Local Government and Housing Committee

It's our fifth evidence session now, then, with Care Forum Wales. I'm very pleased to welcome Melanie Minty, policy adviser for Care Forum Wales and Sanjiv Joshi, treasurer. Thank you, both, for coming in to give evidence to committee this morning.

Perhaps I might begin with a couple of initial questions before we turn to other committee members. Firstly, on social care capacity and workforce, we regularly hear, of course, about a lack of capacity in social care services and shortages in the workforce. Could you tell us about the current situation from your perspectives? What's the scale of the problem, as it were? Where are the main pressure points and how is that impacting on hospital discharge delays?

I think it's a variable picture across Wales. Certainly, the feedback from our members is that they are experiencing delays in discharges from hospitals coming to them because of delays in assessments, so there aren't enough social workers. In terms of the sector itself, social care workers—there is, in some areas, a very heavy reliance on overseas workers, which is becoming increasingly problematic for a number of reasons, but it's becoming more and more complicated to actually recruit from overseas and meet all of the legal obligations. It's also, I think, more than social care staff—it's very difficult to judge it in isolation. It's such a holistic picture, and I think a lot of the issues are from our community services, like general practitioners, not having access to wraparound services, but also the clinical staff. One of the common issues we hear is people finding it difficult to get through to ward staff when they're trying to arrange to go in and do an assessment. So, the whole system, I think, is rather creaky.

I think the social care sector—Sanjiv will correct me if I'm wrong—has probably stabilised a little bit since COVID. It's not as dire as it was, but the pressures are still there, and with the national insurance contributions, of course, coming in now—the extension—that's going to make it very, very difficult. I think we'll see that an unintended consequence will be that employers are forced to suppress pay increases that they had planned, and some will be making redundancies, so that is going to have an impact, obviously.

Bore da. I'd just like to add that although Mel has given you an overall picture, there are some changes that need to be recognised. Post pandemic, we were on our knees. There were two factors—Brexit as well as the impact of the pandemic—that meant that the workforce depleted quite severely. In a sense, overseas recruitment has been a saviour. We're now seeing problems, when we recruit so heavily from overseas, on assimilation and maintaining the quality of services. These are problems that can be overcome, but what we were facing was a cliff edge, as far as our workforce was concerned, at the end of the pandemic. So, from that perspective, it has changed.

Also, there have been a couple of initiatives that have assisted in stabilising the sector. For example, recognising and valuing our care workers with the Welsh Government initiative of a real living wage—that went a long way. There were a couple of boosts that our staff got with bonuses at the end of the pandemic. All of those were very well received, much appreciated, and assisted us in what was otherwise a very, very difficult, challenging time. So, we've got to recognise that there were improvements.

What we're now seeing is the impact of those particular initiatives not being carried through. We needed to build on them. For example, the real living wage—the first year, when it was announced and was implemented, providers had to give an undertaking to commissioners that we were paying the real living wage. Since then, that's become aspirational, as commissioners have not had the funds, or so we're told, to follow through and maintain those real living wages. So, we have, now, if you like, new problems arising out of well-intended, good initiatives, which aren't consistent and continuous.

Okay, thank you very much. Is there anything in addition to what you've already said that you'd like to bring to the committee's attention in terms of key measures to improve recruitment, and obviously to retain staff, to have a more sustainable workforce? We’ve heard as a committee about shortages of social workers and domiciliary care workers in particular. Is that your experience?

Yes, unfortunately, we couldn’t get a domiciliary care provider to come with us today, but I know that there are a variety of issues. Recruitment is always particularly difficult in rural areas. The nature of the work, of course, is very stressful and people are out working on their own.

The real living wage, as Sanjiv said, isn’t reaching the sector, necessarily, but the real living wage is really a drop in the ocean. We can’t compete with the statutory sector on terms and conditions, so we have to concentrate on trying to make the work as fulfilling and interesting as possible. That’s not always easy with the way the work is commissioned. A lot of work is spot purchased. There is a reluctance, which I understand, by the statutory sector not to block-book something that they might not need, and that would be a waste of public funds, in their opinion, but it means that providers can’t actually offer guaranteed hours, in many cases, especially in domiciliary care.

We’ve also got a rather perverse situation now where there have been bidding wars in certain areas, which means that more people are coming into the market, the work is spreading thinner, and there’s not enough work to go around all the agencies that we’ve got out there, and that’s particularly difficult for international workers, when you need to guarantee their hours.

What I think we would like to see is a much greater emphasis on commissioning for outcomes, rather than transactional commissioning. It’s better for the individual, but it’s also better for the care workers, because they’ve got more time, they’re not being measured on how quickly they travel between clients, and they can spend time with that client and actually make sure that they’re meeting their outcomes and not just giving them their medication or washing up their breakfast things. I think that fulfilment is key for us.

Okay, Melanie.

Perhaps I can just add, on the capacity side, and Mel’s described it, we have capacity, it’s not that we don’t have capacity, but the whole commissioning structure of spot purchases means that we’ve got to adapt and change for the needs as they arise, which is very difficult when we are working in a sector where you’re trying to provide a service on a longer term basis, which means you need a stable workforce, you need a motivated workforce, you need to provide career paths et cetera. It’s very difficult when the overall environment you’re working in is one where you’re spot purchasing, or where commissioning is on the spot. It becomes a transactional-type arrangement, which doesn’t work well with having continuity and consistency in our services.

