National Assembly for Wales

Welcome, everyone, to this meeting of the Local Government and Housing Committee. The first item on the agenda today, as always, is introductions, apologies, substitutions and declarations of interest.

We've received an apology from Laura Anne Jones, a member of the committee, and Altaf Hussain is substituting for her. The meeting is being held in virtual format. Public items of the meeting are being broadcast live on Senedd.tv and a Record of Proceedings will be published as usual. The meeting is bilingual, and simultaneous translation is available. Are there any declarations of interest from committee members? Siân.

Diolch yn fawr, Siân.

Okay, item 2, then: the role of local authorities in supporting hospital discharges—a piece of work for this committee, and this is our first evidence session today. And I'm very pleased to welcome our two witnesses, Professor Jon Glasby and Professor John Bolton. Thank you both for coming in to give evidence to committee today. Would you like to just briefly introduce yourselves? First of all, perhaps, John Bolton. John.

Good morning, everyone. My name is John Bolton. I was a former director of social services in England. I ended up working in the Department of Health in England. And then, 15 years ago, I set up a consultancy, became a visiting professor at Oxford Brookes University, and one of the areas I've spent a lot of time looking at is hospital discharge, including major work in Wales, before the pandemic. I've done very little work in Wales since the pandemic. So, some of my evidence may be dated, but I think it's probably relevant for you.

Thank you very much, John. And Jon Glasby.

Shwmae and bore da. My name is Jon Glasby, I'm a professor of health and social care at the University of Birmingham, and a social worker by background, and I lead a UK-wide centre, called IMPACT, which is the UK centre for implementing evidence in adult social care. And we've been working around this topic in particular with colleagues in west Wales around improving older people's experience of being discharged from hospital.

Bore da, Jon, and diolch yn fawr. Okay, I will begin then with some initial questions around key issues and barriers before other committee members come in with further questions.

Firstly, could you give a brief overview of what you see as the main issues and contributors to hospital discharge delays, and your view as to why it seems to be such a long-standing and intractable problem? Who would like to begin? John Bolton. John.

Yes, I'm happy to start. Okay, well, what my work shows is that most, particularly older people, but actually most people, need a period of recovery, rehabilitation, whatever you want to call it, at the point of discharge. And if we can get that recovery right, we can support people in a way that helps them to recover from the loss of muscle tissue, the lack of confidence—general issues that are always there when people have been involved in either medical or surgical treatment in hospital. If we can get those services right, we can make a massive difference to the outcomes for older people when they leave hospital. 

And those services are a mixture of services. They're services that the NHS provide, community nursing in particular, a service often called 'rapid response', where nursing services are put around the person and the person is helped with the management of their medication and the management of their condition, their post-hospital experience, or it could be a more care-led service. So, it’s best when it’s therapy-led, so if you have a service that is often called domiciliary care, reablement recovery service, mostly run by local authorities, and if that is a therapy-led service with care workers supporting people under the guidance of therapists, we can get really good outcomes, improving older people at the point of discharge. So, that’s the kind of model that I’ve been advocating.

For a small minority of people, they might need bedded care. Again, there is very good evidence, very good research from Exeter University, which shows that if you have, again, the therapeutic input and the right nursing input, many people who get bedded care will make sufficient recovery to be able to go home, if they’re offered the right services. And what we’ve found across the United Kingdom—not peculiar to Wales or England or Scotland or Northern Ireland, but across the United Kingdom—we find there just isn’t the volume of those services that are required in order to meet the needs of older people in particular, but it could apply to other patients, when they’re discharged from hospital. So, everybody makes a small attempt at it. Some people get it wrong; some people provide the wrong services. We know, as there is very clear evidence, that where the right services are provided, we see very good results, very good outcomes for older people, and I think the problem is we just haven’t really invested in what we call intermediate care services. We just haven’t invested in those services; we haven’t given them priority, and those services require the NHS and local government to fully collaborate. It really only works when you’ve got both systems totally working together, joint teams, pulling people together.

When we did our big study in Wales in 2018-19, we did see, in Bridgend, for example, a very good example of early stages of that kind of service developing. So, we’ve seen it in Wales. We saw some good stuff in other parts of Wales, Wrexham, for example. I don’t know whether they sustained and kept those improvements, but they were starting in that period.

Thank you very much, Professor Bolton. Professor Glasby.

Diolch, yes. So, this is a long-standing and intractable problem, and it goes right back to the beginning of the NHS, or indeed even before the NHS, and it’s a problem in all major health systems, not just in the UK, and I think, really briefly, there are five reasons for that.

First of all, when it comes to leaving hospital, for some people, there are competing notions of good practice. So, we have an acute hospital model, which is basically around volume and throughput, trying to get as many people as possible in, treating them, getting them well again, and then getting them out, so that we can get new people in who need the services even more. It’s a throughput model versus a social care in the community model, which is based around empowerment, about choice and control, about making long-term decisions that will affect the rest of your life, potentially. And at the point of discharge, there are competing policy and practice priorities, and there are two notions of good practice, neither of which are wrong, they're just kind of incompatible with each other and constantly bounce off each other, a sort of throughput versus an empowerment model.

Secondly, we often focus on hospitals, and we have quite a hospital-centric approach, and we tend to see success as freeing up beds. That’s really important, particularly when services are under pressure, but it leads to a different approach than if you ask, ‘Well, how do we keep people healthy and well in their homes and their communities, and how do we help people get back there and to be the best that they can be if they do have to have a brief spell in hospital?’ It’s a different kind of question and a different kind of notion of what success would look like. And focusing on hospitals too, I think, also leads to it being seen as a discharge where the hospital is discharging somebody and then its responsibility ends, rather than it being an ongoing transfer where everybody has a role to play, as John was describing.

Third, I think because of the pressure on services, we tend to focus on discharge, and maybe we don’t focus enough on the risks of premature discharge or poorly co-ordinated discharge, on tackling some of the relatively short-term delays within hospital. And we focus less on admission avoidance in the first place, more on getting people out the other side than we do on stopping people going in in the first place.

Fourth, particularly at the moment, there are just major issues of capacity, so even minor delays in some of our processes can cause some of our systems to break down and to back up. A head of operations in a hospital described it to me as being a bit like a motorway on a bank holiday, when there's too much traffic on the motorway, and you just need a bit of debris or roadwork, or even just people coming on and off at a junction, and the whole thing grinds to a halt for no reason that you can quite put your finger on if you're in the car. And then, suddenly, after you've been waiting for a bit, it just starts up again, again for no reason, and there's just too much capacity trying to use too little service. So, it can go awry really quickly.

And then, finally, as John was suggesting, I think a lot of our responses have often been quite short term, quite small, and they've been pilots. They've never been sustained for long enough, typically, and they've never been big enough and strategic enough to rebalance the system as a whole. So, they've always been in addition to how the system always worked, rather than something that helps to more fundamentally reshape it.

Okay, Professor Glasby, thank you very much. Just a couple of further questions from me in terms of whether you might expand a little on what you've told us already. The role of local authorities, for example, in addition to what you've already said, would you add anything in terms of the particular roles and responsibilities of local authorities in that discharge process, what they might do differently, really, to overcome some of those issues that you've identified?

They've definitely got a really important role to play as part of a whole-system response, but there is, I'd argue, a risk of distorting local authority and social care priorities, if we just focus on discharge from hospital. The risk is that we then focus on the bits of social care that touch the NHS and that touch hospitals. So, we often focus on older people and on care homes, for example, when social care is much broader than that. About half the budget gets spent on people of working age, for example. I saw one survey where I think 80 per cent of NHS leaders saw adult social care capacity as having the biggest impact on urgent care, when, actually, at about that time, I think four in five requests for social care support came from the community, not from hospitals. So, discharge is really, really important, but it shouldn't distort broader local authority and social care priorities.

As John said, I think we need a more strategic approach to working together that helps to keep people healthy and well at home and to recover after hospital, and that needs to start with the work that local authorities do in communities around the kinds of lives that people want to lead together, and about how we best organise some of those services to deliver those lives and to support those lives, rather than a debate about how can we free up beds. I think the most progress that I saw around this agenda was probably in the 2000s, when there was a much more strategic approach to and investment in whole-system intermediate care services, both before and after hospital. And, indeed, there was very significant practice support for health and social care communities to help them learn from each other and to do something differently in response. Policy agendas have sometimes, when we're under pressure, got quite punitive, where you identify a particular partner as being the problem, rather than policy responses that are geared up towards support and building collaboration. So, in England, we had an initiative called the change agent team, for example, who worked all over the country to provide practical and peer-led support in the realities of the workplace—a model that my own centre, IMPACT, does very much now, all these years later.

So, I think those are some of the things I'd say about the role of local authorities: crucial, but not at the risk of distorting social care priorities, and then a key partner in supporting people to lead the kinds of lives they want to lead in the communities and the homes that they come from, and then a key partner in that broader and more strategic whole-system approach to intermediate care, albeit with an agenda that maybe has lost its way a little bit over the years, in the way that John was describing.

Okay, thanks very much. I see Lee Waters indicating. Lee.

Thanks. Can I just go back to your previous answer, when you said that there'd been too much of an emphasis on pilot projects that then hadn't been scaled and hard-wired into the system? This diffusion of innovation is always the tricky bit, isn't it, the spread-and-scale approach. Are there examples that you can point to of where that has been done successfully? Because there doesn't seem to be any shortage of good practice, what seems to be the difficulty is then making that the norm, and it's hard. But are there any ways that we could, maybe, recommend, of how to do that successfully?

So, I've tended not to see many, if I'm honest. I've seen health and social care communities that come together, that do well for a period of time and then something happens, either in the local relationships or the local leadership, or sometimes, because our health and social care policy at a national level can be quite divided, something will happen in one of those sectors that will have the unintended consequence of pulling further apart that local relationship.

So, we were really involved, for the University of Birmingham, working with partners in Torfaen early on, when they were developing what became the forerunner of intermediate care in that area, and I think in a number of different parts of Wales from that model. And the progress was really, really impressive, but what I don't know is the extent to which that was mainstreamed or maintained as the policy context changed.

With my own centre, IMPACT, which tries to do something similar in adult social care now, we've found that a twofold approach is the most effective: that local support and the realities of the workplace to help people do something different in response to the problems that they face, or the opportunities that they have, and to work out what is and isn't making a difference, coupled with what we at IMPACT call national embedding, where we have a very strong relationship with policy makers, regulators, workforce bodies and others, in each of the four nations of the UK, to try and scale innovation, not just by telling people about it, or encouraging them to follow suit, but by trying to find ways of getting it built in to how adult social care gets done through the way it's regulated, or the way that future professionals are trained and educated, or what have you. So, I think you probably need a combination of that local innovation and practical support with that linked commitment to national embedding, to scaling innovation by making it how adult social care gets done, rather than it being something that you try and spread by telling and encouraging people around, or solely by telling and encouraging. But I haven't seen anywhere crack it, if I'm honest. I don't know if John would have a different answer.

Yes. I've seen places do much better in England, as I indicated. We saw very good signs in Wales five years ago and I just don't know how those have developed—Bridgend, Wrexham and Conwy immediately come to mind as places that were starting that journey. I know that you're now working, Jon, with people in west Wales, in Pembrokeshire and Carmarthenshire, et cetera.

So, I suppose I would just—. My more recent experience in Wales was very disappointing, because there was a system where there was a clear problem; there was support from central Government, from the Senedd, to support the challenges, but I felt that the NHS and the local authority just weren't talking the same language, weren't thinking together, and almost, each wanted the other to take responsibility and they didn't want to take it for themselves. It felt very sad, because I don't think it's a policy weakness, in the sense that, from what I've read and seen, the policy direction seems to be good in Wales. But it's just the implementation of that.

I assume it's the pressures of business. Jon Glasby described earlier that the pressures on both systems are huge and that hasn't enabled them to come together and find their joint solutions. And I suspect alongside that was a lack of identifying how intermediate care would work in that area. For example, there was very little evidence of NHS investment in that community nursing I talked about. There was some evidence of investment in both bedded care and homecare from the local authority. But it probably also needed someone to bang their heads together. I like Jon's reference back to those change agents, because they can make a difference. Sometimes it needs someone just to sit with the local leaders and say, 'Come on guys, let's get this together.'

Do you think that's a leadership gap? Do you think it's an absence of incentives? What might we do at a system level to try to nurture that?

It almost needs to be a stronger diktat than you have already, I think I would say. I don't want to ignore the enormous pressures that both the NHS and local government currently are experiencing. I don't have to repeat them; we all know and understand their great pressures. Of course, when people are working under pressure, what are their priorities? What are they going to give the greatest time and resource to? That's a challenge, and I suppose because I've been working in this field, I think this deserves some priority.

But I also am aware, as Professor Glasby said earlier, there are very big competing priorities for these systems, so I recognise that it's hard. I would want to continue to push that, actually, getting the right kind of intermediate care framework—that seems to me to be the solution. In the places that I see, mostly in England, that have done that well, you can see the reduction in delays, the better flow of patients, the reduction of people going from hospital to residential care and the better support they get at home. You see massive differences in those systems that get this to work, and it only works, in my book, when you've got the therapists, the care workers and the nurses working collaboratively in the community.

Okay, let me just—. I'll bring in Professor Glasby and then we'll go to Altaf and Siân. Professor Glasby.

Yes, I agree entirely with John. You may find that this is quite a boring interview, because I tend to agree with John. Just to illustrate those pressures, though, when I was training as a social worker, my first ever case that I was given as a student was an older person who, unbeknownst to us, had been admitted to hospital. And then, when we finally managed to track them down, they were ready to leave, and the ward said, 'This person can come home today. Can you get her home?' I needed more time than that in order to try to support the person home, and the hospital got quite cross about it. I knew that it was really, really important to support that person home. I knew that hospital was the wrong place for that person to be. I knew that it's disorientating. I knew that there's a risk of a decline in your functional independence and that there's a risk of hospital-acquired infection. And yet, hand on heart, the stuff that kept me awake was the 19 other people in my case load, all of whom were frail, older people with dementia living alone. I was really worried that one of them would die. 

Now, I knew this twentieth person was also really important, but I was trying to balance that alongside the other 19, who, in one sense, I felt, needed me a little bit more that given day. That was—I was going to say 20 years ago, but it was probably 30 years ago, actually, now I think about it. But I do think that those kinds of pressures are just really real in people's minds as they're trying to juggle these kinds of things.

