carers.

And then, alongside this, I think there's an opportunity for us as a Government in the production of the loneliness and isolation response to the challenge. I think some of that is around thinking creatively around intergenerational, the connections across different age populations, young people, carers, older people, and beginning to transform the way we set things up. So, coming forward and going forward, I think we should look at how we bridge some of those groups to support each other.

Can I look at the financial implications of one of your policies? That's the increase in the amount of money individuals can keep before charges come in. We've just gone up to £40,000, which is personally I think very supportive for individuals. But, there is a consequential cost, because a lot of them are now saying that the cost that would have been delivered by the individual has not been met elsewhere. So, they're not actually replacing that cost. As a consequence, we're finding that charges for those who are not supported, who are self-funding, have increased to subsidise, basically, the implications of your policy. What assessment are you making of the implications for the financial aspects of your policy on the sector, to ensure that there's no situation where a provider may find themselves in difficulty because they're now running short of costs?

There are a number of responses to that. One is, if you note in the statement I made in the Senedd yesterday, we talked about the work we're doing on market stability, which we're bringing forward because we recognise there are financial pressures not only on independent providers but on local authorities, on third sector and others generally across the whole piste of the care setting. So, I think our analysis on market stability, which includes increased reporting mechanisms through Care Inspectorate Wales—all of that will stand us in better stead as a mechanism for identifying where there are creaks in the system and how to anticipate them and respond. 

You mentioned what we've done there with the capital—the retention of costs that individuals can do and the capital threshold. As you rightly say, we had a manifesto commitment that we would take this up to £50,000 by the end of this term. We've already done two tranches of that, £30,000 last year and £40,000—but it hasn't been a loan, we've actually set aside some funding with that. So, when we did the first increase to £30,000 back in 2017-18, this was supported by recurrent funding of local authorities of around £4.5 million. It was based on estimates and modelling that we had done that that would be—. And it was independent research, by the way, underpinning that modelling that we commissioned on raising that capital threshold. Interestingly, in our evaluation of that first year of raising it to £30,000, we found out that around about 450 residents benefited across Wales. It was an additional spend incurred by authorities of just over £2 million. Now, that was a mid-year point, okay? So I anticipate it's going to be more than that; it's a mid-year point. Actually, that's quite a positive position, so we anticipate—. We put aside £4.5 million, and mid-year draw-down on that was around about £2 million. If you look at going ahead to the £40,000 limit that I announced in April, this is supported by an additional £7 million, and we will monitor that as well. But we are committed to taking it up to £50,000, so we're putting the money alongside this as well.

Now, there are other issues, I have to say, with the independent care sector, in terms of the strains on them. For example, things we can do differently in Wales: we can deal with issues such as things around living wage. So, we've committed to that but we've put £19 million into local authority budgets to enable them in their agreements with providers, both social enterprise providers and independent sectors, to actually manage that transition. We do expect as well though—and this is in agreement with independent providers and others—that they have a part to play as well in matching this. It isn't all going to be £19 million from central Government, who will provide all of it; this is an agreement that we do this together. There is a commitment to tackling the living wage, but we've put money into that.

We've dealt with, in things like domiciliary care, the issue of call clipping. So, when we took through the recent Regulation and Inspection of Social Care (Wales) Act 2016 regulations—the phase 2 regulations—we said we will end the process of where domiciliary care workers are paid only for the time that they actually see people face to face and they don't get paid for their journeys. We can do that in Wales, so we're doing it. But alongside that, we've actually put funds into assisting that process as well. So, we're not doing any of these and saying, 'You have to do it alone'; this is a collaborative approach with Welsh Government, but in the expectation—I have to say, David—that we not only improve the outcomes for individuals but we improve the outcomes for the workforce as well. We can do things differently in Wales.  

I missed one part of what you were saying. 

Can you just say what you're doing to ensure that the self-funded individuals are not basically being charged such a level of fee to subsidise those who are now funded by the authorities and that there's more parity across the picture? 