Yes, thank you very much. Peter.

Yes, I just wanted to—. Something you said, and what we’ve just talked about—you’ve got enough capacity. In fact, there are more people coming to the market and there’s not enough work to go around. I’m trying to correlate that with the messages I’ve heard from local authorities that they have hundreds of hours of unmet need each week. I remember one chief executive telling me, 'Peter, you can give me as much money as you want, that won’t cure the problem, we can’t get the people.' So, I don’t know what—. Has this change happened recently?

Yes.

In theory, then, there'll always be elements of unmet need because you can't set up contracts quick enough and things like that, but that shouldn't be a big problem now, should it?

I think it’s very variable. I think that’s happening in certain areas depending on how the council contracts and whether they run a bidding process or they use favoured providers, as it were. There will still, I think, be some problems. Historically, west Wales has always been more difficult because of tourism—young people want to work in the tourism industry in the summer and then come in in the winter, so you’ve got constant churn. So, it’s very variable, I would say. There are still recruitment issues in some places, not just in social care workers, but in nurses working in social care. That's a particular issue for us.

Can I explain the point we're making here? When we say there is capacity available, it's not permanent. It also changes according to the processes of commissioning. So for example, when we talk about a bidding process, imagine you have a domiciliary care provider who's been providing those services for 20-odd years but is being now undercut by a newcomer. At some point that's going to put in jeopardy the business that they've been running for 20 years. So that capacity may disappear, and therefore you end up with capacity and shortage at different points because of the process and the way it's being procured.

I think Peter will come back in a minute, but just before Peter does, with the elderly mentally infirm beds, is there a particular problem there in terms of shortage?

That's my perception, certainly what we're told by commissioners. You need more care hours when the people you're looking after need more support. I think it's perhaps some of the older residential homes that don't provide nursing haven't kept pace and don't provide that service, but it's also again down to funding. There is, I think, one area in Wales that doesn't actually pay a higher rate for EMI than they do for standard residential care, and that's replicated throughout the funded nursing system as well. It reduces incentive, not because you can't make the profit, but because you can't break even if you're not being paid to provide the hours of care that you need. There are some areas where, possibly for historical reasons, I don't know, it has become particularly bad and there isn't enough EMI.

I would say the way the funding works is at the heart of these issues. There is capacity, but in the wrong places, if you like. Where it's needed, if the funding isn't right, you're not going to have the capacity. As a care provider, I run an organisation where we have 14 care homes across south Wales and mid Wales, and when we set up any provision, it's a long-term plan and we work on a business plan with certain levels of funding. If the commissioning priorities change and the funding streams are in some way distorted, we can't work to those plans, we can't offer those services. If we then repurpose for other services, that's capacity lost where the need is. So in a sense, from my perspective and from most providers' perspective, it comes down to funding.

We've been running care homes in Wales now for 23 years, and we see over that period how decisions made on funding, on direction of what care is required, what the priorities are, impact the needs and what we can provide five years, 10 years later. There were some funding issues seven or eight years ago on recognising the additional resources needed for dementia, and I think that's played out when providers have looked at what provision they want to provide. They, if you like, despite the demand being high in those areas, have moved away because it's not viable for them to run businesses for that purpose.

I see. Sanjiv, thank you very much. Peter.

I wouldn't mind just exploring RPB funding. I know you've been quite critical of regional partnership boards allocating funding, particularly for the creation of more step-down and reablement services. You say funding is largely going in-house, and that many supposedly new models of care appear to be just extensions of existing statutory services. So I just wondered, can you tell us a little bit more about your views on this and the changes you want to see in the way that the RBPs commission?

I think part of the issue is a confusion between the not-for-profit agenda for children's care and the rebalancing agenda of having a reserve of in-house provision in case a monopoly provider goes out of business. What we're seeing is an increasing number of local authorities are receiving funding particularly from the accommodation with care grants to build care homes. Some are supposedly new models but, to me, they seem to be just like a very expensive niche care home that probably will be very expensive and never recover its costs.

For instance—I wouldn't normally name—in Carmarthenshire they are building a home for £19.5 million, where there is capacity throughout the county, and people have got spaces in their care homes. At the same tame, none of the regional partnership board funding in the majority of partnership boards will actually reach the sector because it's all earmarked for rebalancing, for new models of care or for preventative measures. Regulated care services are not just private providers, but third sector who are providing regulated services. It's kind of left out on a limb. I can't see any particular evidence from the boards that I sit on that it's being engaged in any of these new models of care.

That's really interesting. That's quite helpful. Thanks for that. Moving on, just a point about joint working. I just wondered how effective joint working practices between partners, particularly health and social services, are on hospital discharge. Are there things that could or should be done differently?

Yes, definitely. The funding is probably the key issue again. We do see delays caused by disputes over funding, but we also see local authorities being forced, more or less, to accept clinical decisions where the person's needs are definitely underassessed. So, in some areas where this happens a lot, providers are beginning to stop taking people from hospital, so that has a big impact. And, of course, it has an impact on local authority budgets as well and on the rights of the individual, because there are people in care homes who should be receiving continuing healthcare and shouldn't be paying for their care at all, from what I've heard from people.