The corresponding issue that you sometimes see in hospital, I suspect, is a psychological one, where if you're a busy matron running a busy ward, and it's full of really sick, really frail people, and there's somebody who's nearly ready to go home, you'll try to do everything you can to support them home there and then that day. But, actually, they're relatively well, compared to everybody else on the ward. You know, deep down, that if you get them home, we'll just fill that bed with somebody who's even sicker and even frailer, and will need you even more. So, you're still trying to pull out all of the stops to get them home, but you know, in your heart of hearts, that if you bust a gut to get them home, it'll just increase the workload.

So, I think there are these practical, human pressures, as well as the sorts of system pressures that play out. And then such is the difficulty of inter-agency working at local level, that it's very easy, as John said, to ask the other person to step up or to see the fault as being the fault of the other person, rather than it being a collective responsibility.

Okay, Professor Glasby, thank you very much. Altaf Hussain.

There's just a quick point I want to make. Great to hear you both, professors. There is no balance between health and social care, and I’ll include mental health as well in that. The equilibrium is not maintained at present. That is what the Government doesn’t understand—that equilibrium between social care, healthcare, mental health care. So, we are ourselves creating that unbalance between these three care services. Social care is important, especially for elderly people, and intermediate care, whilst they get it—. My question is: do you think we should be saying that we should have less care towards the end of life, or it has to be more? People don’t understand that. I think the NHS is struggling, when we know that good health is the cornerstone of our society. I think there is a problem. They are not understanding, they’re not investing the same, as you said, in our social health, which is important. To remove that imbalance, we need to have equal sides of all these things. You could call it, as the Welsh Local Government Association has said, the 'health triangle'. Thank you.

Okay. I don't know whether either professor would want to make a brief response, or shall we move on to Siân Gwenllian? Siân.

Shall I respond?

Yes, please. Yes.

I don’t think it’s changed particularly. There are some really good examples of where it works well and there are examples of where it doesn’t work well. I was almost going to make a slightly different point. One of the pieces of work I’ve been looking at over the last two or three years, mostly in England, I hasten to add, has been: what is the patient experience in the acute hospital and to what extent does what happens in the acute hospital prepare or not prepare the patient for leaving the hospital? I was partly influenced in this when I read a Spanish study of the hospitals in Barcelona, which showed that if they got patients mobilised while they were still on the ward, before they were discharged, they had much lower levels of need at the point of discharge, and therefore it was much smoother making those arrangements. So, there’s a kind of thing about the way—. And I agree with what the Member’s said about it’s the person. How do we see the person? Do we see the person as being a patient who is in hospital and then out of hospital, or is the person going through a journey, and that journey is happening whilst they're in hospital, where we need to be ensuring they're not—? A loss of muscle tissue, their loss of confidence—all those things are being addressed, and their need for recovery post their medical interventions. They're all part of what happens in hospital, a part of what happens in intermediate care and part of what happens in the continuation of the quality of their lives.

I think I wanted to make the point that the patient, the person's experience in hospital, is very vital to this, and we've found in hospitals—and I've been working with some geriatricians in England on this—that, actually, if we could begin to introduce—. We started introducing breakfast bars into acute hospitals, so older people were mobilising themselves, getting themselves out of bed, beginning the process of getting used to doing things well before discharge was being discussed, so that the normalisation of the activity of daily living actually wasn't stopped for two, three weeks when they were in hospital, but actually starts before the discharge. I think that's another way that people are beginning to see this. They're beginning to see, yes, this is a continuation of a person's life, not a series of episodes of acute hospital, nursing care, social care. It has to be seen holistically.

Okay, thank you. Jon.

Yes, I'd agree, and the evidence that we submitted in writing was a small guide that our Ask IMPACT team had produced around what the evidence says about what really matters to older people and families during the discharge process, which is so fundamental to the outcome and to their experience, but can often get overlooked by the system, particularly when it's under pressure.

My favourite article on this was a small piece in the trade press in the 1990s based on a project in Age Concern Fife in Scotland, where they'd got a group of frail older people together who'd all had experiences of being in hospital recently to write a good-practice guide around hospital discharge. They came up with a 10 or a 12-point plan, and there were two things that were fascinating about it. One is it was identical to anything that the researchers ever said about hospital discharge since we started to research this in the 1960s—you could boil it down into this 10-point plan. And then, secondly, it was so common sense that you just couldn't argue with it. If it's the middle of winter, it's freezing cold and it's late at night when I'm being discharged, could someone have come in in advance to turn the lights and the heating on and to make sure that there's some food in the house before I'm discharged home? It's quite hard to argue with that kind of logic when you approach it from the expertise and the point of view of the person and the family.

The point about staff is we have a separate health and social care system that assumes it's possible to distinguish between people who are sick, who we label as having healthcare needs met largely free at the point of delivery and funded nationally, from the needs of people who are somehow merely frail or disabled, and they're labelled as having social care needs—they're the responsibility of local government; it's organised locally and people are means-tested and contribute towards the cost of their care. I'm not sure that that distinction between health and social care has ever really made sense, but increasingly it feels unfit for purpose in terms of the number of people with multiple long-term conditions.

And then rising out of that distinction we've got different legal frameworks, different organisational systems, different budgets, different IT systems, different cultures and ways of training and educating practitioners and leaders and so on. Staff and leaders move heaven and earth on a day-to-day basis to try and find ways of joining that up in a way that works as best as it can for people and families, but there are so many disincentives and so many barriers. There's a very famous article called, 'Five laws for integrating medical and social services', one of which is that you can't integrate a square peg into a round hole. And a bit like I said at the start, for me, coming out of hospital when you've got ongoing needs is just the classic, classic example of all of us trying to find ways of integrating a square peg into a round hole. That's just the nature of the problem that we have to solve together.

Okay. Thank you very much, Professor Glasby. I'll bring you in, Peter, but just to say—I should have said earlier—if Members wish to speak, could they raise their hand physically, please, rather than use the virtual raised hand? Peter, yes, please.

Thank you, Chair. It's a really fascinating conversation, and as a past council leader, I can see some of the issues here. Unless we can get those fundamentals right of leadership and co-working, things aren't going to get better. Is there a strong case for us to be quite radical in saying, ‘Look, enough is enough. We do need social care and health together’? And obviously, that means social care moving to health, and then that entity commissioning certain things like domiciliary care through councils or whatever. Or is there some sort of hybrid that will work better?

Another question, even though I never thought I'd be saying this: is this misalignment between health board regions and several councils—? My own health board has five councils and has to interact with different systems. Whilst I've been an advocate for retaining the authorities we've got at the moment, is that causing an additional complexity for health boards that is making it even more difficult for them to have a joined-up approach? I'm playing devil’s advocate a bit, but sometimes we might need radical solutions, we might need a rethink. I just wonder what views there might be on that. Lee is smiling there, because he knows it would have been difficult for me to say that.

It's very interesting in Wales, for me. In Wales, you've had in different stages of your history some really good partnerships. I remember the Gwent frailty partnership, where five local authorities in the south-east of the country were working together, trying to tackle frailty in older people, and working with the health board in partnership to do that. I remember in the north a collaborative that, because of the borders of the health board, again was bringing the local authorities together to work collaboratively with the health board. So it has worked, but I think, as Professor Glasby said earlier, these things tend to be, I'm not saying short term, but in terms of history, they're relatively short term. Even if they're 10 years, that's short term. But they don't survive, because they're based on individuals, on people, and how they work.

I'm not somebody who's argued that bringing health and social care together as big entities is the solution. In the field of intermediate care, I can see that is best done when people collaborate. There are models I see really working well in England. For example, in one place, the community health staff, the therapists, the social workers, the linked care workers, they're all co-located, they just work out of the same office. They see each other every day, they work in partnership, they share patients, they share people, they work together to get the right outcome for those people. It doesn't need a structure to enable that to happen. There is a structure, there's a governance structure over that, but that's not what determines the good practice. It's the way people are co-located.

In fact, when Professor Glasby was talking about his early days in social work, I remember my early days in social work, and we were in the same office as the district nurses. I would spend time and just knock on the door, ‘I'm visiting so and so today, does anybody know so and so? How do we help them? What's the best thing we could do together to sort them out?’ It was just friendship, collaboration, partnership. So I don't think we need structural solutions, and you have examples in Wales in periods of time when it's worked quite well; it has just not been sustained. So it is something about how do you put the incentives to sustain those partnerships when they grow and develop.

I agree. I think it's a question of both/and rather than either/or. With my policy hat on, if I was starting with more of a blank sheet of paper, I would have a more integrated system. And indeed, my personal preference, which will probably mean that I'm never invited back, would be to have integrated health and social care commissioning, but to integrate that into local government structures, so that those are based within locally, democratically controlled services. That's possibly not a very popular view, but that would be my personal take on those issues.

However, structural reorganisation often makes things worse rather than better for a considerable period of time—it becomes an end in itself rather than a means to an end. And the danger is that the policy context shifts so rapidly, by the time you've got through the reorganisation, the policy context has then moved on somewhere else, and you're onto the next one. So, you're in this stage of permanent revolution, as it were.

The frail older person who's in hospital today, who needs to come out and be supported, can't wait for us to more formally integrate health and social care—they need support now. And that's the stuff that John was saying about services before and after hospital—about intermediate care, about therapy-led approaches, about rapid-response nursing, about co-location, about more strategic investment, and so on.

I think both those viewpoints are really fundamental, but they're slightly different. One is a longer term debate about the future of the best way of organising our work together; the other is how do we better support older people to come out of hospital in the here and now. And both those questions are really important at the same time.

Thank you, both. Altaf Hussain. Altaf, just raise your hand if you want to come in, rather than using the virtual symbol.

Thank you very much. Just a quick point. I started as an orthopaedic surgeon, and I was a consultant, in the 1960s, 1970s, 1980s, 1990s and 2000s—up to 2010. What is happening at present, I have never seen this. We would operate on the patient, and soon, in the post-op treatment, I would start asking them to move their limbs, so we would never see the wasting of the muscles—No. 1. No. 2: every time a patient would come to hospital, he would be admitted under a consultant head, and it would be that consultant who would be discharging him. In my lifetime, I have received only one phone call during night-time, when the staff wanted to discharge a patient—they had no bed. I had to put my foot down: 'No, it cannot be done unless I see the patient'. Now, it has consequences; I would see them myself in the follow-up treatment. So, that is not happening—it has been taken over by the managers, who were introduced to help clinicians to deliver the NHS, not otherwise. So, I don't know—I think it is going wrong. We have to work together to help it, otherwise there will be no NHS.

Does either professor want to respond on that point? No, not really. We'll let that stand, then. Siân, did you want to cover anything further in terms of intermediate care?

I've written quite a lot about this—so, read the papers. But the simple answer to the question is you need community-based services that are nurse led and therapy led, and both are focusing on helping the patient recover from whatever the trauma, whatever the set of incidents that both led to their admission and happened during their admission.

You need care workers who are working with the patient, with the therapists, and who are encouraging them to regain skills, to maximise their potential for independence. That's the jargon that we tend to use. But it's how do you help someone to recover from that series of episodes. That is a combination of nursing and therapists. And that's in the community. People recover best in the community; people recover best in their own homes. Most people want to be in their own homes. 

However, there are always some people who, at the point of discharge, aren't quite ready to go home, for various reasons, usually medical reasons. And we need, again, specific beds. You see different models. The common model is either a community hospital—you have them, of course, in Wales—or it's the wing of a residential care home, where there are dedicated staff, again with therapists and nursing support, and the focus is on helping people to get back on their feet so that they can go home.

There is a very good study by the University of Exeter that shows how those bedded services could be run and should be run. The University of Exeter study says that two thirds of people who need bedded care at the point of discharge won't need that care if you give them the right help during those intervening periods. However, what we found when we did that big study in Wales that I referred to in my submission—'Right Sizing Community Services'—we found, and I use this word advisedly, people being dumped out of acute hospitals into care homes, just to get them into a bed, where the bed had no facility to help the patient recover. And what happened was that the patient was then stuck and remained in the care home.

So, if you don't get the right level of therapy and support for people—therapists, nurses, working in partnership—to help people get home, you'll just end up putting more and more people unnecessarily, too early, inappropriately into a care home. And that's what happens. And certainly we saw lots of that happening in Wales when we did that big study. That was our challenge to the systems: how are you going to change that? We asked them both to strengthen their community offer so that more people could go home, and we asked them to strengthen the kind of bedded provision that they have so that there was a recovery programme for people, so that those two thirds could go home.

I will end by saying that, of course, there are always people who will then need residential care. It's about a third of that population. Getting that right is, for me, the basics of what this intermediate care needs to look like. 

Are we clear enough—

I'll bring Professor Glasby in, Siân, and then come back to you, if that's okay. 

Diolch. I think that this is really important. Most people, as John said at the start, need time to recover and to be the best that they can be before they should be assessed as to what might happen in the long term, ideally in their own homes. And nobody, in my view, should be assessed in hospital for a permanent move to a residential bed without an opportunity to try another way of doing things first.

I agree entirely with John, there's something really important about these being therapy and reablement focused and led, and often they're seen as a cheaper form of care and the model gets watered down, whilst for me it's one where you need to invest to save. There needs to be sufficient capacity, and it needs to be sufficiently well organised to actually affect the overall balance of services, otherwise it doesn't have the impact that you want it to have. And, indeed, hospital-based clinicians try to refer through to individual pilot projects and find that they don't quite meet the criteria and they don't refer a second person through; it falls down. 

I think it's really important that these services are inclusive of people with dementia as well. A lot of the early pilots would say, 'Oh, this is only for people with physical health problems, it doesn't really work for people with dementia.' And that would just rule out whole swathes of people for whom this is the most important. And then you also need that capacity in the broader system afterwards. Otherwise, when services are under pressure, there's a danger that the bedded element that John referred to can get just as blocked, if you like, as the hospital services that we were trying to free up because there's still nowhere for people to go after that period of rehabilitation. 

A long time ago, the former Audit Commission looked at this, and it coined the phrased, 'a vicious cycle'. They argued that resources are really, really tight, and when older people are in hospital, too many people come out and go straight into permanent residential beds and there's insufficient money being spent on preventing people coming into hospital in the first place and recovering after hospital. And then the more people who come out and go into permanent residential beds, the less money is available for prevention and rehabilitation, so you go round and round this vicious cycle. They argued, all those years ago, that you need to strategically and collaboratively invest in prevention and in recovery and rehabilitation as a way of breaking out of this vicious cycle, and that was 20 years plus ago, but I still think that diagnosis is right to this day.