Yes. We are very aware of this, and occasionally I will get letters as a Minister—not too many, but I do get occasional letters on this. There is work that we're doing at the moment. We're not going to get into the business, by the way, of saying to local authorities, 'Here's the precise amount that you need to charge', because we recognise that actually there's quite a jigsaw pattern of provision of care across the country. There's a mix of independent social care, traditional in-house provision and so on, and that reflects differences locally and that will be reflected in different fee setting. And also, of course, there's a different picture in terms of those who self fund: what sort of provision people are looking for, what they're paying for in terms of that self-funding package. So, we're not going to step into the independent market and say, 'This is exactly what should be paid uniformly across Wales.' We recognise there will be variation—

I accept that, but are you assessing the different levels across Wales to ensure that there's fairness in the charge, both for self-funders and for authorities? Because, for example, take, in my constituency, Neath Port Talbot—it shouldn't necessarily be being charged higher rates, because of depravation areas and struggling, than, perhaps, Cardiff, which is far more affluent in one sense. Are you sure that these fees are fair and reasonably consistent?

Yes. We have an eye to this in the work that we are doing. So, whilst rigidly sticking, David, I have to say, with, 'It's not our job to interfere with private providers' in the open and transparent—and that's part of the Regulation and Inspection of Social Care (Wales) Act stuff that we've taken through—the open and transparent way that they inform potential residents of a care setting what they will need to pay and what they will get for that in a private care setting, in a purely self-funded arrangement, we do have a view to making sure, both in terms of local authority fee setting, but also independent sector or social enterprise, social value organisations, that there is more of a harmonisation of what happens across the piste across Wales. So, one thing that we are doing, without interfering in a draconian way, is working with the sector, with providers, to develop a toolkit to help, first of all, local authorities set fair and appropriate and transparent fees for residential care places. This doesn't mean that it will be the same everywhere, but it will be fair and appropriate to that setting, to that area and there will be more harmonisation around the fee setting. And this should also, by the way, because of the way that it's been done with the private and independent sector as well, help harmonise the fee levels—not only across authorities, but also the gap between publicly funded and privately funded placements. This is not the same as saying the Welsh Government is setting fees or telling local authorities or private providers what to charge. But, I think, in developing, very collaboratively, a toolkit that will say, 'This is the process that should be gone through, both in terms of liaison with local authorities, but also in terms of the liaison with a potential self-funder', that should lead to greater transparency and greater harmony around fee setting, both with self-funders and with local authorities.

Nick Ramsay, I think—. Did you want to come in, Nick? And then Jane.

I did, yes. It went back to the first question that David Rees asked. Good morning, Minister, by the way. And you answered part of it in terms of the current funding that's going in and you said that this is a groundbreaking piece of legislation—I don't doubt that it is a groundbreaking piece of legislation—but we've been here before with other pieces of legislation. I'm thinking back to the mental health Measure back in the last Assembly, I think it was.

What about the question of longer term funding? Okay, at the moment, you're juggling limited amounts but you know what the pressures are. But what if, in the future, the next few years' time, just beyond where you're thinking at the moment, things do get worse, constraints get tighter? Are you confident that when the pressure's really on, this legislation will still be able to deliver then? Because it's great to have good legislation, but if the funding isn't there in the future, then we know that there could be problems.

I'm going to split it into two things. One is what we can do within the current financial limits, and we've touched on some of those already. The other aspect is that longer-term issue. If, for example, it is perceived that there still isn't enough, frankly, money in the system, then how do we deal with that? There's a long history to this, as you know, both at a UK level and a Welsh Government level. It stretches way back into the late 1990s where the first inquiries looked at is it politically saleable—is it saleable to the public to look at other ways of levering money, for example, into social care specifically. Many of those initiatives have been dug into the dirt, frankly, sometimes in the politics of run-ups to elections and so on. But I'm glad say that now that we're in a position in Wales where we now have additional freedoms around tax and levies and so on, we have started the discussion. We have started the discussion around whether there should be alternative forms within Wales of levering additional money into the system. Now, there are big questions around that. As you know, Professor Gerry Holtham has brought forward a suggestion around a social care levy that would be, in his model, hypothecated towards social care. But then there would be questions around what part of social care: where would you get maximum leverage within the system? Would people be willing to pay for it? Could you get agreement from the UK Government that Wales should actually go down this line and experiment and do something different from England? But it is an acknowledgement—