So, it's partly funding, and I don't think integrated funding is working as it was expected to. Most regions have put up some sort of system, but they're all different. For some of them, it'll be integrated in name only, and there's still very much a debate over who pays for what. I think the relationships will be different as well. My perception from sitting on different partnership boards in different areas is that some health boards and local authorities—. Particularly with the financial situation at the moment, there's a lot more tension between them.

It's almost like that different partners don't understand or don't want to understand the other partner's situation, so you can't arrive at a holistic understanding of what's needed.

Yes.

Yes, and we struggle to understand why we have a delayed transfer of care issue as providers. If we stepped back, really, there are three major stakeholders here and, in a sense, by framing it about how local authorities work with health boards is perhaps missing that there is a third stakeholder here, which is the provider. For the system to work, these three have to work together and find solutions. We struggle with how the system is, if you like, developed and imposed, and it's probably the reason why it doesn't work as efficiently as it should.

From our perspective, we're sitting outside those discussions. All parties want to avoid delayed transfers of care. In the NHS, you have clinicians saying how patients get deconditioned; once they're clinically optimised, they need to be out, for the best for the patient. We have providers who want to take the elderly admissions; that's our business model, that's what we want to do—we want to deliver care in our homes. And we have the local authorities, who want to discharge.

It all comes down to protecting budgets and how they're set up. If you look at the holistic, as you put it, it's costing £500 a day to have a resident in hospital, when the solution in the care homes is at about £200 a day. So, you would have thought that, somewhere, we would be able sit round a table and solve this, and have the resources applied in a way that they don't work against each other.

We've heard it several times when we've taken evidence: is there enough sharing of data and information across, certainly, health and social care? I wonder how you fit into that. Do people ask you for data, or can you access the data you need when you have got to provide something?

As far as data, I think the local authorities and the health boards have all the data they need. Most care homes provide weekly updates on how many empty beds they have, and I think the capacity in the domiciliary care sector is similarly reported. We report in. What we don't see is the needs, et cetera, the assessment process of when we need to assess—. The system doesn't work efficiently. To give you examples: we've been sitting through, trying to work with the different parties to resolve some of them. The sorts of issues that come up are that the homes did not come to assess, there have been delays in assessing. But the counter to that is, sometimes, the same assessment is sent out to five different providers. So, when this happens repeatedly, four providers miss out, then there isn't really the urgency to go in and assess. These are simple examples, but these are things that can be sorted out, because, ultimately, there's only one assessment and one bed that the person needs to move to. Therefore, there is no reason why that can't be resolved.

I think there's a wider issue as well. If they could have some sight of the assessment, it would help care homes in making a more informed decision. It's much easier, if you've got a balanced view of someone, rather than a snapshot of visiting them in a hospital bed, to understand whether you can meet their needs, as well as the fact that we quite often hear about patients being discharged into care homes and arriving without their medication, without all their records, without a recently agreed do-not-resuscitate plan—all that sort of thing. I know, in England—and I think possibly Scotland—providers, for some time, have had access to NHS e-mail, which we haven't got in Wales, because I think it's quite expensive, so it hasn't been prioritised. But I do think that would help.

If I may just go back to the previous question, about the integration of where social workers and hospitals could work better together, we were reading the response from the British Association of Social Workers about the need for social workers to be more respected in hospitals and to be more engaged, and I think that's absolutely right. Because if you discharge someone based just on a clinical diagnosis, then you lose everything that the social worker brings about the holistic care and their well-being, and they will know the care homes in the area a lot better and know what they can provide and what's suitable.

What we often find is people will come in with a clinical diagnosis, but they have social needs that can't be met—they might wander, for example, they might be more dangerous in their behaviours than people have been led to believe. But once they're in the care home, it's very difficult to get them reassessed. I've seen some awful threads of conversations on our WhatsApp group, with people desperately saying, 'I have someone who has started to become violent. It's not safe for other residents or for staff, but there are no hospital beds. Social services, it's out of hours, so there's no-one there. The police don't want to know. What do we do?' And in the end, they probably end up calling the GP and asking for sedation, which is not the response that you want. So, there are some quite serious impacts of not getting it right.

That was really helpful. Thank you. That's all from me, Chair.

Okay. Thanks, Peter. Siân.

Moving on to social worker assessments, you've—[Interruption.] That's fine. We've touched a little on this already, the social worker assessments. How much of a barrier is that in the process of discharging people from hospital—that wait, perhaps?

Sorry. I didn't entirely get it, but I think you were asking how much the lack of co-ordination between the two affects discharges.

Social workers.

Social workers, sorry.

I was asking about the assessments—the social worker assessments—that need to happen. How much of a blockage is that in terms of the discharge?

I think it can—. I think, in some areas, it's probably worse than others. But, certainly, I've heard from one member, for example, that someone was in hospital for about six weeks because the social worker was off sick and there was no-one to provide cover for them. So, at that point, yes, it can become quite dire. It's getting access to people out of hours and getting access when people are on holiday, and there's no-one to backfill.

Does it help when there is a social worker based in the hospital?

I would imagine it would do. I think, if you can—. It's got to be more streamlined, and it's got to enable the two to integrate and to understand each other better, and to work together more co-operatively. All the pilots that people have done in the past about sitting people in together, it has helped. It's helped boost co-operation, because it has to, if you're sitting next to someone and you're getting to know them and understand them. So, I think it can only be a good thing.