Thank you very much. Siân.

Any views on that?

I think that's a very valid point. Obviously, the answer is it has to be the collective system, but what is the collective system? And I agree—I think governments have to define that in terms of what they want and how they want their system. Your system is unique, as you've designed it in Wales. Your health boards have a really important role to play in this, but it needs to work with the local authorities. I think that's a challenge for the Welsh Government to determine.

Okay. Let me just bring in Altaf. Altaf Hussain.

Well, it is very important and, as I said earlier, the patient is not discharged unless they're discharged by the consultant under whom they're being treated, whether that is to the intermediate service. I know that we used to have Mountain Ash hospital, we used to have Aberdare hospital, we used to have smaller hospitals, rehab hospitals, and I would go there and I would discharge the patients from there once they were fit enough to be discharged. Now, with regard to dementia, here is the problem: the problem is that dementia is progressive. Now, a dementia person cannot go from an intermediate setting to a home setting; you need to have a better place for that person. So, we're not thinking of that. We have to think of that. And, again, the consultants who are treating them, we don't see them now. It's their responsibility. That is what is important. Otherwise, we'll be paying billions, really, towards litigations every time, and still we would not know who is in charge of that patient because everybody is there.

Okay. I don't know whether either Professor wants to respond to those points. No, perhaps not. Lee, did you want to come in on anything in the time that we have left?

I think we've covered—. I wanted just to try and nail down some sharp thoughts on what you thought the Welsh Government should do at a strategic level and what we should do at a community level. I think we've covered a lot of it in the discussion, but if there are any additional thoughts you had to help us crystallise what we might recommend to change, that would be very useful.

So, I think, for me—. Sorry. After you, John. I beg your pardon.

No, carry on, Jon. You carry on.

So, I think, for me, nobody should be assessed for a permanent care home bed while in hospital, and I think that kind of statement is really important. As I said at the start, I think governments often focus on freeing up beds, and actually asking the question in a broader way about how we support people to live the kinds of lives they want to lead in the community is a better way into that question. When systems are under pressure, there's often a sticking-plaster solution to the funding. So, in England, a small pot will appear to tide you through the winter, and the danger is it's too small, it comes too late in the day to be spent well, and it tends to make things worse rather than better. So, there's something about the lead-in time and the funding to be able to plan those kinds of investments well and jointly. That needs to be done together as well. So, again, in England, I've seen situations where the NHS may receive some money, and it might purchase some beds in a care home wing to try and move people out of hospital, and sometimes it will do it unilaterally without working with its local authority partner. And I've seen examples where people have been placed in a care home that the local authority thinks isn't good enough and wants to close, and we place people from hospital into that care home. And, actually, we've enabled that care home to carry on operating because of the investment that's come from the NHS. So, when we don't join up those commissioning intentions, there can be all kinds of unintended consequences.

I think there's something about good practice and capability development for strategic commissioning arrangements, particularly around intermediate care. There's something about the national data and performance framework to help us better identify good practice and areas for improvement. And I also wonder, just as an aside, and I touched upon this just briefly, whether there's scope for a more comprehensive strategy about living well with dementia as well, which would touch on some of these issues, but be much broader than that.

Perhaps finally, allied to some of that is practical support, like the old change agent team in England, or the work that IMPACT does now, which feels even more important, actually, when systems are so under pressure that it's really hard to create the time and the head space to be able to build the relationships and do the sorts of things that might actually make a difference.

Thank you very much, Professor Glasby. Professor Bolton.

I think Professor Glasby's put that really well. I will make the point about dementia care, only partly to repeat what my colleague has said. I find, generally, it's a kind of cinderella service. It's not well developed. It's particularly not well developed in the community and, slightly contrary to what the Member said, there is evidence that, actually, people, certainly in the early stages of dementia and more moderate dementias, are best placed in their own homes. But they need levels of support to manage that, particularly also if there are carers around—they'll need support to manage that.

We can use technology really well these days. I helped to manage my own father-in-law with dementia remain at home by using technology, among other things—family members and care support going in. And, actually, when we did this study in Wales, again, both Wrexham and Bridgend, I remember, had community-based dementia specialist services trying to support people, where everywhere else were trying to support people with dementias through their general services, and my view was that wasn't working. So, we need to avoid, necessarily—. Of course, there are people who will need a more care home environment type of support, but there is a significant number of people with dementias who can be supported at home if we've, again, commissioned the right level of support, and that applies to hospital discharge. I think if you go to a place like Leeds in England, you'll see some very good intermediate care for patients with dementia, and they have a very good record of getting people from hospital, back through their intermediate service and back to their own homes where they can be safely looked after. So, I just want to re-emphasise that.

There was an audit done in Wales of who were the long stayers in hospital, who were the people who were actually taking lots and lots of bed time, and I think I'm right in saying that 99 per cent of the long stayers in the hospitals in Wales at the time—I think this was about 2017—had a dementia. And I doubt that's changed today. Certainly, I find the same in looking in England, Scotland, Northern Ireland, the Republic of Ireland—all the places I've been to and looked at this, you see that that is a challenge. So, actually, if there was a simple thing we could do that would make a big difference, getting dementia care right would actually be a big gain because of the number of excess days in hospital for dementia patients, mainly because people don't know what to do with them because the services aren't there.

Okay. Thank you, both, very much indeed. That's all we have time for, I'm afraid. If, either professor, you wanted to write to the committee with any further points, please feel free to do so, and it's possible we might come back to you with some further questions.

John, could I make a small point? 

Altaf.

A very small point. Obviously, I’m grateful for your thoughts, really, and what you said. We used to have psychogeriatric wards and, in those days, dementia was not that much diagnosed—you know about that—and we had nothing like Alzheimer's services. But we had those wards, and they were being looked after by the elderly care consultants. They have gone, you see, and that used to be good care, although, at that time, we didn’t know that those patients used to have dementia. But they were there, looked after by the consultant in charge and the nursing staff, and the social services.

Okay. We’ll leave it there, I think, because we haven’t got any further time, I’m afraid. But, Professor Bolton, Professor Glasby, thank you very much for coming in to give evidence to the committee today. It’s much appreciated that we’re able to draw on your expertise and experience as we have. So, thank you very much. You will be sent a transcript to check for factual accuracy. Diolch yn fawr.

Diolch yn fawr. 

Thank you. Diolch. Okay, the committee will break briefly until 10:25. 

Okay. Welcome, everyone, to our second evidence session today on the role of local authorities in supporting hospital discharges. Firstly, a couple of apologies. I should have said earlier that Lesley Griffiths, one of our committee members, is unable to make the meeting today, and, in terms of this evidence session, Councillor Mary Ann Brocklesby, leader of Monmouthshire County Council, was due to give evidence but isn't now able to do so. Okay. We do, though, have several witnesses here to give evidence to committee today. Perhaps I could ask you to introduce yourselves, starting with Councillor Charlie McCoubrey.

Bore da, bawb. Charlie McCoubrey, leader of Conwy County Borough Council and Welsh Local Government Association spokesperson for health and social care.

Thank you very much. And Councillor Jane Gebbie.

Good morning, everyone. My name is Jane Gebbie. I'm deputy leader and cabinet member for social services here in Bridgend, and I'm also a WLGA spokesperson for health and social care.

Diolch yn fawr. And Lance. Lance Carver.

Hello. I'm Lance Carver. I'm the director of social services in the Vale of Glamorgan, but I am here today as cadeirydd of ADSS Cymru.

Diolch yn fawr. Jason Bennett.

Bore da. Jason Bennett. I'm here as chair of the All Wales Heads of Adults' Services.

Thank you. And David.

I'm the principal manager of adult social care in Denbighshire. A social worker by trade, I've spent half my career in the NHS and half in local authorities.

Okay. Diolch yn fawr. Thank you all very much for coming in virtually to give evidence to committee today. I'll just begin, then, with a few questions on key issues and challenges. Firstly, I should say as well that this isn't an exercise in trying to apportion blame in any way. We appreciate that hospital discharge is a complex issue and we want to focus on the challenges, the practical steps forward we can make in terms of committee recommendations. So, that's the spirit within which the committee approaches these matters. As I say, we appreciate it's a complex set of circumstances.

Okay, then. In terms of those key issues, from your perspective what are the biggest factors, would you say, affecting delayed hospital discharges, and what are the main challenges for local authorities as part of that process? Who would like to offer their view? Yes, Charlie McCoubrey.

Diolch, Gadeirydd. Clearly, we're all committed to providing the best possible services for our residents and looking out for the most vulnerable, but our ability, our resource, our staffing numbers, the funding implications of diverting staff—. In Conwy's perspective, we'd had to more or less divert staff who would be looking at domiciliary care packages to accelerate getting people out of hospital, and that then brings a significant financial cost to us. In Conwy's case, in the third quarter of this year, we had an additional 10 per cent of care home residents, which was a £2 million increase in our budget, which was effectively an overspend, which adds 2 per cent to our council tax for the following year. Staff retention remains a real, real concern, and subjectively I think the terms are too narrow in terms of that focus on 48-hour discharge, rather than actually looking at the overall package and the well-being of that individual and where their care needs would be best met. So, it remains incredibly challenging, but clearly something that we're all keen to work on and to look for solutions.

Thank you very much. Jane, did you indicate?

I did. Thank you very much, Chair. I think, on some of hospital discharge, the information that you all receive is misinforming you. And I'll give you an example. So, we use the term '48 hours clinically optimised' in health board settings, but that doesn't actually mean that someone is ready to leave hospital, and under the Social Services and Well-being (Wales) Act 2014, we have a responsibility to show our own due diligence when we are providing packages of care. As an example, we keep using 48 hours as, actually, as soon as we hit that point, it's a delayed discharge of care, for whatever reason, but, actually, if someone needs a best interests assessment, that's actually a seven-day legislative period that we have to use in order to do that. So, I think that some of the data is misunderstood. 

We also have problems in managing access to care homes. Bridgend care homes currently are working at a 95 per cent capacity rate. That actually doesn't give us an awful lot of leeway when we are looking for packages of care. And we also have to understand that any resident or patient that we are going for residential accommodation for has a choice and a voice themselves, especially if they have capacity, which means that they have to make an informed decision. Not one of us on this call today, sitting in committee, would be expected to find a new home within 48 hours of someone saying, 'Well, you can't go home. You need to find somewhere else.' We wouldn't do that. We would look with them at the most appropriate setting for them to be discharged to. 

And I think that the other thing that we need to understand is, for local authorities—. I'm actually chair of 'A Healthier Wales' now as well, and I think that one of the challenges that we see is we're reducing budgets in the early intervention and prevention space, things that we know will keep people healthier, with improved well-being, out in communities before they even get to hospital. But we're limited with budgets—you know, you've already had that conversation. But I suppose that's my initial contribution. Thank you very much, Chair, and Members. 

Okay. Anybody else like to add anything? Jason.

Yes, thank you. Just to follow on from previous comments, 48 hours of clinically optimised is not somebody being well, that means that the medical team have the opinion that their treatment can continue in the community. Quite often, that's not the point at which social care are legally supposed to intervene. Treatment and support for somebody who is unwell is an NHS function. With our integrated approaches and working collaboratively, we've seen us occupy some of that space to move people out to help them recover at home. So, we're seeing a drift of responsibility. As we take that on, unfortunately people get coded under this 48-hour rule as a social care issue, which feels a little unfair when we are supporting the system.

I think that there's a narrative around the number of delays and the percentage. So, looking at January, in our submission that we gave in written evidence, some 2 per cent of people in hospital were awaiting a social care assessment. That's not a high number. It's significant for those individuals who want to get home, but, in terms of the overall system, I would argue that's not a huge number. That same month, we were supporting 30,000 people in the community in Wales and dealing with over 10,000 new requests for community assessments and contacts.

So, we need to see the hospital discharge process, as important as it is, in the context of a wider community system, that we are providing a huge amount to support to our citizens. We need to be cautious about an attributing of blame culture that comes with some of the reporting, which is unhelpful to partnerships and to staff morale on the ground. We need to look at this pathway monitoring, as I would prefer to call it, rather than delays—just tracking people's journeys and making sure that the journey is as quick as it can be for them. And, for the reasons that Councillor Gebbie gave, some of those pathways will be longer than others. Some people who are fit and well—. So, if I went into hospital, I would hope to come home really quickly without any intervention or support, whereas somebody who is 90, frail, is going to have a little bit more planning. Yet the 48-hour rule applies equally to everyone.

So, it just feels like it's a bit of a blunt instrument—with good intention, I have to say. We need to monitor pathways, we need look at the whole system, we need to see how we can support people. I think we often misunderstand that social workers are a lead co-ordinator for assessment and they can rely on health assessments, whether that's allied health professionals' or nursing assessments, before they can conclude their assessment. And an assessment isn't a one-off, 'Let's sit down and fill a form'—that is not an assessment by a professional social worker. It relies on a conversation with the person, understanding what matters to them, and helping them make life-changing decisions, quite often. So, I think the 48-hour terminology is particularly unhelpful in that way. So, those are just my opening remarks.

Okay. David.

I do think it's important that we reframe the narrative, because I think this distinction between health and social care is both inaccurate and not particularly helpful. We work in community resource teams, where we work with colleagues from health, community nurses, community therapists. We also work with the third and voluntary sector. And it's community resource teams—I think we face the same challenges and the same frustrations. And so, I think it's far better to distinguish between community health and social care and in-patient care because that's the kind of division that creates some of the challenges. And I think the current narrative around who's to blame for this is also quite unhelpful, because, actually, it’s a very complex system and everyone has a role to play in it and it’s highly unlikely that you’d be able to identify one part of that system that was to blame.

No, absolutely, and, as I said earlier, that's certainly the committee's approach to these matters. If we look at discharge to recover and then assess and that approach, which Welsh Government, I think, in its guidance is very much in favour of, we hear that that's still not happening in practice often enough. Could you tell us what you think are the main barriers to that model and how they might be overcome? Jane.

Thank you very much, Chair. I’ll give you a starter for 10, and other colleagues then can come in, I suppose. We see significant challenges around continuing healthcare funding and funded nursing care funding. We have lots of argued arguments, we have lots of robust debates. We have the same teams, integrated teams, sitting in a room arguing around this. And I’ll give you a prime example. I have, actually, a piece of casework on my caseload at the minute: it’s a tetraplegic resident, who, with a C5 and C6 break, the health board currently has determined is not meeting any criteria for continued healthcare funding. This is a person who needs specific nursing tasks undertaken every day—that is not social care.