It would raise interesting questions if they refused, wouldn't it, about the extent to which—

If we were to go down this line—. Mark Drakeford, the finance Secretary, has been working in detail on the fiscal elements of this. I've been tasked by the First Minister with chairing an inter-ministerial group on this, which will look at all these policy implications whilst aligning with the fiscal discussions that are going on as well. I think it is an opportunity to flesh out whether such a Wales-based scheme could be runner—whether we can get past the logistical hurdles. So, for example, if you did have a system that did lever in additional money somewhere within the health and social care paradigm within Wales—and I say that, by the way, because we're moving to a system on the back of the parliamentary review where we're going to be talking about 'health and social care' not 'health over there in that area and social care over here', both in policy, but also in terms of funding streams, I think, as well. But on that basis, if we did take this forward, can we overcome the logistical issues of providing a different approach to the care of people in Wales? What would that mean in terms of border issues? What would that mean in terms of UK Government?

We'd like to think that the UK Government would say, 'Actually, if you wanted to go ahead with this in Wales and if you can bottom out how to do this, we'd welcome it, because part of devolution is that laboratory of experiments.' Well, let us be the one. People often say that with the size of Wales we can do this stuff, but there are a number of hurdles we need to get through—not only the permissions to do this, in a sense, but also where it would have most effect. We must not use it as an excuse for not doing everything we can within the current constraints, which does mean that more joined-up thinking, that more collaborative way of working, the use of regional partnerships to joint-commission, pool budgets, look at needs of populations across a region rather than in one single local authority and one little part of it. We can do lots of that before we even get to this, but I think we are looking forward in Government to taking forward the work in the inter-ministerial group to look at all of these aspects going forward, but there is a way to go yet. First of all, we need to make sure we're making full use of the tools that we currently have, which are significant, I would say, in terms of what we've done with the legislative underpinning here. 

If you look, for example, Chair, in terms of bang for buck, in terms of fiscal responsibility, the progress that we've made, even over the last six months or seven months since I've come into post, the regional partnership board work has been significant. I've often described it as the 'get into the rubicon and cross it' moment for local authorities and health boards. There is a feeling now amongst many of the regional partnership boards that they have crossed that thing. They are openly saying to me, 'We think we can have bigger bang for our buck on, for example, commissioning of adult social care facilities, adult accommodation, by combining our resources', giving—to come back to that market stability thing—greater confidence to providers out there that there is a regional budget of significant strength that they can pin their planning on, going forward, that they can provide better outcomes to people, because you're planning across a spatial area: the needs of a local population, but across a bigger area as well.

So, those sorts of mechanisms, regardless of what we might do with Welsh taxation, a social care levy and so on, are there for us to use now to deal with the pressures, and we have to put some real impetus under that. I hope, by the way, that what comes out of the parliamentary review on health and social care, what will come forward shortly within the long-term plan for health and social care, will give us the real turbocharge behind that to drive that agenda forward, regardless of additional forms of money.

Jane, you wanted to come in on this.

I'm going right, right back now—[Inaudible.] I think, probably, you've had a letter from me recently, actually, Minister. The fee levels are still set by the local authorities. Obviously, they come to us, the independent providers concerned about difference in fee levels, when they are providing services, perhaps, to populations across two or three local authority areas. In my area, it's often Cardiff, the Vale and Bridgend. So, it's very welcome, and I have heard that there's a—. I'm just questioning about the toolkit because I do recall many, many moons ago when I was health and social services Minister that we developed a toolkit then—or a toolkit was developed. So, you worry about the fact that, sometimes—was it inadequate or are we learning lessons from the past 15, 18 years of devolution in terms of how we can get these things right? Because obviously it does have an impact on equity and clarity and fairness in the fee level system. You won't know this answer because you're very new to the job. Judith might or Albert.