Yes, I endorse that. In our experience, the social worker's role in the hospital setting is invaluable, and, in fact, when you bypass that, you cause bigger problems down the line. Again, that's picked up by the number of times discharges repeat admissions to hospital and so forth, and the number of times the patient or the resident has to move elsewhere, if it isn't the appropriate placement. I think what came across was there needs to be high value on the input of a social worker in the hospital. They need to be valued, and that would make a big change, and we think a very positive change, to the flow through the process. But also I think we've also got to protect the decision-making processes and not have, for example, funding or budgets imposed on those decisions. For example, as Mel said, if the social worker has identified the right setting, and funding is an issue, then that should not mean that the decision is forced onto the social worker to make an inappropriate placement.

But what happens is, when somebody arrives at the care home, there's another assessment that happens. Is there a need for the two assessments? Should the social worker assessment, and that interaction with the person, continue throughout that person's life, really?

Sure. Absolutely.

But it doesn't.

It should do in theory, shouldn't it?

Our assessment in the homes are based on the assessments that we receive, so we have to have that starting point. Clearly, over a period, those assessments get reviewed and the needs change and so on, because these are long-term placements, but it is key to have the right picture at the start, otherwise very valuable time is lost in delivering the right care.

And it is set out in the legislation as well that you have the initial assessment, and the provider has to do their own assessment to confirm that they have the correct level of staffing and qualifications to be able to meet that level of care.

Turning to the most complex people, who need care that is expensive, is that a particular—? I think you referred to that, about protecting budgets. Is that a particular area that we should be looking at, in terms of the discharge?

I think it is, particularly, in some ways—and this isn't Sanjiv's area so much—in younger adult care, because those can be very expensive packages, because you've got younger people who have more social needs. A lot of it tends to be 1:1 supervision, and that's where, quite often, there's a misunderstanding of what makes 1:1, what does that actually mean. And I've heard of commissioners going into homes and saying, 'You're spending too much on food.' Things like holidays are being drastically cut back for younger people. You do hear, in certain areas, that there will be disputes because a social worker will place someone in a care home, and the care home will say, 'Yes, we can meet their needs.' But then the commissioners within the local authority will say, 'Well, I didn't agree that, and I'm not paying that.' And then you're left with nobody wanting to pay the bill or to put someone somewhere else. So, I think that is particularly vexed. But it certainly plays out in older people’s care as well, because the funding doesn't follow the individual's needs and the attention that they need.

Can I add? I think the special packages and the higher cost packages are only amplifying the underlying problem that we have in long-term care. So, if you think about the basic packages for care homes, we have different categories: we have residential, EMI residential, nursing, and EMI nursing. If you look at the packages there, if you look at the fees—or what we like to call the individual’s entitlement, because that's the funding, the budget, that the local authorities provide—there is such a variance in fees. I think we have submitted the fee table to yourselves, but, just to give you an example, we have two neighbouring local authorities where the nursing fees per week, there's a difference of £180. That's £9,000 a year. It's not far from here, and I don't think—. It's public, so I can share that we're talking about Cardiff and Rhondda Cynon Taf. The difference in fees is around £9,000, yet we have—. So, imagine the pressure that puts on. And it's not driven by the needs. So, the needs would not be that different from a placement in Cardiff to a placement in RCT. But when you have those sorts of differences in budgets, you find that the placements become difficult, the packages become difficult. That then gets amplified into packages at higher levels. The basis, the value basis, of establishing the fees are not standard, not universal, not on an equitable basis.

Okay, Siân?

You have more questions on that, I think. Yes, thank you.

Okay. Lee Waters.

Thank you. Yes, just to follow up on that, then, you said earlier that one of the issues that the private sector had was the issue of viability as businesses. And, obviously, you’ve just told us there's great variation across Wales in the levels of fees that are agreed. So, is there a typical level of viability? Is there a typical level of profit that makes this a worthwhile market for the private sector to be in?

I think what we do is that we work on business plans—. I'll now talk from the care home perspective. We work on business plans set out over 20 years to provide a service to see what it is viable. Of course, we have to have profits, and we don't see 'profit' as a dirty word. But these are capital-intensive businesses. For example, the average capital employed in setting up a care home and running it, in the private sector at present, is now around £250,000 a bed. So, there has to be—

Just to be clear, I’m not using this as a pejorative at all; I’m just trying to understand, for the purposes of planning, what is the minimum viability level that the NHS should be assuming the private sector needs in order to be a part of this sector.

Right.

Is there a percentage?

The fees are set per resident, and they’re set through a methodology. And this is where the problem is, that the methodology isn’t applied consistently throughout Wales; it’s driven by the local authorities. So, we look at—. Providers will provide their information, financial information. They’ll go through the vetting process, et cetera. And then a fee will be set based on that. But it’s not done consistently, and, at times, it’s sort of reverse engineering. It’s what the authority can afford in their budget, which then works back into our fees. That leads to those variances.

I understand that, but what I'm trying to establish is: what is it? Is it 20 per cent, 10 per cent, is it 1 per cent? What is the working assumption that the NHS should have of the level of viability that the sector needs?

Okay. Sorry, if I can assist you, percentage of what? Are we talking about fees? Are we talking about capital employed, profit-based—?

Sorry, you said earlier that there’s a minimum level of viability needed in order for the private sector to operate. I’m just trying to establish what that minimum level of viability is.

Well, we try and work on an 11 per cent return on capital employed.

Okay.