And I think one of the challenges that we see is around the funding distribution. We do see that across Wales. So, when we’re trying to get a residential nursing placement for someone, there is a cost pressure there. Local authorities are currently picking that up, because the contribution that we receive from health boards across Wales is insufficient. And I’ve got lots of other professional colleagues on this call today, and they’ll give you a better example than I have around some of those costs. But we’re certainly not paying nursing homes for the tasks that they are completing for these people and it is something that I think we need to urgently address. Thank you very much, Chair.

There is, though, support for that model, then, Jane, is there?

Oh, yes.

Yes, okay. Lance. Lance, you—. Yes, go on.

There is broad support for that model and it is happening, but with some significant caveats, I think I should say. I think Jason, in his evidence, referred to the assessment of somebody being clinically optimised being very different for individuals. So, somebody can be considered clinically optimised, but, actually, that will often mean that there’s nothing else the doctors can do for you. That doesn't mean that you’re well, and so individuals may require a period of rehabilitation, convalescence, therapeutic input, all of which are the responsibility of the NHS, not the responsibility of local authorities, and so the NHS is perfectly within its gift to make those arrangements and support that kind of support for an individual themselves.

I think the concern, and I think this would probably apply to discharge to assess models where there are step-down accommodations—. There is a real concern that an individual moved to the wrong type of accommodation will potentially become stuck, and so, rather than them having waited an extra day or two in order to have recovered and go home, they’re moved into a strange environment that they’re not used to, with staff that they’re not used to, and expected to recover. That takes more time, and, I guess, more resources overall, if you take a step back and view the whole system, than perhaps a properly organised discharge, which includes therapeutic input and rehabilitation. So, it’s not a panacea.

Okay, Lance. Did I see Jason?

Yes, I agree with Lance’s last comment; it’s not a panacea. The principle is a good one, and, as David said, we have community resource teams where that is exactly the model that’s followed, with integrated teams; people are supported on discharge to recover and have some of that reablement, and then are assessed at the end of that programme. That is a well-known pathway that’s been established for well over a decade and works incredibly well.

The discharge to assess for somebody with more complex needs, where you’re talking about a care home, I don’t agree that that’s an ethical approach, unless you have wraparound support for that individual—so, the therapeutic interventions, the nursing interventions that help that person continue their recovery. As Lance outlined, there is a risk that that person’s moved out of hospital and is lost to the system, because the priority is to get the next person out of hospital, not to help that person go home from that interim placement. So, it is a risk that we lose people.

There’s some really good evidence from Professor John Bolton at the Institute of Public Care at Oxford Brookes that says if you have the right kind of step-down facility, with all those therapeutic interventions, people will go home. If they don’t have it, they will remain in care, with all the connotations that come for them and their lives and their families. So, there is a danger to it; it’s not a panacea. It needs to be seen as a continuum. For some people, it’s the right thing; for other people it will do harm.

There is a question in my mind about the reduction in NHS bed base that we’ve seen over the last decade. There’s a 19 per cent reduction. Has that led to us moving people out of hospital for whom we would have done that rehabilitation in hospital and that discharge planning for that day or two that Lance mentioned, and we would have got it right? Has that reduction in beds forced us into a position of moving people out quicker than we would if we were redesigning the whole system? So, I think there’s a lot to look at.

The other thing that was mentioned about continuing healthcare: yes, continuing healthcare, on the surface, seems like a complex area, but, as was pointed out, it’s within the NHS’s gift to streamline that process and to fast-track people into that system so that they can go home or to a placement. We do tend to make that an overly bureaucratic process. That, on the whole, can be quite unnecessary. Our multi-disciplinary teams pretty much know by seeing somebody whether they hit triggers for continuing healthcare. The process and paperwork around it is more complex than necessary in my view. Clinical judgment should never be replaced by bureaucracy.

Okay. Could I—? David.

Thank you, Chair. I think it’s a very good model. I think there are challenges. Pathway 0, for example: I think staff on wards are often reluctant to consider pathway 0, because they tend to be a little risk averse and they worry that if somebody doesn’t go home with something they may return to hospital. I think the other thing with pathway 0 that’s often forgotten is what it means is a return to the care of the unpaid carer, and I think services for unpaid carers are under-resourced. If you were to read the recent ‘State of Caring’ report, it shows a significant deterioration in the carers that we rely on so heavily, and so I think we do need additional resource for them in order that pathway 0 can be successful. And then, in relation to pathway 1, it's often very difficult to find the care and support that people need in order to use pathway 1. It's not a poor practice issue, it's not a social workers not completing assessments quickly enough issue, it's simply that there isn't the resource in the community for that.

I have a slightly different opinion on pathway 2. I think, as John Bolton says, as long as you go into the right facility, then there is a very good place for pathway 2. However, on the whole, we generally use facilities such as standard residential care, and people can decondition in standard residential care in the same way that they can in hospital.

Okay, David. Thanks very much. Just in terms of the availability of appropriate intermediate care settings focused on recovery, we've heard already that there is a shortage of those settings. Any ideas as to how that might be overcome, so that we can have more capacity there? Lance.

Interestingly, we developed some of that capacity in my local authority area, supported with funding via the regional partnership board, which not only provided, I guess, a homely residential care environment, but also support from therapy staff, physios and occupational therapies. It sounded ideal, and we initially opened six beds. The reality was we couldn't use them, not because of there being a problem in terms of staffing, but because there wasn't the demand for it. I think what we saw was that people were either fit enough to go home and desperate to go home—people want to go home; they don't want to go into a care home—or so ill that, actually, a residential environment, even with therapy support, wasn't sufficient to look after their needs. So, I think it seems counterintuitive, because it seemed like a really sensible model, and, for the people who we did put through it, it seemed to work, but it was a very small number of people, and, for us, it wasn't justifiable to keep it running.

Okay. Jane.

I do think we need a further, more exploratory conversation with our housing and voluntary sectors in this regard. We know that some of our RSLs, our registered social landlords, have the ability to create some solutions to these problems, preferably in supported living accommodation. I say that, because you're able to step up and step down care needs in that regard, and we do know from our population needs assessment that we are going to have further demands on those services within a 10-year period, when you think about our ageing population.

We also know that we've got a lot of people out there that are deconditioning with their health. There's something for me about that we need to encourage our residents, and what levers do we have to encourage our residents, to be healthier and look after themselves a bit more, because they're all living longer, but they're not looking after themselves, necessarily. We can see some of that in the demand for specific services, drug and alcohol teams. We've got people that are older now that we know have got alcohol-related brain injury just from their amount of alcohol use, as an example, and we know we've got an increase in those cases.

I think it's important for the committee to recognise that we don't actually, across Wales, see that discharge delays are due to housing supply. That's not what it's about. It's about that step-up, intermediary position. Where can we get somebody conditioned sufficiently to return home with more limited care packages available to them? Because the quicker that we can recondition people to get back out, the less they cost us in care services going forward; we sort of delay that process, because we're looking after them a bit better. Thank you very much, Chair.

Thanks, Jane. Charlie.

Just to agree with what Councillor Gebbie said, Conwy's got the second highest over-65 population in Wales. We get a lot of inward retirement, and we see a lot of isolation and loneliness. There's a lack of family support there, they're away from their families, so we know that we offer care at an earlier age than we would do in some other areas. But our spend on the acute element of providing care is massively hampering our ability to do those softer things of community engagement, community groups, which play a vital role in keeping people healthy and getting them out of the house, for their mental health and well-being. So, that remains very challenging.

Okay. And Jason.

Thank you. Just to respond to your follow-up question, I think the way to enhance this is about that collaboration that David talked about in those community resource teams. So, this can't be seen as a social care approach, where you're talking about people recovering from illness, and recovery and rehabilitation—that's a role for the NHS. As Lance said for the Vale, a residential home doesn't have the skills and nursing skills to support somebody who is acutely ill or complex, so it has to be in partnership with the NHS, clinically led, clinically supported by those skilled medical nursing professionals, with us playing our part, of course, but it has to be done in collaboration.

Okay, thanks. David.

Thank you. This relentless focus on hospitals and this hospital-centric system that we work with has resulted in a depletion in the availability of services across health, social care and the third and voluntary sector. And that's having two big impacts that I think are relevant. The first is that those community services are keeping people in the community, keeping very unwell people in the community, and the more we deplete those services, the less they're able to do that, and they're causing inappropriate admissions. We know that the majority of hospital bed days relate to people with chronic conditions, or the elderly and frail, and they're people who are actually damaged by hospitals. We know deconditioning—. Hospital-related deconditioning is a very well-known condition. So, hospital actually damages them in many cases, whereas, if we had greater services in the community, we could keep those people out of hospital. And then, of course, at the other end of the system, because those services are depleted, we struggle to find the services that we need in order to discharge people.

So, I do think it goes back to that point that we do need to reframe the discussion and the paradigm and we need to place a greater focus on the community so that we can keep people well. Most people want to remain in their home, they don't want to go into hospital, and we need to be able to do that, and to do that we need to be properly resourced.

Okay, David. Altaf Hussain.

Thank you, Chair. I just want to make a point, really. As you know, I was a consultant in orthopaedics and we would have people who would be staying and occupying beds for a long time. I'm not sure at present what percentage of patients we're talking about who need this pathway that we are talking about. But what would happen in those days is that we used to have a meeting with social services and a guy would come and we would talk, as consultants, and once he gave you his assistance, everything would then be in place and the patient would be discharged. I have been hearing that patients staying in hospital are losing their muscles and all. It would never happen, because services would not be taken away from that patient. Physiotherapy would be there, occupational therapy would be there, nurses would be looking after him, and it would be the responsibility of that consultant under whom that patient would have been admitted. And it would be he who would be looking after, also, the patient in the community or in the care home; he would go there. We had GPs going into care homes; that's not happening now, really. And we had many small hospitals, where we would routinely go and check all these things. It is all fragmented. I don't know who is in charge now of these patients, and obviously they don't know themselves who is treating them. Am I right?

Would anybody like to respond to that? Any of our witnesses? No? Yes, Jason.

Sadly, I would have to agree with quite a lot of what was just said. I don't see the level of in-patient therapies that we used to see back when I was present in hospitals, back a generation ago, it seems. With those reductions in beds, we've seen a reduction in available therapy staff. Occupational therapies are primarily being brought in to support people with discharge planning, rather than using the skills that they have to help people recover. Physiotherapy is very scarce in hospitals; they do brilliant work when we have them. And I don't see a lot of rehabilitation assistants on wards that help people to have a 24-hour rehab approach, which is absolutely key to orthopaedic recovery and stroke recovery. So, we see this medical fitness clinically optimised and then the rest of that work is supposed to happen in the community. I think, for me, I would want it to continue pending going into the community, so it should be a continuum. So, you should have rehab from day 1 of admission, certainly day 1 of recovery from an orthopaedic condition, and then that just continues to happen as you move through the system. It shouldn’t stop pending discharge planning, because that’s creating a deconditioning that we’ve heard about, which wouldn’t have happened in the previous arrangement, because people were supported to recover—actively supported. I do see exactly what you’re saying, unfortunately. I don’t want to admit that that’s right. It's not right for the system, but it is a current reality.

Okay. David. 

Sorry, I was having a problem with my mute. I recognise the challenge of people not knowing who is responsible for a patient. I think that’s a very current challenge, and I think, again, it’s a capacity issue. Something we’ve done in the south of Denbighshire, which we’ve not been able to replicate elsewhere, is introduce a complex case meeting, where the GP, the district nurse, the community therapist, the social worker, and even the third and voluntary sector now, meet with the GP to discuss a patient in detail and take ownership—put a wraparound service around that patient and take ownership of the care and support that they get. But I don’t think that that’s available in most areas. And I think it is a capacity issue, and if you look at every area now, there was a day when you’d have a social worker for the long term, now you have a social worker that completes an assessment, and then that patient goes to review. It’s the same with district nurses, with community therapists, with GPs: you see a different person every time you interact with the service.

Okay, David. We’ll move on to Peter Fox. Peter.

Thank you, Chair. Good morning, everybody. I just wanted to look at little bit at regional variation. I’m conscious we’ve got a couple of different regions here, and obviously you might not know or understand all of the variances, perhaps, in all regions, but I would like to get an insight to why you think there might be variations. How do you believe that we could achieve more consistency across the piece, if there is an opportunity to do that? So, if you’ve got any views on your own areas, that would be really handy. I'm not sure who'd like to kick-off? Lance.

I think there's inevitably some variation, partly because each, I suppose, local authority area and each health board area has quite different populations, and we heard Councillor McCoubrey talk about his, with the second highest number of old people. That would be very different from a very urban centre, such as the capital, Cardiff, in terms of the challenges. If you have a population that is predominantly older actually it means you’ve got fewer working-age people as well to actually be available to support them, and so you can end up in a really, really difficult compounded position, I guess. So, there’s the availability of staff and, actually, I suppose, also increased numbers of people who require support.

And then I think the other thing is the funding arrangements—funding isn’t the same. Funding is calculated on a fairly ancient formula, which, I think, certainly predates a number of Welsh Government policies that have been put in place, which, in my view, probably have reset the arrangements. So, the one I’m probably thinking of in particular, in terms of some of the charging mechanisms that are in place, is the cap on non-residential charging. For an affluent area prior to that, most people would have made their own arrangements, because they had money and would have contacted care companies and organised those things themselves. When that cap came in, individuals came in to statutory services in order to have a spending cap, essentially, on the care that they needed—understandable. That's the legislation that was put in place. The funding formula predates those arrangements, so you inevitably have real differences in terms of funding. There are all sorts of other quotients I could take on in terms of socioeconomic deprivation and so on; we know that there's a direct link with that to poor health outcomes. So, all of that, wrapped up together, is likely to mean that there is variation.

Certainly, from an ADSS Cymru perspective, we do a lot of work, and Jason will do this through AWASH as well, which is the heads of service group of ADSS Cymru, where we look at how we can, I suppose, bring practice together, learn from best examples and so on. But, again, you're working with a different health board, so what may be achievable in one area perhaps can't be achievable in another. Geography can be different—you've got people who are living in very remote areas versus urban areas. I know that even within my local authority, we've had problems in the past with supporting people who live in farm locations, whereas those in the centre of our busiest town—it has been much easier, because the staff who are going to visit them can go on foot, so they don't need to have cars. It really comes down to really quite fundamental and, probably, quite obvious things, when you actually get into the detail, but on a high level it doesn't look obvious.