No, I'm hoping Albert has a longer institutional memory than I do, but before Albert answers, one of the good things about the approach we are taking with this toolkit, which is still being developed by the way, is that it's being developed with the local authorities, with full engagement with providers and with health boards as well, and when it is finalised we will be recommending this across the piece and across the whole of Wales as the basis of it. But the fact that it's being developed by providers and local authorities right across Wales as well stands us in good stead. We're not going to get to the point, as I said in answer to David, that we're going to prescribe rates and so on. The fact that we have a set of processes and procedures that lead to a more harmonised way of doing it and setting of it should deal with some of the issues around equity of fee setting and so on, both at local authority level but also on self-funders. You've probably got a longer memory than me. Were you there at the previous—?

Well, I've been working in the social care sector for 30 years in Wales, so I've been a journeyman as well. The issue, I think, that is a difference this time round is that we are looking at setting a model, a toolkit—the language we're using—together with the providers, with the health and social care professionals, that commissions for quality. I think that's the biggest distinction I would draw. We've got to get into this field where we're delivering on quality and that's what the Regulation and Inspection of Social Care (Wales) Act 2016 and legislation is about. I think that the change over the last 15 to 18 years has been that there's been a tremendous approach on commissioning around price. Partly, I can understand that local authorities are having to look at the financial arrangements, but there is a real cost to that if we don't get the quality right. 

So, the model that's been set up and worked on and co-produced—the care home steering group is the lead; providers are around that table—it's not just health, social care and other agencies; they're around that table as well. There's a cost of care working group that's actually leading on this work. We've had workshops, and John Bolton, actually, has been in helping us to get this right using his experience and knowledge so that what we can set up is a template for local authorities and health and partners to be using in that approach, as I've mentioned, around commissioning for quality services and sustainability, so that people get the service that they need when they need it and in a way that responds in a completeness to their needs.

It may lead to a financial cost, which will—a light will shine on it, won't it?

Yes, indeed. 

Can we move on with Mike Hedges? Thanks.

I have a couple of questions on the finances. You've talked about additional money for social services on two or three occasions, but isn't that within the context of real-term cuts to local government budgets overall? All you've done is allocate money in a certain way, but the total sum has been reducing.

You might be taking me above my pay level now, but it may be helpful in going above my pay level to—. I would reiterate in a sense the information that's been supplied by the Cabinet Secretary for Finance as well, which rightly identifies the increase, both in terms of per head of population but also on aggregate, that we put into the social care element. But, Mike, I agree with you—there is a wider context here and it's set against where we are with austerity. There are tough choices being made about wider funding.

Local government is putting larger and larger proportions of its non-education money into social services, which, as everybody who's a representative will know, is hurting all other services within local government considerably. So, I think that's the context in which we need to look at it.

You talked about pooled budgets. I just have a cold shiver going down my spine when I think of what actually happened when primary and secondary care were joined together and secondary care was stripped of money by hospitals—

Primary care.

—when primary care was stripped of money by hospitals and money went into secondary care. I once said: we haven't got a national health service, we've got a national hospital service. So, isn't there a danger that, if you put money in for social care and health, the people in the hospitals will say, 'Oh, we've got more money now'? That's been the thing—that money hasn't moved into hospitals and that it's a matter of fact. Whether they should or they shouldn't have is a matter of debate, not a matter of fact—that every time money has been pooled, hospitals have won.

Right, a couple of things. One is: I think there's a wholly different approach to fiscal rectitude on our health service, generally, now being taken by my colleague Vaughan Gething, in terms—

Do you?

Yes, I do, and we're yet to see the full year's outcomes and so on, but I think the approach that is set, and excuse me if I put it in layperson's terms, is that, in terms of health spending, they need to live within budgets and do that, and Vaughan is holding very firmly to that.

The second point, however, is what we do with both existing funding and funding going forward. So, whether it's integrated care funding or whether its core funding, based through regional partnerships, whether it is, as we take forward the transformation we need in bringing health and social care together—. If, in line with the Social Services and Well-being (Wales) Act—and this is where fiscal elements hit onto policy elements—you focus on the outcomes, needs assessments of the population, area plans about how to resolve those issues, whether it's an ageing population, as this committee is currently looking at, or it's adults with learning difficulties, children in care or secure accommodation, and if you then say, 'There's your needs assessment', as a regional entity with the health boards and local authorities together, you focus on those outcomes and we will line up the funding accordingly to match that. So, it ceases to be a battle between local authorities and health boards.