That does change, depending on interest rates, depending on external factors, how available capital is. When capital is tight, that needs to be higher. When capital is more available—. It seems to be going up now from the 11 per cent.

I understand. Thank you for answering the question. So, across Wales, you said, different local authorities and health boards are providing different levels of fees. Are there areas of Wales where that 11 per cent is not achievable?

Yes, that's the problem.

Okay.

And just to answer your question, the 11 per cent of what is also important. For example, we have some authorities using £80,000 as the base, others using £60,000. And if you look at comparisons—. For example, in Carmarthenshire, they use £80,000 as the base, but Carmarthenshire themselves are now building an in-house home at £330,000. So, it also matters what that 11 per cent is of, on the viability.

Okay. And I think you mention in your evidence that two boards, Cardiff and Vale, and Aneurin Bevan, are more effective than others at commissioning. What is it that they’re doing that the others should be learning from?

I think they recognise the costs better. What we would say is there are always going to be variances, but they engage better. Aneurin Bevan and Gwent local authorities have for years worked with providers on understanding their costs and working their fee methodologies around that. And similarly, Cardiff and Vale have very active engagement with providers. So, their understanding, and their fee-setting processes don’t get in the way of commissioning, whereas, with others, the tensions arise on those basic areas, and we don’t get past that to be able to have the conversations about what are the appropriate placements, what are the best outcomes for the residents.

So, does that mean that there’s no consistent approach across Wales?

Yes, very much so. We’ve been looking forward to the—excuse me—new national office coming up with a fee methodology so that we can apply consistency. Sorry. And that, I think, would include agreeing a consistent level of profit or return on investment. Sorry. It's not really—

Have some water. Take a break and have some water.

Just while we're waiting, could I bring Laura in, because, Laura, you wanted to come in on this particular point, did you?

Yes. Thank you, Chair. I just wanted to say that what I've heard from visiting care homes is that the consistent methodology needs to be there, because it's different between neighbouring constituencies, and it's not really a suitable method. There is always going to be fluctuation in terms of costs that care homes face, but there have been significant costs recently—national insurance up, food up, energy up, the real living wage up et cetera—to the extent that some care homes have said they're on the brink of closing, particularly the ones that have just established themselves, not so much the long-established ones. Have local authorities reacted to that at all in terms of the percentage that they're putting forward to you? Because obviously they're struggling as well. I was just wondering about your thoughts on that, just to add to what Lee said.

Again, it's very variable, partly because there is no fee methodology, and partly because a lot of areas aren't engaging with the sector to understand those costs and those increases. Some are more transparent than others. For instance, Cardiff, whilst giving a really good increase this year, has been very honest in admitting that they know it's not going to meet all the changes, whereas other local authorities in the past have been known to make an offer and say, 'And this will cover all sorts of things' but you know it can't possibly, because it's such a low percentage. There's no accountability or explanation of how that fee is arrived at, often. But yes, I do think it's very inconsistent, and in some areas it actually feels as if the sector is being deliberately underfunded and that it will be compensated by people building their own in-house care homes.

I'll just bring Peter in briefly.

Thank you, Chair. It's on that point, on viability issues. I'm anxious that perhaps there's an all-singing and dancing new public sector thing put in place and it's got multimillion pounds; actually, they should always be working on best value as well, and creating value for money. What would be their return on capital invested for their section? If they're only going to turn over a 1 per cent or 2 per cent value for money on that, where there is capacity in the system already, which could have delivered what they were trying to fill, all they're doing is eroding the opportunity of the private sector to fill the gap.

You've summed it up. We can't understand. It sounds irrational. We know that in the public sector, for their internal accounting in the past, they would have a contribution of 8 per cent on their capital. I'm not sure whether that still applies. These are not publicly disclosed numbers, but certainly it's not value for money, and ultimately even if it was what we would call 'free money'—Welsh Government grants et cetera—there's a national debt, which is at 5 per cent or higher. Therefore, you've got to put some number on the cost of that capital. You've summed it up. We have the private sector delivering incredible value for money and being eroded by underfunding, and then we have the replacement—the public sector spending four or five times that amount. It doesn't make sense.

And in addition, it's not unusual for local authorities who have their own care homes to charge about £200 a week more to clients than they pay to the independent sector.

Can I just add? It kind of adds to all the questions that have been asked. As independent providers, ultimately the costs are very similar throughout Wales. If you think about how carers are now underpinned by the real living wage, and other costs—utilities, food, environment and property costs—are very similar, when we have these sorts of variances and underfunding, we would say the ones who have sat with us and looked at our costs are closer to the true cost, and that would be the likes of Cardiff—the local authorities at the top of the table. With the ones that aren't, providers have to respond because they need to survive. So, what we are seeing more is that we're now turning to third-party contributions—we're now having families contribute to have the residents in a home, which is highly inequitable. It's unfair on those residents that it's being subsidised, although it should be provided through the local authority funding, or, for that matter, through the NHS funding.

Okay. Lee.

Thank you. Melanie Minty was telling us earlier that she acknowledged that there was monopoly provision and that when that provision collapsed, there was obviously market failure and there was a role for the state. Just in terms of your debate, you're obviously saying that the state shouldn't be getting involved and we should be utilising the private sector first. Obviously there is a huge danger in over-relying on the private sector, because we've had corporations buying up large homes, driving down prices and standards in order to maximise profits, and then going under. So, there's a legitimate role for the state here, isn't there?