Thanks for that, Lance. I'll bring Jane in. Jane, perhaps you could reflect also on that wider WLGA perspective, because, you know, you will have that wider overview across Wales. Perhaps you could give us a flavour of how best practice is being shared.

Best practice is being shared, and I suppose one of the things I will say—. So, if I give you a really good example across Wales of our falls teams; every local authority was provided with funding to have one falls team. However, one of the things—. I suppose my challenge back is that we need to look at hospital admissions from care homes. Twenty-seven per cent, currently, of hospital conveyance is from care homes. So, we know that those people are having falls, they might be end-of-life, but it's that reporting around that sort of thing. So, I think we need to use data more, if I'm really very honest. Also, we need to think about—. That's an early intervention and prevention strategy. All of us, either as local authority officers or members of authorities, want to avoid people going into hospital at all costs. So, I'll keep banging on about early intervention and prevention in this space. I do so deliberately, because I do think we need to refocus those priorities. We had the 50-day challenge. What our data proves—. In our written submission from the WLGA, we have proved that we are dealing with more and more social care contacts and social care packages going out to our residents across Wales. So, we met that challenge—in fact, I think we excelled in it—despite the fact that some of that challenge wasn't actually achievable, and I think that's important to note.

Whatever the challenge or policy decision that comes out of the Welsh Government, my ask is that you ensure that it meets other legislative criteria. A prime example of that is five to seven-day working. I'm trade union made, as most of the Members will be aware. You cannot consult and do new contracts for all staff—. You cannot do five to seven-day working in that 50-day time frame—it just wasn't achievable. That was put down in black and white for all of us to achieve, and it wasn't achievable in the first place. So, I suppose that my one challenge back to the Welsh Government is that whatever you ask us to do, we will endeavour to do whatever we can to the best of our ability using the best practice that we can, and we know that we have some really, really good models.

I'm sitting here today and I've got a case study in front of me, because as I'm regional partnership chair as well for CTM, one of my responsibilities is the regional innovation hub. We did a project when the challenge came out last year from the fuel allowance that was being cut from UK Government. We put a bit of a challenge together with all of our organisations, and we focused on housing data. So, it's about how we use our data and how we can use it innovatively. We know that the NHS spends £1.4 billion treating illnesses linked to cold or damp housing. And some of that we know that we can do something about. We know that we can do something about it. A quick case study of one gentleman we’ve assisted in that space with a £15,000 underspend budget—that was all we had to use to support this. What we ensured was this gentleman received nearly £3,500 in a back payment in pension credits, and he will now receive nearly £11,500 in pension credit annually, and he had a council tax reduction, and he received full housing benefit. So, we know that we can use data, but we need to be smarter with our data use. And we know that all that data is collected by Welsh Government, but I’m yet to see any real information come out of Welsh Government in relation to that data and what is it that you do with it. Because I think, for us, we’d like to understand what you’re collecting it for, what you’re using it for, and how we can use that data really sensitively, but also how we can actually task other organisations to use that data more effectively.

Thank you, Jane. John, are you all right for me to invite people in?

Yes, carry on, Peter.

I've got Jason, Altaf and Lee. So, Jason.

Thank you. I just wanted to build a little bit on what Lance has said about the funding formulae. I’m going to sound ungrateful now, and I don’t mean to be, but we get winter money, we get short-term money, and we’re always grateful for investment, but the short-term initiatives, often via the regional teams, can create that inconsistency.

We have a huge number of policies in Wales, most of which are designed to do very good things about keeping people at home and keeping people healthy, but we lack a single coherent strategy with long-term investment. We have the Well-being of Future Generations (Wales) Act 2015, but we still try to plan winter to winter. It feels like winter is predictable, and we should be able to have a 10-year strategy for health and social care with appropriate funding that is a modern formula based on needs but with a few clear strategic aims. I think we’ve got too many policy directives, too much short-term planning, and that leads to that inconsistency that you see.

Some of that inconsistency is the brand. So, for the Vale, we have the Vale Community Resource Service, and David has talked about the community resource teams—the reality is that they’re the same thing. They’re intermediate care. So, sometimes the inconsistency is branding, but sometimes it’s because we’ve prioritised different things based on chasing funding or local availability.

I would say that short-term funding, the 1,000 bed days, the 50 day—I don’t know what next winter’s one will be, but it’ll be something snappy—those things lead to that fragmentation. I would urge support for a long-term initiative, with perhaps 10 achievable things that we all buy into, because we know they’re right for the population of Wales, but properly funded.

Thank you, Jason. Altaf, do you have questions?

Yes, it was regarding, listening to Jane there, the 27 per cent from the population of care homes—[Inaudible.]—fractured neck of femur. I have worked on it, and the fractured neck of femur is one of the subjects that I have thoroughly investigated, and it is published worldwide.

My submission is: do we need a home assessment of a person at some stage in his life, maybe even as a trial, to avoid these pre-hospital assessments, to avoid these admissions with fractured neck of femur et cetera? That means you are assessing the person at home at some time and giving him an MOT for another 20 or 30 years, maybe when he’s getting the state pension. So, that is important, because that will give you—. That will prove to us that, yes, there is a population there who need care. And even if he goes into the hospital, we have that pre-assessment of that person who will now be occupying the bed in the hospital. I think we really need to look into this.

No. 2 is that innovations are at the top end at present. Everybody is welcoming the technology; I don't know how long they will last and how much money we'll be spending on it. But there have been innovations about the mattress, about the beds; you can get an alarm. Like you have a fire alarm, you have a carbon monoxide alarm in your home, you can have an alarm like that that does not allow a patient to fall from his bed. And then creating new homes where there's less clutter, less furniture, and friendly furniture. We're not doing that.

Thank you. Clearly, that's a lot of what Jane was saying about preventative. Lee, did you want to come in on an earlier point?

I just wanted to pick something up on a point that Jane was making about the interdependencies here. Clearly, this is a very complex system, and there are lots of different drivers of the different parts of the system, so I understand there's no glib, easy answer to this. But you mentioned, Jane, the example of the reliance on housing, you mentioned the reliance on the hospital discharge process. There are various things that have been done over the years to try and get some joined-up integrated thinking: local government has a seat on the health boards; there are regional partnership boards, which you chair. So, there are structural solutions that have been tried to be forged to try and get more of a joined-up approach, but, clearly, there's still lots slipping through the gaps. Of course, there's different ownership and there are different drivers. Do you have any thoughts on any system changes we might make to have a greater sense of system accountability and less buck passing?

Trust you to ask a tough one. I think what I would say, Lee, is what I'm keen to avoid is more layers of governance. I think we've got enough governance already. I think we're over-reliant on—. I've got a whole team now that sit there and produce data every week for the Welsh Government as part of my regional partnership, and when I look at some of the data they're producing for you, I don't know what it's used for. We've got health colleagues within that regional partnership space; we don't agree anything funding-wise that is not on our population needs assessment as an issue. We have six different work streams. We have lots of different officers and partners working in that space. We won't agree funding—. So, there's RIF funding. Anything like that that comes from the Welsh Government all goes through the regional partnership board, and unless it meets our population needs assessment or our market stability report, so that we know that there's an issue that we need to address, they don't get any funding for it. 

What we are keen to do is have a bit more of the early intervention and prevention space. What we do know from local government is that—. You'll all be aware that we've suffered austerity; there is no getting away from that. You know how much money has been reduced out of local government since 2014. We've reduced money in the early intervention and prevention space. So, where people used to go to get support, guidance and advice—. And that may not be statutory advice and information; actually, it's generally non-statutory. Because the earlier that we can intervene with some of this, the less likely they are going to go on and use statutory services, unless it is an absolute must, because people want to live in their communities. If we can make them feel valued in our communities and use those spaces well, we know that we'll keep them there. 

What we also know, though, Lee, is we are going to need some additional housing. We know that our regional partnership is already having discussions about what would be the best fit. We know that we're going to have a demand on any cognitive impairment—so, dementia, essentially—homes that we are going to need in future years, because the demand is such that it's going through the roof. People are living longer as well, and that's a good thing, but what that tells us is that medical intervention is really good, but we need to get much better, like we used to be, in the early intervention and prevention space. The more that we can avoid people going into hospital, the better. Those conversations are happening, and I don't know what else to say, really, to reassure you, because we are limited for funding, we're limited for time, we've got those limited resources and we use them to our absolute maximum.

I just gave you an example of £15,000. That was an underspend from a regional innovation hub that we hadn't spent on something else. It cost us less to deliver another bit of service. So, for £15,000, we actually contacted nearly 700 people and affected nearly 2,000 people in that space. But that wasn't about a leaflet. It was about turning up to events that were already happening or having that personal conversation. But the difficulty and the challenge that we had in that space was around the data use, because we were trying to use health and housing data and never the twain shall meet, and you'll understand all the conversations around data at the minute because that's a significant challenge whether that's in local government or in health. I hope that helps.

John, I've got a few people who want to come in on this. Do you want me to bring them in or have you got them?

We do need to move on, so we'll have to have briefer answers, I'm afraid. David.

In response to that, I'm at a bit of a loss, really, as to why we are in the situation we're in, because if you look at the legislation we're fortunate to have in Wales, we've got the Social Services and Well-being (Wales) Act 2014, we've got the Well-being of Future Generations (Wales) Act 2015, we've got ‘A Healthier Wales’, a document just published by the NHS confederation. It's all saying the same thing. The document from the NHS confederation says it's all about moving from treating illness to prevention. On workforce, it's about going from short term to long term. So all the answers are there, but what we're tending to do is continue to focus on the hospitals, and hospital discharge, and really a lot of that is dealing with failure demand rather than dealing with what would actually bring about change, and that is increasing our offer in the community.

Just going back to the bit about inconsistency, that is due to population need, but also that's different models. In Denbighshire we've adopted a model called strengths-based practice and community-led support. We have a long-standing relationship with the national development team for inclusion, and that's about re-engaging people with their communities, and I think that's something that's being lost. It's contained in all the legislation that we have and all the guidance, but it does tend to be seen as a nice-to-do rather than something that's essential, and I actually see it the other way round. Re-engaging people with their communities and focusing on their strengths is something that derives far more benefit than constantly seeing them as an illness or a delayed discharge.

John, I know Lance and Charlie wanted to come in on the last question. Or do you want me to move on?

Well, if Lance and Charlie could be brief, we'll hear from them both. Lance. 

I'll be really quick. David said some of it. The reality is I think the reason we have this is because we're focusing on the wrong problem. The numbers falsely drive you to look at the wrong problem. I think we've described why the 48-hour thing does that. I think it's what Altaf said earlier: we should be focusing on the resident or patient outcomes, not on patient flow. You're looking at the wrong thing and therefore it's driving the wrong approaches.

I think the pressure is in primary healthcare as well. We as a health service have way too much emphasis on hospitals. In other areas, they have much stronger primary care sectors. You couldn't run a dental practice without an x-ray facility, whereas we don't have that. You have to be referred to hospital and have your x-ray and go back a week later. That's clearly nonsensical. We're 600 GPs short across Wales. So again, I'd agree with Lance, we're actually looking at the wrong area here. We're not looking at the root cause of it.

Thank you, Charlie. Peter.

Thanks. I'm conscious we have a lot of questions to ask, but I briefly wanted to, even though we've touched on it a bit before—. In previous evidence sessions, we've heard that there might be barriers between the key partners being able to work together successfully or in the best way they could—health and local authorities. I wonder what your reflections might be on that, and if there are some immediate things that could help better working. Something was considered earlier about co-location, for instance. So if there are any views on that, they'd be welcome. Jane.

Thank you very much, Peter. In the Cwm Taf Morgannwg area we've just agreed a memorandum of understanding between all local authorities and the health board. That memorandum of understanding is about the integrated team approach that we need to have. One of the challenges that we have in the integrated space is we have much more flexibility in local government to appoint. Health boards do not have that same arrangement; it's much more difficult. There are an awful lot more barriers for them to appoint staff to work in communities, and, quite often, they come to us to arrange that.

What I would say is, though, one of the difficulties we face in that arrangement is the disparity of pay between the workforces—with health and local government. We prioritise health boards, and I understand why we've prioritised health boards. Particularly around the COVID pandemic, we saw all the challenges that our health colleagues faced. But local government was out there in the community, doing the same sorts of things, and taking on more responsibilities than they should have been.

One of the things I will say about social care staff is that, over the years, social care staff are now picking up more and more nursing responsibilities. Our social care staff should not be responsible for bowel maintenance, as an example. They should not be responsible for catheter care, other than emptying it. So, there are all manner of things out there where we know we've got our staff, technically, stepping over the line. But if they don't do it, nobody is. So, I do think that's a significant challenge. It is a wicked issue, but something that we need to get much better at managing. Thank you.

The things that damage partnership working with us the most are—it started in COVID—the absence of a parity of esteem. I work in social care, my wife works in the NHS; we were treated very differently, and it was a stark difference. The blame game that we currently have, where there's a determination to blame delayed discharge on local authorities—that's causing huge problems. And then I think, worst of all, it's the continuing healthcare process. CHC panels are gatekeepers, they don't respect the multidisciplinary team—that's whether it be nurses, health therapists, social workers. But it does drive a wedge between health and social care. And it is just about gatekeeping. There's no citizen at the centre of it. I think Jane made a comment earlier about the citizen being absent, and it certainly is with CHC—it's simply a gatekeeping function.

Peter, I think we'd probably better move on, if that's okay. Siân Gwenllian. 

Certainly from a Conwy perspective, we were having really serious problems a year or two ago. We did an independent piece of work with LaingBuisson as to what the fair fee would be. But the reality was, in that financial year, which is the last financial year, our entire funding from the Welsh Government was £4.6 million; the care home fees increased by £4.8 million. So, every single penny we got was swallowed up just in the care home fees element. We've solved that problem to a certain extent—I think it was another £3 million or £4 million this year. But that's a big factor as to why we've had over a 10 per cent increase in council tax over the last three years, because we had another £40 million of wages.

So, that gives some indication of the scale of the challenge, and that's where our money's going to. I think there's £100 million overspend this year on social care across Wales, and that's estimated to be £260 million next year. For us in Conwy, you're just staring at a wall because it's completely unsustainable to have those levels of council tax and the level of cuts that we've had to put in there. But, yes, we've solved the problem for the time being, but that's just to the detriment of everything else that we've done and the detriment to people's incomes, with what we all know is the most unfair tax of all—council tax.