I do get what you're saying, Mike, because this has been a huge transition. This helps us pool budgets but it's been a huge transition for regional partnership members of those boards to look at each other in the eye across tables, like we're doing today, and saying, 'Do we jointly own what we're trying to do?' They've gone at a different pace in different ways, but they're getting there. I go to people now, like the Gwent partnership who are, frankly, telling me, 'Minister, can we do more with this stuff?', because they're seeing it. We need to get to the point where it's not battles over what silo is funding in, where we do a job as the Welsh Government of introducing funding that's focused on outcomes, but also the people sitting around those tables in partnership saying, equally, 'Core funding: it should be focused on outcomes.' Let me give you a good example of thinking around this as well. We have 13 years' experience now of things like Flying Start. One of the four pillars of Flying Start are health outcomes. Going forward, as we look—in fact, we have a debate on this later on today. Going forward with models such as Flying Start, where is the wider joined-up thinking around how you fund more work on that that isn't purely to do with one budget over here, one budget over there, but is actually saying, 'Well, if it's speech and therapy, health impacts and so on'—? Sorry, I know we're going off the ageing population aspect, but it's the thrust of that.

Okay. Can I—?

Sorry, just before you ask, Mike, just to say we still have two or three questions that we need to ask you. We're running out of time. Are you okay for five or 10 minutes, just to deal with those?

Yes, I'm fine, Chair. That's fine.

You've been very fulsome in your replies, but there are two or three things that we still need to get to, so I'll come back to Mike.

The last point I want to make: I think the point you raised there about health—. Somebody at 85 with a bad knee: they have a knee replacement. A knee replacement operation works well, but the fact they're 85 and they spend two months in hospital, they're now incapable of going back home again and they become a social care need, where they could have, for the last five years of their life, gone on with painkillers et cetera with that bad knee. What you've done now is put them in a situation where you've had a successful hospital operation, the hospital gets a tick, but what you've actually done now is created somebody who was capable of looking after themselves at home, now into a social care setting. Pooled budgets don't solve that; pooled thinking solves that.

I agree entirely. Pooled budgets is only a means to an end, and it isn't a universal panacea, but it's one of the mechanisms. It is that integrated thinking and, actually, the stuff that we've done with ICF funding to focus on people not actually spending time in hospitals, but using teams of people that are joint health and social care to rapidly get them back closer to the community and into their own homes, and then using the sort of care and repair initiatives and so on, with the third sector, to make sure that the delivery of that package is rapid, because we know if somebody sits in a hospital bed, you are adding years to the deterioration for every day that they're in there. So, you're right, and that's exactly the thrust that we're at with this funding, and the funding needs to follow that approach to get people back to their homes quicker, faster, not have the more expensive repair cost by having somebody laying in a hospital bed or elsewhere for a longer time and deteriorating even further.

But I would say we're in a darn better position now in Wales to actually drive this forward, because as the parliamentary review pointed out, we're not starting from a blank sheet. They went around the country from north to south and said, 'We can see examples of where this is working—joint thinking, joint funding—now, how do we make that commonplace?' Vaughan Gething and my ask of the regional partnership boards is: if you can see what's working, make it commonplace. You don't necessarily need additional money to do that, to make it commonplace. And the next stage, I have to say, is taking that thinking and making it transformative across fiscal thinking and policy thinking, to take up the next stage of avoiding the situation where somebody is allowed to deteriorate in the wrong setting and the wrong place.

The operation works, but their life is made worse.

Yes, yes.

I think there's one question still from Nick and then I'll come back to Jane to see if she'd like to wrap up, if I may.

Do you think there is a need for fiscal reform of local government alongside your proposals for structural changes, and if so, what might it look like?