Yes, there is, but I don't think there are that many of that kind of care home out there anymore. And in an area, for instance, like Carmarthenshire, where this big new build is going on, the majority of care homes in the area are small and medium-sized enterprises, family run, and because they haven't got the reserves of the larger companies, they're going to probably go under first.

Just to show that it's a problem for all providers, third-sector care homes are commissioned in exactly the same way as the private sector providers, and most of our third-sector members have sold their care homes because they are not viable. So, whereas the private providers are doing what they can to move investments around and take loans out, the third sector can't do that in order to comply with the regulations on charities and most of them are leaving. Christie & Co did a report that showed that 40 care homes had closed since 2022.

Can I ask about the national framework for commissioning, which was published last summer? Has that started to have the effect that it was designed to have and are there lessons that can be learned already from that?

I would say that it hasn't made any difference at the moment—it's very much in its infancy. I think we're pinning our hopes on the national office. I think in the future, it will be very helpful, but there have been issues in being able to recruit people to the new office. We have a little frustration in that there are toolkits—we did a lot of work a couple of years ago with Professor John Bolton on the 'Let's agree to agree' toolkit. So, it's there, but not being followed in a lot of areas. So, it is frustratingly slow and I don't think it will come soon enough to avoid some of the immediate pressures that we're facing, but in the long term, it will be very valuable.

And just finally from me: are there things that we might recommend as a committee that would help?

Can I just come back to the point about large corporations and private equity et cetera being in the market? The reality is that, in Wales, they're probably less than 5 per cent of the market. The majority of the market, of our members, are small and medium enterprises. We've heard several times that this is a big concern, but I think it's an imaginary concern, and there are—

Well, with respect, it was your colleague Melanie Minty who used the term 'monopoly supply' earlier. Any monopoly provides a danger to provision, doesn't it, whether it's a private equity-owned monopoly or it's locally owned monopoly. A monopoly is a monopoly.

We would say that the dominant players and the monopsonies are the commissioners. If you think about placements, they probably control 80 to 90 per cent of the market. We are price takers—we can't set our prices. We are commissioned and our, if you like, referrals are admissions, which come primarily from the NHS and the local authorities.

Sure. I think you've made your point clearly that there needs to be a greater consistency and a greater openness about the viability that is required from the private sector, and that needs to be factored in if the NHS wants to use the private sector. That needs to be understood and that's the price of doing business. If it doesn't, as you rightly said, it needs to show the alternative provides value for money. I think that is clear evidence and helpful.

I want to just finish by asking this: you said the national commissioning framework is still in its infancy and hasn't lived up to its promise yet; are there things we might recommend that could help with that?

I'd like to see the Welsh Government hold commissioners more responsible and accountable for the fees that they're setting, rather than taking a step back and saying, 'Well, it's a local decision.' Yes, it is, but when you know that funding isn't going where it's supposed to—. I know there are a lot of arguments against it, but there are things like not ring-fencing the funding for real living wage, so that in some areas, it was not spent on real living wage, it was spent on libraries and so on. That's not helpful to the sector in making sure that the money is going where it's needed.

Thank you.

I think that's all we have time for, I'm afraid. Thank you both very much, Melanie and Sanjiv, for coming in to give evidence to committee today. You will be sent a transcript to check for factual accuracy. Diolch yn fawr. Thank you very much. We will break briefly until 11:20.

This is evidence session 6. I'm very pleased to welcome Rob Simkins, head of policy and public affairs for Carers Wales, joining us here in our committee room, and joining us virtually, Kate Cubbage, director of Carers Trust Wales. Thank you both very much for coming in to committee to give evidence today. Perhaps I might begin with a couple of initial questions, and then we will turn to other committee members with further questions. Actually, sorry, Peter Fox will begin and then we will hear from other committee members.

Good morning to you both. I would like to start by touching on the role of local authorities. I'm just wondering if you can talk us through the specific role and responsibilities that local authorities have to support unpaid carers in the hospital discharge process. Can you describe what should happen in contrast to what currently often happens when the cared-for person is being discharged from hospital?

I can go first, if that's okay. In terms of local authorities' responsibility to unpaid carers throughout the discharge process, much of that is underpinned by the Social Services and Well-being (Wales) Act 2014, which outlines duties on local authorities in terms of support for unpaid carers, providing information and advice and support, carers' needs assessments and proactively going out and identifying unpaid carers and helping them to recognise that they are carers as well. So, that would probably be the main bit of legislation that underpins local authorities' responsibility in that respect.

In terms of what is currently happening and where we would probably like to be, practice differs and varies across the health boards, across local authorities, which I think is probably an issue in and of itself, there's not enough standardisation. But there are pockets of good practice and pockets of practice where things are just not working. That's placing massive amounts of pressure on unpaid carers, on who they care for, and it means that when people are discharged from hospital settings, often that discharge completely falls apart and they're readmitted. So, I think, yes, we're a long way from where we want to be and unpaid carers supported adequately by local authorities but also by health boards can play a key part in addressing some of those issues as well.

Thank you. Kate.