Care homes are increasingly reluctant to accept what we can afford to pay. They will hang on for a short time, when they'll get a self-funder, or they'll get another local authority in the area, or the health board, who will possibly pay more. So, we are finding it an increasing challenge, and it's also preventing people from coming into the market, and so capacity is decreasing. I think it's Jane who said that we generally run at around about 95 per cent occupancy. When you start talking about it, they've got to clean rooms, they've got to do everything else, so if it's actually 95 per cent, you might as well call it 100 per cent. There's rarely enough capacity that we can place somebody at short notice.

Okay. And Jason.

Thank you. Yes, a couple of issues just around care home placements. So, we talk sometimes in Welsh Government about trusted assessors. Care home managers have a legal obligation to say that they can meet the needs of a resident before the person moves in. To trust somebody in a hospital, which is busy, with changing staff, on their view as to whether their needs can be met is very hard to do. So, care home managers find themselves having to visit hospitals to assess people to see if they can meet those needs, which is a legal requirement on them personally. So, they have that personal responsibility as the responsible individual.

That legislation isn’t always understood by people in the hospitals who are under pressure and think, ‘Why can’t Mrs Jones just go home to care home A, they’ve got a bed?’ It’s not as simple as that. Plus, Mrs Jones has got a right to choose where she’s going to live for the rest of her life, possibly. So, Mrs Jones needs to have a right to have the information, to have a discussion with the manager and have a view on that home. David’s already mentioned the fees and people with top-up fees or who are willing to pay more for a privately funded home. That kind of economy drives behaviour.

There’s another point I wanted to make around the fees: there’s a difference between a residential home and a nursing home. A nursing home by nature has got nursing staff, clinically led, so should be dealing with more complex people. Nurses in nursing homes are not funded to a level that I would feel would be fair. The funded nursing care rate is based on a very junior nursing rate. Last time I checked, it was based on a band 5, which is newly qualified. I would argue that if it was put through 'Agenda for Change', the equivalent NHS job would be a band 7.

So, we’re underfunding the nursing element. That means that it’s very hard for care homes to attract highly skilled nurses to that market, so it creates instability. That drives people to want to do residential care rather than nursing. With the complexity in our community, you would expect nursing to be increasing and residential to be reducing, but that’s not what we’re seeing in practice. That’s leading to the challenges then of, when somebody in a hospital needs to go to a nursing home, there is very limited choice and very limited availability. And when you then add on the continuing healthcare arrangement, in some areas the continuing healthcare rate to a care home is only marginally higher than the local authority's plus the FNC rate; in some areas, there’s negligible difference, despite the increasing complexity. So, then you’ll get care homes that will be reluctant to take people on that basis as well.

So, it’s a very complex area, but it needs proper structure, proper funding. We need to look at the support for the nurses in those homes, who are doing an incredible job. They would be managing a ward if it was a hospital. They’re dealing with complex physical conditions, as well as increasing cognitive impairments such as dementia, so they’re having to be really multiskilled and lead that team clinically. So, I think it’s a complex area that needs a lot of investment and support.

Okay. Siân.

Shall I come back, Chair? So, in short, yes. Sometimes, that's for good reasons, because it's been their home for a number of years and the person's needs have increased and we don't want to disrupt that care, and they can get wraparound support from district nursing, for instance. So, that's appropriate. But on other occasions, then, no, there are places that are residential that should be nursing. And if I think of a former authority—not the one I'm in now—we had to close a home. When we closed it, it was residential, all bar one person who moved out of there and went to nursing on reassessment. So, it does drive that kind of behaviour of residential homes overstepping their responsibilities, and for good reason supporting people, but probably at risk.

Okay. So, we'll have to move on, I'm afraid. Lee. 

Thanks. I wanted to ask some questions on data, which we've actually covered, so I won't repeat them, but I would like to ask about digital and information sharing. We've had evidence from the Royal College of Nursing that says that fax machines are still being used in places and a heavy paper-based system is adding to the problem. And I think we know that the Welsh Community Care Information System—WCCIS—has been a long-promised programme to try and pipe the systems together digitally, and it's been a troubled project, I think it's fair to say. It's due now to come in operationally next January. I just wanted to get a sense from you as to how confident you are in that, and, more generally, about the state of information sharing and digital systems that speak to each other.

Who would like to respond?

Jane is indicating, I think.

Okay. Jane.

And Lance. Do I think we'll get there? Yes. I don't think we've got any other choice than to get this system up and operational, because otherwise, the risk to local authorities and to our residents is so significant, we might as well just drop a bomb in the centre of Cardiff.

And I say that deliberately because we've met with so many challenges over the course of this project, and we still meet them today. We need people to be on board with this. I think we need to try and use every lever that we have available to us to get this system up and operational, and there's—. Welsh Government are asking us, as partners, to work in social partnership, and everybody on the call today is in that space, we think it's quite right and proper that we do do that, you know, but that includes Welsh Government as well; and I often feel that we have teams of officials—not Members, I hasten to add—we have teams of officials that put barriers in our way in order that we can achieve those tasks in a timely manner. I'm trying to be very tactful about the way I say this. But we need to be working together; we have no other option. Otherwise, it is a nuclear option.

So, we need to get very much quicker, we need to work in social partnership; that's across the board. You'll be aware that every local authority in Wales went at risk on this arrangement and this system demand, because it was supposed to be an all Wales. So, we were supposed to have originally done a pan-Wales system for the replacement of WCCIS; that is not the case, and we now have regional arrangements because we couldn't afford to wait any longer. And at the time, local authorities didn't know whether we were going to get any funding and support in that arrangement either, so we've all just had to get on and do it. So, I'm saying that very bluntly, I hope you take it in the spirit that it is intended, but we're all very concerned and worried about this arrangement at the minute.

I'm not trying to tempt you into saying something undiplomatic, but can you give us an example of the sort of barriers you feel have been put in your way? 

So, we were informed originally that WCCIS would be unable to be hard-wired for the data migration, as an example; that is not the case and we can do a hard link for that data migration. At the minute, we're limited to 1 GB day—that's not enough. We need to hard-wire it, so that we can download, and we need the users to be able to test the new system out. I think that's one of the key things for me. We can't do this in isolation. We need practice, service—. You know, we need the practitioners to be able to use this system to identify anything before it goes completely live.

So, it needs to be a partnership approach from all levels of governance, whether that be from local authorities, to the digital team in Welsh Government, to Ministers, to suppliers; whatever that may be, we need to work in true social partnership, and to have those honest conversations. Because otherwise, we're going to be on a sticky wicket.

I think Lance wanted to come in, and then David. Lance.

I think local authorities were in a difficult position because it was local authorities who were predominantly using WCCIS, and the system was going to expire, so they had to act, and I think that has meant that there is some separation in terms of commissioning arrangements for a replacement IT system; we're not all going to be on the same system like most authorities were. But I think the end result, actually, is more authorities are going to be on the same system because of the way that it has worked. It's also held together tightly by a local authority senior responsible owner group. But the immediate impact, I think, even following a successful implementation, will be potentially a slight retrograde step in terms of connectivity with health services.

That said, I think that will be short lived, and the future will be much more integration enabled, and there are some really innovative projects happening around Wales. Certainly, in my region, I now have a summary care viewer that enables staff in the health service and the local authority services to see, at a top level, the records of an individual patient that we are sharing. So, we will be able to do that again once we have the new IT system put in, but it will take further work. So, if we weren't having to replace, then, yes, we could have carried on doing that within WCCIS. So, there is going to be a blip there, but if we hadn't taken action, I think Councillor Gebbie's already described the kind of impact that might have happened, so I'm not going to repeat it. 

David. 

Yes, I think there are significant gains and efficiencies to be made by greater use of tech. I think most of the providers now, unlike the legacy systems where they were server based and it was very difficult for them to talk to one another, most of the providers these days that have cloud-based systems use interoperability—i.e. the ability for those systems to communicate with one another—as a selling point. What tends to get in the way is information governance professionals within organisations who create security models that effectively prevent one system from talking to another. The advice generally seems to be, 'If in doubt, don't talk to one another, because that's safer', and that, in fairness, is because of the consequences of a data incident, which can be huge for organisations and very expensive. So, you can understand their position.

Jason.

Thank you. Colleagues have said a lot of what I would have said. WCCIS is primarily used by local authorities, not health boards. I sit in an integrated role in my day job—health and social care; there's a whole plethora of different systems that my staff have to access. But one of the things that we're really interested in for the future is how does the citizen be part of that, because it's their record, yet we're reluctant to share the records with them.

We heard earlier about having early conversations with people about their future care needs. There's a conference today that I should be in, and it's about anticipatory and future care planning—it's in Cardiff, it's a national conference—to start to have that conversation. That needs to be underpinned by a person holding their own wishes and feelings and their own record, so that that can be given to an ambulance that arrives when they've fallen; it can be seen by a GP that's monitoring their chronic condition; it can be seen by a social worker when we have to talk about care arrangements. And that has to start with the person having a conversation.

I liked what was said earlier about retirement planning: once you get into that, or if you've got a diagnosis from a consultant that means you've got a different life trajectory than you expected, having an early conversation before a crisis. But including people in the IT system is key for me. We quite often talk about sharing between health and social care. We need to do this in partnership with people, so that they can take responsibility for their own care and be part of that journey, and have their wishes and feelings known. There are a number of people delayed in hospital for court of protection reasons, some of which would have been avoided if we'd been able to anticipate their care needs with them, and talk through their options. So, my plea would be, when we do this great work—and we have to replace WCCIS; we have to get that sorted—but, after that, we then need to move into a position of integration, but integration with the person themselves as well.

Okay. Lee, if you're content, I think we may have to leave it there, because we've already over-run our allotted time, I'm afraid. So, just for me to thank all our witnesses for coming in to give evidence to committee. You will be sent a transcript to check for factual accuracy in due course. We may write to you if we have further questions following your evidence, and we'd be very grateful for responses. And if there's anything further you wanted to provide us with from your point of view in terms of further written evidence, that would be absolutely fine as well. Thank you all very much. Diolch yn fawr. 

Okay. Committee will break briefly until 11:50.

We've reached item 4 on our agenda today, our third evidence session regarding the role of local authorities in supporting hospital discharges. And I'm very pleased that we're able to take evidence from the Welsh NHS Confederation, and I wonder if our witnesses might briefly introduce themselves for the record, starting, perhaps, with Jennifer.

Thank you, Chair. My name's Jennifer Winslade. I'm the executive director of nursing for Aneurin Bevan University Health Board, and I lead within my health board on the six goal programme, and specifically discharge pathways.

Okay. And Cath.

Good morning, and thank you, Chair. Cath Doman. I’m the director of health and care integration for Cardiff and Vale regional partnership board. I'm also the senior accountable officer on the care action committee for the region.

Thank you. And Gethin.

Good morning, Chair. I'm Gethin Hughes. I'm the chief operating officer at Cwm Taf Morgannwg University Health Board and the executive lead for the six goals in the health board.

Okay, thank you all very much for coming in to give evidence to committee today. Perhaps I might begin with some questions on key issues and barriers. So, from your perspective, what are the biggest issues, the biggest factors affecting delayed hospital discharges, and the reasons that lie behind them? Who would like to begin? No volunteers? Jennifer.

Thank you, Chair. So, I think the reasons behind hospital discharge delays are complex and multifaceted, and it doesn't just relate to how we manage discharge pathways. From my perspective, it's how we manage the whole system and how we focus our attention on how we ensure that people can be cared for as close to home as possible. So, for me, admission avoidance plays a key part in this, and our work with our local authority partners in how we keep people well at home for as long as possible. I think there is a question for me about how we know, so some of the data and the information and some of the outcome metrics aren't always available to support that, and we have much better data when we look at hospital discharge delays.

As I say, the reasons around discharge delays can be complex. They range from, for me—. We have some very complex patients now in the system, patients who may be homeless, patients who have very complex family situations, or patients with very complex needs, and they can be very difficult to place because those placements don't always exist in the community. We have some legislative complexities around Court of Protection, mental capacity, perhaps some misunderstanding of the legalities of that, but also what that means for the care of citizens and patients within our system. And I think there are complexities around how health and social care work together, but also around some of the capacity within social care in particular, so capacity to undertake assessments, capacity to source placements or to provide care at home, and then capacity within the domiciliary care sector. So, there are a number of, I think, very complex reasons why patients can end up for an extended time period in hospital.

But, for me, we need to focus at both ends of the pathway to make sure that we are preventing admission for as many patients as possible, but also that we are focusing on that integrated health and social care response, holding each other to account, and that accountability around the right referrals, the right assessment, the right timeliness, but then ensuring that we work with our broader communities and local areas to ensure that we've got the right support in the community. So, we know, for example, that our care home sector—. It is very difficult, particularly for patients who have dementia, to find those placements. I think there's a broader partnership commissioning piece that is about, as well as market sustainability, how we look at the needs of the population and ensure we work with care home providers in a very different way to commission a contract for their needs.

Okay, Jennifer. I don't know—does Cath or Gethin want to add anything. Cath.

Thank you. I have very little to add to what Jennifer's already articulated, but I would just emphasise that this is absolutely a team game. We do need to operate as a single system working across the NHS and social care, and it's a very easy narrative to jump to, isn't it, that it's all about social care. And, actually, a lot of the control is within the hands of hospitals, in terms of processes within hospitals as well. I think that that nature of really, really complex people, with very complex needs, and everything that goes around that—so, the views of families and carers as to what the right solution is for the individual, and sometimes a reluctance to leave what’s seen as the safe place of the hospital to go on to the next stage of care—can be quite a significant blocker.

I think there’s an overall capacity and demand issue for social care, and a resourcing issue for social care. Locally we’ve had a huge amount of effort going in from our local authorities into resolving this problem, but they are also trying to balance the massive demand that’s emerging from the community. So, I absolutely couldn’t criticise their effort and their input, but it’s in the context of a really challenged context for local authorities and the health board.

And I think, just to re-emphasise Jennifer’s point about needing to shift the narrative from getting people out of hospital, to how we keep people safe and optimised and independent at home. And that’s a real challenge, isn’t it, because there isn't any additional investment for this, so it’s how we use our collective resources to achieve that, and have a common aim between us across local authorities and health boards. Thank you.