Fiscal reform of local government: that is not something that we are currently looking at ourselves. I think we are very much focused on, in line with the question that Mike Hedges had previously, lining up the focus of the available funding now on delivering the outcomes for individuals and population needs, and that joint approach to pulling the funding together, pulling the partners together, the joint thinking of it, rather than wholesale fiscal reform of local government.

I think what we've heard as a committee is some mention of a national funding system, for example, for social care. Is that—?

Albert, I don't know if—.

Certainly, at this juncture, committee, we haven't had a discussion around a national funding for social care. What we are currently doing is working with local government colleagues in terms of the annual revenue support grant.

So, your proposals pretty much fit in with the current structures that are there and don't need—

Yes.

Yes, okay. That's what I was getting at. Thank you.

Okay. I'll come to Jane, then—. Go on.

I think that discussion, if I'm right, has focused particularly on England, hasn't it, and I think some of the IFS work?

Yes. We've just had evidence about different funding models, and that's included a national approach.

I think that's partly why it throws us a little bit, because the context now, in Wales, is so different.

I just want to go back to—. You've already talked about Gerry Holtham's work and the fact that you're chairing this committee, this working group, inter-ministerial group. It would be helpful to know if that's started and what the outcomes are that you are seeking, but also to know whether you've had access yet to Gerry Holtham's additional work on his indicative economic analysis, because obviously that's going to be crucial in terms of looking at the way in which this could be taken forward—very much a long-term goal.

Thank you, Jane. Yes, I can give you an update on the inter-ministerial group that we are establishing. We've been doing a lot of work behind the scenes to set the terms of reference for that group to make sure that they are right, that they dovetail with the work that the finance Secretary is doing with Gerry Holtham, and internally as well, on bottoming out the economic models, the fiscal models, that would underpin it. So, there's work hand-in-hand. But it's setting the terms of reference around those issues we discussed earlier: if there were to be such a mechanism, can we bring the public with us? What would be acceptable to the public? I think that's a big issue around it. Is it more acceptable, for example, in the eyes of the public for it to be hypothecated or non-hypothecated? Or would something generalised within the Welsh tax system that is emerging be an appropriate way to do it instead? There is the Gerry Holtham model. There are other models that are now available to us under the Wales Act 2017.

So, we've set the terms of reference, or we're setting them at the moment—I don't think I've signed them off yet, but I know they're pretty firm already. We've considered that, on that inter-ministerial group, there are certain people who have to be there, and that would include the Cabinet Secretary for Finance; local government; housing probably as well, because of the issues of the ageing population and the need to dovetail this with housing provision as well; myself, clearly; but we're looking at what the membership should be—plus, of course, senior officials.

Our anticipation is that we will have one and possibly two meetings before the summer. It may be that the first meeting will be to actually agree and sign off those terms of reference and the work streams that will flow, and then the second one will be a more substantive one to actually really get into some of the detail of it. We will also look to be inviting Professor Holtham along to present his work so far. He hasn't fully bottomed out yet his work on the indicative economic analysis, but it's work that's in progress. By the time we meet as a firm full meeting before the summer recess it may well have gone further, we hope, than it has, so we can have that bottomed—

We hope so as well, because we want him in in July to talk to us.

All right, okay. We're thinking on the same timescales here. So, it is progressing. There's a real will, I have to say, across the Cabinet to look at this. Not to leap at this, but to actually explore this and to see whether, in light of Nick's earlier question, beyond what we can currently do and within the context of the constraints in which we operate, if there is something more that is palatable politically and logistically to the public. It has to be that as well. And that's the sort of policy work streams that we'll be taking forward on our inter-ministerial group, and how we will do it.

I mean, obviously, also, we need to go back and look at the work that Gwenda Thomas did, for example.

Yes.

We've been around this so many times in terms of how we pay for social care and, hopefully, that will not be lost in terms of the way forward. It's not either/or; it's probably moving on with more funds.

Yes.

Okay. Thank you very much then, Minister. I think we've covered everything we wanted to, but if we didn't, we will write to you, if we may, just to pick up any points that may have been omitted and of course you'll have a transcript just to check for veracity or any comments that have been picked up correctly. In which case, diolch yn fawr iawn i chi.

Diolch yn fawr.