Absolutely. So, in terms of hospital discharge, unpaid carers remain an often unseen and undervalued partner in ensuring that patients are discharged from hospital to the community safely, efficiently and sustainably. I'd like to highlight that initiatives such as discharge to recover then assess have had real unintended consequences for unpaid carers and have resulted in patients with high care and support needs being discharged into the community before carers' needs assessments have been undertaken. This is both because of waiting lists for carers' needs assessments and because the choice to action local authority assessment for those with care needs at a later date has, in some cases, resulted in carers having to have their needs assessed along the same timeline. This is especially the case where a joint assessment has been requested, or even presumed as what the carer wants. So, we believe that there's an important opportunity for carers' needs to be assessed and that has to happen at the earliest opportunity.

As committee members will be aware, local carer organisations across the country, including network partners of Carers Trust, provide specialist hospital facilitator or hospital outreach worker services. These provide really vital support for carers who are caring for a person in hospital and as that cared-for person is discharged from hospital. But a challenge we face is that these are often funded on a year-on-year basis, either by the health board or through Welsh Government ring-fenced annual funding, or regional partnership boards, therefore local authorities by extension, via the regional integration fund. And speaking to the point that Rob has made around inconsistency and variation in approach, that lack of certainty around funding has made embedding services and staff retention really challenging, and these are key to pathways of getting carers to local authorities to have those assessments that they have a statutory right to.

Both forms of service that I've described should be referring carers into carers' needs assessments, but we know that that isn't really happening. So, if I refer to the Public Services Ombudsman for Wales's own-initiative investigation, 'Are we caring for our carers?', which was published just last year, it shows that just 2.8 per cent of carers are actually having their needs assessed, and half of those are receiving a support plan to meet their needs. That report noted that early identification is key, and as Rob described, that role for healthcare professionals and the health board, alongside local authorities, is really key; they need to connect together. This research, I think, in addition to the Association of Directors of Social Services Cymru rapid review in 2023, is really compelling. That review itself highlighted that there are waiting lists for carers' assessments in most areas, which prevents carers from having the support that they need, and many carers are not being offered an assessment as a result. The report also captured the lack of referral from healthcare to local authority as a barrier to effective support for carers, describing questionable engagement from the NHS in some areas, with one interviewee saying that they had not received a single referral from GP, district nurses, or the hospital discharge team in three years.

Thanks for that. That's really concerning, because unpaid carers are just fantastic and they fill a huge void in our care need, and I hate to think that they're being taken for granted. Their assessment needs are fundamental, and I absolutely hear the point you make that that should happen in advance of, certainly, the people they're caring for coming home. So, I suppose that leads me into the next question a bit, really, because, talking about barriers, what are the current barriers to ensuring that unpaid carers can access local authority support when the person they care for is discharged from hospital? It seems that unless they know what that carer is up against at home, how will the authorities support them, unless they know that, so I don't know—have you got any views on that?

Yes, I think there's just a massive lack of knowledge and data Wales-wide, but, again, practice varies, with regard to carers' needs. Some of that is because such a pitifully low number of carers are having their needs assessed. You can measure it a number of different ways. By the most generous measurement in our 'Track the Act' report, 8 per cent of the carer population in one local authority area are having their needs assessed over a 12-month period, which is not what the Act sets out—far from it, in many ways.

So, the lack of carers who are having their needs assessed is a massive issue, in terms of them being able to plan. We know that via regional partnership boards there are meant to be population assessments and planning going on, and carers form a part of that. But if you aren't having carers having their needs assessed, how on earth can you adequately plan and try to be deliberate and strategic over the medium-to-long term in terms of the issues that they face? I think there's a significant failing there.

I do have a lot of sympathy for colleagues in local government, because they've faced a challenging period for a number of years—they're juggling a million and one other duties. There are ways that, without additional capacity and resource, practice could be improved, and we work closely, along with colleagues in the Carers Trust and along with colleagues in local government, to try to do that. But without greater capacity and resource to permit local authorities to carry out more assessments, that will have an impact on their ability to plan and that will have an impact on carers being able to access support as well. There needs to be leadership that comes with that capacity and resource too. The Wesh Government—. Yes, it's councils' jobs to implement the Act, but, you know, can we stop passing laws that we can't implement? There needs to be leadership around that implementation gap there as well.

Yes. I'm not sure if—.

I don't know—Kate, did you want to come in on these points?

Yes, absolutely. I, of course, would agree that unpaid carers are exceptional people, and I would like to highlight to the committee some of the barriers that unpaid carers face by sharing a story from an unpaid carer. This story is from 2024, so relatively recent. It revolves around an older couple, both with health problems and poor mobility. I'm not sharing geographic information about this case study—I'd be happy to do that privately with the committee, but I don't want to remove the anonymity of this carer who has shared their story.

So, in this example, the husband has been in hospital for eight months, and his wife, despite significant health problems of her own, visited daily. The journey took her two and a half hours each way by bus. During the eight months he was in hospital, a discharge plan had been discussed on several occasions. However, a decline in the patient's health had meant that that had not been possible, and the discharge was delayed. One day, the carer arrived to visit her husband as usual. But on arrival, she was informed that her husband had been discharged and was in an ambulance on his way home. Understandably, the carer was upset and was anxious, as there was no provision for her husband to get into the home, and she didn't know how she would be able to cope and provide the care that he needed.

A health board-funded commissioned care officer was able to respond really quickly, liaising with ward staff to explain the gravity of the situation. The hospital arranged a taxi for that carer to get back home, and also arranged for an emergency response team to provide support that weekend, until a social care package could be put in place. However, the carer was unable to cope with the level of care that her husband required and without the necessary home adaptations being put in place. The following day, an ambulance had to be called and her husband was readmitted just 40 hours after his discharge from hospital. He remained in hospital for a further two months.