Thank you. Gethin. 

Yes, I totally agree with what both Jenny and Cath have shared. I think there are some fundamentals that absolutely lie at the heart of this. One is about trust, and it is about each partner having confidence in the decision-making of the other, so that we are confident that we’re all acting in the best interests of the individual, not in the best interests of organisations. And that then underpins the ability, I think, to begin to shift that change of process, so that we begin to trust each other’s assessments. You know, if you look at the data, a large proportion of delay will often be attributed to assessment time. If we work together in a better way, and have that continuous trust between both sectors, then we can release that time more efficiently, because we know that, when a patient is assessed at home, they will get a more appropriate assessment than when we assess their needs in a general hospital.

I think the other piece is cultural, or cultural with families, because, again—. And both Jenny and Cath have touched on the assumption that a hospital is a safe place to be. And if you are frail and older, and you are not unwell, being in a bed in a hospital is probably the worst place than you can be. And we know that, for every 10 days that a patient spends in a bed in hospital, they will lose 10 years' worth of muscle mass. And so the impact, then, on our population, and their ongoing need, becomes ever more significant. So, I think there is, absolutely—. How do we build that trust and develop that culture between health and social care? But it is also about how we as health and social care work with families to really understand how we act in the best interests of their loved ones.

Okay, thank you very much. Just in terms of that assessment process, there seems to be a lot of support for discharge to recover and then assess as a model. Welsh Government’s guidance is quite strong on it as well, isn’t it? But we hear that it’s often not actually taking place in practice. So, I wonder if you could perhaps share your thoughts on why that’s the case and how the barriers might be overcome. Yes, Gethin.

I guess that comes back, fundamentally, to trust, and the ability and willingness of all the registrants. And, of course, there is that professional accountability for all involved here, both in terms of the healthcare professionals, but also the social care professionals, around their professional registration. But it is about—. For discharge to cover and assess to work really, really well, it comes back to that level of trust, that the individual who’s making that assessment in hospital for that patient to go home—the other participants within that MDT absolutely trust that. And I think, for me, that is probably the biggest enabler. I work with three different local authorities, and we have a different—. We've got different levels of adoption with D2RA, in that respect, and if you come back to what is the core driving focus of that, I think it is that ongoing level of trust and commitment between partners.

Okay. I think I saw Cath and Jennifer's hands up as well. Cath.

Thank you. Yes, this is something that we've implemented pretty successfully in Cardiff and Vale, and I think all parties really agree that assessment closer to home is absolutely the right place to undertake that, and hospital is probably absolutely the wrong place to do that. The way we've enabled that in our region is we've used money through the RPB, so I think there is often a debate around who is the responsible commissioner for this. Local authorities obviously can't commission things that are NHS responsibilities, and there's a debate as to who is actually responsible for funding that step-down accommodation. So, we've used our regional integration fund to the tune of nearly £3 million a year to support discharge to recover and assess, in various guises, whether that's spot purchasing care homes, or it's other step-down accommodation.

There's a debate as well as to whether finding the right match for an individual in that step-down accommodation—. I think, sometimes, we think we could cohort groups of people into one place. There is quite a reluctance to do that, because particularly with complex people, this is about getting the right match and the right level of support to make that discharge to recover and assess effective, and there's a risk that people often cite of the problem of delays just being bumped down the system, so they're bumped from a hospital setting into the discharge to recover and assess setting. So, it's really critical, then, that you've got that wraparound support in terms of assessment, reablement and rehabilitation, to ensure that people move through that system effectively. So, I think the way we've got through this is to almost remove the argument about who is the responsible commissioner and use money that is in that central space between the health board and local authorities. Again, I suppose we'll come on to this later, but in terms of how we enable that in the future, really getting to the bottom of a clear accountability and responsibility for who, ultimately, is responsible for commissioning this sort of care—. For me, it's an opportunity to do something jointly across local authorities and health boards. Thank you.

Okay. Thanks, Cath. Jennifer.

I would agree, again, with everything that Cath and Gethin said. I think, from my perspective, this brings us back to the point that Gethin raised on deconditioning. We know that the longer somebody stays in hospital, the worse the impact on their outcome. We know that hospitals provide fantastic care but aren't always the safest place to be if you're frail and elderly in particular. I think discharge to risk assess and recovery is a perfect opportunity to look at how you do something different within a person's own home and their own setting, or within a care home that is much more about enablement and empowerment for that individual and their family. However, I think I would agree with Cath's point that the accountability and responsibility needs to be absolutely crystal clear. In Aneurin Bevan, we work with five local authorities, five different processes again. We've done a lot of work with our local authority partners to have consistency, but there are variations. We've again used RIF funding to enable us to have programmes of work that enable that D2RA process, but I think some of this does come back to being absolutely crystal clear on the points of the journey, and that does relate to some of the other barriers around the Court of Protection, mental capacity et cetera as well, being really clear around the accountability and responsibility for both the local authority and health. I spent a large part of my career in England, and I've worked in joint commissioning scenarios for, particularly, vulnerable groups, which I think have enabled us to unblock some of the accountability and responsibility concerns. But I do think there's a real opportunity to move some of this forward at pace in Wales because of the conditions in Wales. I think there's an opportunity for us to do something very different for these groups of people who need to be in a home-based environment, wherever that may be.

Thanks very much, Jennifer. Siân Gwenllian. 

Who would like to answer? Cath.

Thank you. The nature of regional partnership boards, as you've alluded to, is that it is a coalition of partners coming together, and they bring their own responsibilities and accountabilities with them. It's a place where we come together and try to line up our ducks across different agencies, heading in the same direction and not working at cross-purposes. I know that the knotty issue of whether it should have increased powers has been around the track a few times and there doesn't appear to be a strong groundswell of opinion that it should become more of a statutory arrangement and have increased powers. But where we have used it successfully is to try to line up our ambitions and to use that funding that we have—it's a free good-for-all, really, isn't it, because it doesn't require any of the organisations to, I suppose, take responsibility for funding a particular solution.

So, I'd say that, whilst that's a good sticking plaster, it allows us to test things out, what we have got to get into, which is what Jennifer was describing, is real clarity on accountability and responsibility for funding and delivering these services—taking out of the way that argument between local authorities and the NHS as to who is responsible and accountable and finding a way of achieving a shared approach. Because at the end of the day, this is a common cohort of people who we're all responsible for, isn't it? It's our population that we're there to look after. So, whilst the RPBs can help us to navigate a route through it, I think ultimately we need to look at the way that the policy and the guidance enables organisations to come together and we get that clarity of accountability and responsibility. 

The policy direction has always been clear, hasn't it? This is about doing more in the community, keeping people healthy, well and independent. We do have a crowded policy and programme environment that's coming out of the Welsh Government. We have multiple programmes that are all trying to address this issue. We've had the work that sits behind RPBs and the regional integration fund. We've had the work that the strategic programme for primary care is pushing in terms of how do we create that integrated community care system, and the six goals for urgent and emergency care is trying to do the same. And the care action committee has obviously put a great deal of attention on this.

There is something about coalescing around a single policy and a single ambition of moving towards an integrated community care system that is absolutely jointly owned by local authorities and health boards and we come to an accommodation between those different partners that this is the right thing to do. Because unless we really unpick some of the different views and opinions as to who is responsible, who is accountable, we'll never get out of the position we are in now, especially when funding is so pressurised across our system. Nobody is going to stand and say, 'Yes we'll take this and we'll fund it', because people simply can't—local authorities simply can't do that.

So, I think that a common approach—if we could negotiate that and navigate that through local authorities, through health boards—and whether the RPBs are the space that supports that to happen, I’d certainly support that approach.

I agree, Cath, with what you’ve described there around where the priority focus needs to be in terms of that initial question.

Reflecting on your second point around the capacity within intermediate care, I’ve got a couple of thoughts on that. The first is we’re already tying up an awful lot of resource to care for these people, we’re just caring for them in the wrong place. Certainly, from my own health board’s perspective, we are looking at how we use our budget differently to increase that capacity. We’ve made a very conscious decision to move resource from providing bed-based care in our acute hospitals into recruiting additional support workers into our communities to work in partnership with our local authority teams, but very much supporting those patients in those first six weeks once they are clinically optimised for discharge.

We know that, once we get a patient home, some of those patients will not need a package after six weeks. A number of patients will need a lower package than we first anticipated. So, it allows us to help work with the local authority-delivered services to try and right-size that, but very much working on a reablement principle—so, with therapists, with medical and nursing support wrapping around that service to deliver that uplift, as you’ve described, in intermediate care.

On the second bit around bedded intermediate care, one of the other challenges is that we’ve got a number of community hospital sites that we use as part of that pathway for those who are on a slower stream of need, but if you look at the current occupancy of those, they are materially impacted by those patients now who are absolutely needing to go on for long-term placement, either with a long-term package in their own home or predominantly those awaiting placement into the nursing residential sector.

So, I think one of the challenges is that we have got a lot of that capacity, but we’re not using it as optimally as we can to meet the needs of this cohort. Therefore, it’s a challenge, because, of course, we’re trying to work in partnership, very much, but some of the rules make that more difficult. It is a little bit about how do we make partnership working, both in terms of principle but actually in a practical sense, easier to do, and that we don’t then fall foul of the different rules that sit around health boards and the different rules that sit around local authorities.

I would say, though, coming back to your very earlier point—and I think both Jennifer and Cath have made this point around the accountability piece—I think it’s really, really important, because at the moment, we all report in different ways, and so there isn’t that consistent approach, I guess, from the centre of how, therefore, we are collectively managing that.

If I could just add, I think this comes back to my first point, which is around where you provide that reablement and intermediate care. The first point should be within the home if it’s safe to do so. If somebody doesn’t have an acute need that absolutely needs an acute medical bed, we should be attempting to provide that intermediate care as close to home as possible, and ideally within the home. I think if an admission is required, then direct access to a community hospital bed with clinician oversight from people who understand intermediate care and how you optimise people within their pathway is where we should be looking, because then you will be able to get that pull back to the home environment again, because our community teams work in a very integrated way.

But what I would say is that it’s difficult to comment on the resources, because I think you have to go back to the need. You have to go back to what is the need of the population, what is the evidence base. We know what the 10-year outlook looks like for health and social care, so how do we start to plan services in a way that wraps around those needs? I think that will give you your demand in capacity and therefore your resource ask, if there is any. So, I think some of this is about how we reconfigure systems in that place-based way, to make sure that we care for people absolutely as close to home as possible. And the first point should be the least acute bed, if that’s safe and appropriate. So, I think it’s how we move the system left, is how I describe it, back to that preventative community focus that I trained in some 30 years ago, dare I say.

Thanks, Jennifer. Siân, are you content?

Yes. Diolch.

Okay. Peter.

Thank you, Chair. Good afternoon, everyone. I just wanted to pick up a little bit on regional variations. We’re not looking—as the Chair said at the beginning—at a blame game or anything, but we’re just trying to understand the effective working practices between organisations, and from your views, if there are barriers or strengths that we need to understand or how things could be done better. I know, Gethin, you talked quite a lot about trust being a fundamental to enable that to happen. I don’t know if I was picking up that perhaps trust was an issue in certain parts of your own area, for instance, and I wondered if that irregularity is something we’re seeing across Wales and we need to find different ways to level out some of the barriers that are stopping that trust relationship being built. I don’t know if anybody wants to have a stab at that.

Jennifer.

I didn't know if Gethin wanted to comment first. From my perspective, there are some things we know that are effective interventions. For me, there’s an evidence base around various aspects of care across a person’s pathway. We do see regional variations; I have variations across five local authority areas within one health board. We do have this very crowded space, as Cath said, but there are some things that perhaps we should put our effort behind in trying to do consistently once.

I think trusted assessor—Gethin referred to trust—is one of those models. I understand there are lots of different models operating across Wales. We haven’t nailed a model particularly in Aneurin Bevan. If we are saying that we should trust each other’s assessments, we should do it once for the person, then we are going to have to move into that space of trusting each other to assess on each other’s behalf, or even across five local authorities on each other’s behalf for them.

But there is something about how we develop the multidisciplinary approach to this. I remember the days when we had hospital social workers. They were incredibly effective, and whilst the capacity doesn’t currently exist in the local authorities, I think that would make a massive difference to discharge pathways, because we would be having those integrated conversations where we would have trust and confidence in each other and be able to therefore do things once. So, I think there are some practical things that we should just put our effort behind on a national level to say, 'Actually, the evidence base says we should be doing it this way. Let's just do it this way.' I know there are complexities in accountability and responsibility for that, but that, for me, is the golden nugget about how we unlock some of this.

Yes, thanks.

Gethin.

Yes, I thank you for that, and agree with what's been said. Trust is a challenge, isn't it, and we're talking about trust between executive teams, we're talking about trust between senior operational leaders and then we're talking about trust between individual practitioners. That's a really big challenge, of how do we ensure—. Those people who've had those long-standing relationships will often go, 'Oh, it's okay, it's so-and-so. That's great. They know what they're talking about. That's brilliant.' We've got to make sure that what we've got is a process that supports everyone to operate in that same way and that drives out, I guess, some of that unwarranted variation. That, for me, is where we need to really focus some of our efforts, because if we do this right, and where we have teams that have got those long-standing relationships, it really does help. I guess it's also, going back to what Jenny was saying earlier about the patient being in their own home, the team that knows the patient best. It is always fascinating when community nurses come into the hospital and the ward team are saying, 'This patient is at this level', and the community team say, 'No, no, that's fine. That is their baseline, that's great. We know they can function at that level, we know what we need to do to wrap around.' And so there's trust between different parts of the health pathway, there's trust between different professions, there's trust, then, between different organisations.

For this to really function, it is about having that set way of doing this work, and I think having it consistently, because whilst, as a health board, we have a primary relationship with three local authorities, I also have a significant proportion of patients coming from other boundary health authorities who work in a very different way. Whilst we might have got a process between the three local authorities and the health board within the CTM footprint, actually, then, if it affects a patient from Powys or a patient from Aneurin Bevan or from Neath Port Talbot, it then is a different process, and how do we manage that? So, there is, I think, that necessity, then, for us to have that very consistent way of doing it, and it is about it being proportionate. I think that, for me, has to be the key bit in any assessment process; it's making sure that it's proportionate to the need to make the next decision, and that doesn't mean it has to be a complete process in that respect.

Cath.

Thank you, and, again, I'm going to build on what Jenny and Gethin have already said. Trust is utterly critical, but it's very, very fragile, and it doesn't take much to knock it. We do have our social work colleagues working within hospital settings, and, absolutely the point that Gethin was making, if you have colleagues who are community based, whether that's social workers or community nurses, they will have a very, very different perception of what's okay, what's acceptable and what's normal for that person and fine to get them out in the community than you will have from colleagues in hospital. So, we work very, very closely, effectively, in the integrated discharge team across the social workers, discharge liaison nurses and others.

Where it becomes challenged is the fact that we have different interpretations of the policy, of the legislation, and I think that's interesting in itself, because the legislation is there, it is what it is, but the interpretation of that is very different, depending on whether you're coming from a local authority point of view or a health board point of view. So, that points, to me, to flaws within the guidance and the legislation, if they can be interpreted in different ways. And it's that interpretation and that perception that sometimes, if we've got differing views or opposing views, can really challenge trust between colleagues all attempting to work together in that environment. But it takes effort, doesn't it? It takes effort and it takes investment from top to bottom, right through the organisation. If our exec teams are setting that tone of trust and good relationships, then that's infectious, isn’t it, down through the teams that are delivering services in and out of hospital. But I think it's that differing legislation impacting on different organisations, different planning processes, different policy, and then that room for differential perception and interpretation that can really challenge trust.

Okay, Cath. Altaf.

Thank you very much for this wonderful discussion, really. There is confusion, really, and I'm confused about one or two things. One is, when a patient is admitted, you're admitting the patient under one head. When a patient is discharged, he is being discharged by that head, and then we talk about the continuation of care, in which you have stages—I will not call it 'intermediate care'; I will call it one of the stages—either towards recovery or towards progressing towards something different, as in dementia, Alzheimer's, alcohol-related brain damage. So, I don't see it here; I see that the consultant under whom the patient is admitted is nowhere. Do you get in touch with him, telling him about the policies, legislation and everything, and then telling him how he is going to carry on this continuation of care of that particular individual? Because it's very confusing here.

And about the 10 days that the patient stays on the bed—10 days and he'll lose all muscle masses—does that mean that the patient is fit for discharge? But then you take away all the facilities, which includes the physiotherapy, which should be his right to have that there. Because on day 1, when he's admitted, we start physio and that physio continues until he is discharged and that allows him not to lose muscle mass.

Okay. Anybody like to respond to that? Jennifer.

If I perhaps make a start, I think—. So, deconditioning and loss of muscle mass is more than just about access to therapies. When someone's admitted to hospital, you naturally become a patient. That means that you put your pyjamas on and you get into bed; you aren't going around your house, making your lunch or moving around to the toilet. We take over that care in a very paternalistic way, which is what we are designed to do in hospital. So, our facilities don't necessarily enable people to operate in the same way, on a minute-by-minute, hour-by-hour, day-by-day basis. So, just the very process of being in hospital does cause that deconditioning, even if—. You know, we have therapies at the front door, we provide therapeutic support throughout our hospital environment, but that's not there every day. And almost it's that bit about this person isn't getting up and down every day, they aren't mobilising around the ward, they've got their pyjamas on, they feel like a patient, and it's how we change that in a way that enables people to be much more active.

So, there is an onus on us as health, but there is, I think—. It comes back to my point around admission avoidance. If we keep somebody at home, with home care going in three or four times a day, they are much less likely to decondition. Even if we bring them into hospital and we say, 'Well, actually, you need to get up and get dressed; you need to mobilise around the ward', it's just not going to happen in that way, because of the environmental issues. So, it is very complex. And I talk about pathways. For me, patients and people move along pathways. So, in the community, you will be under the care of your general practitioner, the community team or your community support, and you come in to hospital, but that's one part of your pathway. And I think we need to stop talking about discharge and talk about transfers of care. Because, when we get to the end point of your acute phase, we are simply transferring you back to the people who know you best. And, I think, sometimes, our hospital-based clinicians get very worried about that, but they shouldn’t, because, actually, they are simply transferring people back to their own home, their own environment and to clinicians who have a very good relationship with them, in most cases, and can provide that wraparound care as part of their recovery. So, I think it’s how we look at it as pathways, and I think the deconditioning is much more than about therapies.

Okay, Jennifer. Thanks for that. I think that's—. Hopefully, that's fine. Siân.  

I understand the arguments around the pathways. The missing link that we haven't talked about at all all morning is the unpaid carers and the third sector. And at the beginning of the pathway, if you like, they are crucial, and along the whole pathway they're also pivotal. And without recognition of the crucial role that the unpaid carers can help with—with a social care package four times a day, but the unpaid carers are the ones who are there overnight, and that is crucial—. And I just wanted to make—. Do you agree with that? 

I'm sure we all do, Siân. Thanks for making that important point. But, Peter, are you content? 

Yes, thank you, Chair, because there's a lot to get through. Thank you. 

Thank you very much. Okay. We'll move on to Lee Waters, then. Lee.

Thanks. So, just touching on the trust issue that we were discussing, I'm just reminded that the approach to nuclear disarmament is 'trust, but verify', and I notice that the NHS Confed is calling for annual reports on discharge information by local authorities and health boards, to bring a degree of transparency and accountability to this, which would potentially help build the trust. But if you can talk a little bit about your feelings about this and, similarly, on national indicators as well—.

Okay. Gethin. 

Yes, I'm happy to start on that. I think, as ever with data, data is there to—. If it’s there to drive improvement and to be there to share that some areas are working and able to deliver better, then I think that’s the power of putting that data into the public domain. I think it absolutely should be there for people to understand the services they would receive if they’re admitted to hospital, and their loved ones. I think it is absolutely around—. Yes, that transparency is crucial in terms of how we drive improvement and drive better performance, but also that we can then use that to share learning. We know what’s happening within our own microcosms, but I don’t really know what’s happening within Aneurin Bevan or within Cardiff and Vale, to understand where they are in the first instance, but, actually, is their data profile different to ours. So, I know that we’ve got different pressures driving the performance in each of our local authority footprints, and we do a lot of that sharing in between, and we do share that data really openly within our footprint, but that isn’t data that’s then historically been placed into the public domain. So, I think it is helpful that it allows us to have that more open discussion in that way.

So, you’d favour putting it in the public domain.

Yes. 

Okay. Can I just go on to information sharing? Because we've had examples where Cardiff and the Vale, for example, have made some progress in having shared IT systems for the Home First team, but we know, more typically, that it's not happening, and there are significant issues of friction in the development of digital solutions, and we've had Digital Health and Care Wales just put in escalation measures, because all these major projects are off-track. I wonder if you can tell us a little bit about your experience through the health board, and how much of an impediment do you think the lack of a coherent digital approach is bringing to this area. Jennifer.

Just if I start. I think it is a significant barrier. Gethin's already talked about the importance of shared information and data, and there is power to data. If you have data, it gives you an evidence base for improvement, and I think that transparency of data across health and social care is pivotal. It comes back to Siân's point also around carer information. How do we have a full picture of third sector carers, social care health that we can connect together, to design that improvement, but also hold each other to account? So, I think information on social care assessment timescales, information on the time taken to arrange a package of care. You can only really improve if you've got that transparency of data as a system, and something that we certainly are trying to focus on in Aneurin Bevan, with our local authority partners, is how we have that transparency, but also the systems that allow us to collect that, because our systems are very different at the moment.

And why are they still different, because this has been a problem that's been discussed for over a decade? Why is there no progress? Jennifer.

So, I think there are pockets of progress. So, we have integrated teams within one of our local authorities, where we're all on the same system. So, our community teams and social care teams all sit on the same IT solution. We have also done a lot of work—. So, we now have an electronic referral process. So, within the CTM footprint, we will automatically generate the referral to social services from the electronic whiteboards on the ward. So, all of that form filling that used to be there doesn't happen. The data is pulled straight from the electronic whiteboard on the ward, and the referral to social care happens immediately. That works for the three local authorities within the CTM footprint. The neighbouring local authorities don't accept our electronic referrals, because, of course, they have a different process with their core health boards. So, that means that we're then not in a place where we don't have to do all the paper stuff and everything else. That's one of the challenges.

I guess the other piece is what is the level of data that needs to be shared. Because there is an awful lot of data that health will collect in an electronic patient record that is probably not of much interest or use to the social worker looking after that patient, in the same way that there'll be a whole load of data that's been captured by the teams providing the domiciliary care that, again, isn't necessarily essential to the health team. So, it's being really clear about what is the core data set that everyone needs to know about the individual, and how do we report that. And that is about integration of data rather than a single system. But we've got to get into a place where our systems are able to talk to one another and not be focused on having a single instance of a piece that tries to do everything for all people. I think that's where we've been historically, that we've got to have one solution that does everything for everyone, and the reality is that doesn't exist. And, actually, a large proportion of that data is not of significant use to either party.

So, you favour common standards, data standards, rather than common systems. Do you feel that the approach that Digital Health and Care Wales has been pushing of common systems is counterproductive?

I think, in this context, I think what we need to have is a common data set that we use in that way and that that will absolutely need the ability to share that data in a joined-up way.

Yes. That doesn't answer my question, though.

It's difficult to answer, because I think, for different subjects, it might be a different answer. But in terms of that join-up at the moment between health and social care, I think it's far more about the interoperability of data sets rather than a single-system solution.

What's stopping progress happening? Because these debates are not new debates.

Well, at the moment, the local authorities are going through procurement exercises for the replacement of their legacy systems. As health boards, we're going through procurement processes. Thirdly, within my health board, we do not have an electronic solution in community services. So, we're going through procurement exercises at the moment for a raft of digital solutions. 

[Inaudible.]—procurement services, are they, between the local authorities and health boards?

Sorry?

The procurement services—

No, no. So, the statutory bodies are procuring their own solutions.

Separately?

Well, the local authorities are currently working, certainly within our footprint, together on that, but the legacy systems are now coming out of contract, which is why we're in a place where we've got to replace.

Sorry. Just so that I understand, are the systems they're procuring going to be interoperable with the health board system? Is that part of the design criteria?

Yes. That is absolutely, certainly the approach we're taking within the CTM footprint.

Okay. And is there sufficient, do you think, joint planning at a sort of granular level, to make sure that these digital systems are compatible?

I'm not a digital expert, so I fear I might be walking into areas that I'm not as well informed in as I could be. The reality is that, with the vast majority of systems that are now in place in these sectors, the ability to share data is a fundamental requirement because we have to be able to submit data to the national data registry. So, all of that is a fundamental part, so that ability to either push and pull data between systems or to feed the national spine in that respect is part of that solution.

Okay. Thank you.

Okay, Lee, you're content?

Yes.

Altaf.

Thank you, Chair. I think I'll ask about the solutions, really. What are your views on the effectiveness of the Welsh Government's strategic approaches on hospital discharge? What specific action can you think would have the biggest impact on reducing discharge delays, and where should efforts be focused both short term and longer term?

Okay. Some big questions there. Jennifer.

Those are very big questions. I think, from my perspective, as Cath has said earlier, there is a very crowded space nationally. We've had a number of different programmes and initiatives that are all working in a way that impact the flow within our hospitals. Therefore, for me, that whole pathway—the admission avoidance hospital pathway, the discharge pathway—from my perspective, the more that we can introduce a needs-led approach that focuses on consistency and the evidence base, but really works to ensure that we're able to take that 'What matters to me?' approach for patients and their families, is going to be absolutely pivotal. Because the 'What matters to me?' is important to somebody in terms of how we manage that pathway and where they end up in terms of their care, whether that's in the home or in a care home. And I think Siân's point earlier around carers is really well made, because, in large part, health and social care aren't there 24/7—they are for some people—but carers are, and listening to carers and the needs of the carers is incredibly important.

But for me, it's trying to make sure that we have the right assessment processes in place. We have that MDT approach, so a multidisciplinary approach, with social workers, hospital clinicians, community clinicians working together, 'What matters to me?' conversations with the families, and then that strategic approach to how we provide services in the community on a place-based approach that joins up the private sector, so the care home sector, the private domiciliary care sector, the social care sector and health, based on a needs assessment of that local population, is what's going to make a difference.

Okay. Nothing to add from Gethin or Cath, no? Altaf—. Cath.

Yes. Again, I couldn't agree more with Jenny's view on this. I think, in terms of how Welsh Government could help, there is something about having a common ambition that is absolutely shared across the NHS and local government. I think if you look, as you have done, and consider the evidence from different parts of the system, from ADSS and so on, there are different perceptions from the NHS and from local government as to what the root causes of the problems are. And I don't think we're in a space at the moment where we have a common view of that. So, getting to that root cause and addressing some of those root causes will help us move forward, and then having that common framework, common standards that we can all share and all work towards achieving. But I think there is so much different interpretation of policy, legislation, responsibility, that there is something about unpicking that and getting to the bottom of what is our common endeavour here, and really going back to basics, because ultimately we do share the population. We shouldn't be able to feel the divide between our organisations, but we do, and a lot of that is rooted in 70-odd years of history and legislation, isn't it, that's built, year upon year, on top of each other. There is something about going back to some basics around what is our common endeavour and the policy and legislative framework that can support us to have that common approach together.

Okay, Cath. Jennifer.

I'd just add two things. I think we need to make sure the outcome monitoring is in place and that's integrated. So, we look at a person-centred approach to outcome monitoring, and that has to be based on, again, the 'What matters to me?' conversation, because outcome monitoring against what matters to people is really important, because that's your criteria for success. The only other thing I'd say is the way in which, sometimes, funding streams flow— 

Yes.

—is not always an enabler to health or social care in providing an integrated response.

Thank you, Chair.

Okay. Altaf, are you content? Gethin.

Yes. I think, just building on that final point from Jenny about the financial flows, I think absolutely that doesn't always help, and we need to have a more consistent way of how that comes into the system. I think the other bit that links to that, then, is making sure that the rules around how we can share those budgets in a really practical way and move money to support that are also unlocked. We end up having to get into very formal arrangements and having some greater flexibility about how we can support one another to drive that would equally be very helpful.

Okay. Thank you very much. Okay, well, we've reached the end of our evidence session. You will be sent a transcript to check for factual accuracy, but just let me thank you, all three of you, very much for coming in to give evidence to committee. It's much appreciated. Diolch yn fawr. Okay.

Item 5 on our agenda today is papers to note. We have one paper, which is a letter from the Chair of the Public Accounts and Public Administration Committee in relation to the committee's forward work programme. Are we content to note that paper? We are.

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