As you can imagine, that carer was really exhausted and disillusioned by that experience, and felt in some way that she'd let her husband down. But with the support of a carer officer, a full two months later, the patient was successfully discharged home, with adaptations having been made to the home and a full care package in place, alongside support for that carer. I think this is a really important illustration of what can happen and the impact on people when discharge goes wrong.

The timing of assessments and the involvement of third sector care officers is really key in making sure that we plan effectively, and there are barriers to that. In some areas, we see third sector involved in multidisciplinary team meetings, and that has been hugely impactful in improving the experiences at discharge. In other areas, because of general data protection regulation concerns, those officers are not able to be part of multidisciplinary team meetings, and that is definitely a barrier for unpaid carers being both identified and having their needs supported.

Thank you for that. Sometimes, the picture you build up in your mind’s eye can be worth 1,000 words, so that was really interesting. My last point—actually, I think you’ve answered it in many ways, because I wanted to talk about what you think would help to ensure that the role of unpaid carers in supporting hospital discharge is sufficiently recognised. Well, of course, an assessment is a clear recognition of them, I can see that. However, perhaps we can put the assessment practice aside to see if there’s something else we need to perhaps explore. How can the role of unpaid carers in supporting discharge—how can that be recognised more, along with the duties to support carers and the cared person? For example, does hospital discharge guidance need to be prescriptive on what should or shouldn’t happen?

Rob.

Yes, I can go. So, I think, yes, Kate’s given some good examples of good practice already outside of the assessment piece. Both Carers Wales and Carers Trust Wales are involved in the Care Aware project, which aims to upskill and train and provide resource and support to professionals in health and social care settings. Carers Wales look after the social care side of it, and Carers Trust Wales look after the healthcare side of it. So, we provide training in Carers Wales for social workers and provide resources, all co-produced with carers and social workers, to try and get that nice kind of Goldilocks moment of what works best for both sides and both sets of experience.

So, yes, it's greater training, greater support and resources. Guidance I think is important, but I’m conscious as well that lots of guidance exists on shelves. Again, we’re talking about people that are not time rich, whether it’s in healthcare settings or in social care settings. So, having the ability to look through that and understand it and implement it is difficult. So, yes, I recognise that as well.

I think there are things that we could be doing, but ultimately, as well, we know that lots of unpaid carers struggle to be identified as carers in both healthcare settings and social care settings. So, by upskilling and training staff, having more information and advice available to help prompt people who might be helping to look after someone in those settings to think, 'Oh, maybe I am an unpaid carer, maybe I am looking after somebody', and then seek support, whether that’s through third sector organisations, whether that’s through statutory services—it’s that almost kind of one-door-in approach where we can work together to help signpost those carers to the best sort of support that’s available for them, whether that’s locally or nationally. I think more can and should be done to raise awareness as well, and that’s one of the key critical factors.

That's a really important point, actually, for carers to understand if they are a carer and not just a concerned family member. Because there are certain things you start doing—Siân, you know first-hand about that. That seems quite fundamental. They don’t know to go to anybody to get signposted to get support unless they know what they actually are.

That's right, yes. So, we've done some research, and I can't remember it off the top of my head, but I'm happy to share it with the committee afterwards, so I don't get my figures wrong. But it takes years sometimes for unpaid carers to become identified or to recognise, and we know that the largest way in which carers are identified is by other carers. You have that conversation to be like, ‘Oh, by the way’, as I know from my experience. Again, Siân's nodding, so I imagine this is resonating with you here. I think that identification piece is really key. We are doing some work with the Welsh Government to try and spread the good word on this. But there's no silver bullet. Some people resonate with the term ‘unpaid carers’, others don't. It can be quite polarising. There are cultural competencies and differences we need to take into account here. Unpaid carers are viewed differently, depending on your background and your culture. So, yes, it's really hard, but a really fundamental part of the process is that identification piece in the first place.

Okay, Peter? Kate, did you want to add anything to what Rob has said on those particular matters?

Yes, and, to support Rob's point, in terms of minoritised ethnic communities in particular, the cultural recognition of being an unpaid carer may be lower. We've undertaken some research in this space and the programmes that we deliver nationally have evidence that there is a gap in terms of awareness, and some of that is a language barrier—there may not be a word for being an unpaid carer—but also a kind of stigma around the cared-for person's needs or taking that role as a carer and describing it in such terms.

I'd also like to highlight the work that Rob described in terms of the Carer Aware project. It is a Welsh Government-funded programme that has run for over five years, and, whilst it is not a silver bullet, it has made significant inroads in working with local health boards and health professionals to improve awareness of carers and the importance of healthcare professionals as individuals who have the opportunity to support carers to understand themselves in such terms and connect to their rights.

Rob referenced the good practice guide to supporting carers through hospital discharge. I'm really proud of the way in which that was developed. It is a solid piece of guidance at a service and policy level, and also for front-line professionals, but awareness of it is again patchy, and uptake of the advice set out within it is not consistent. So, I think there's a real action there, that there is something that has been developed, that is effective and just needs to be rolled out and embedded.

I think it's also worth noting evidence from Carers Trust's network of local carer organisations that demonstrates the importance of integration. So, when we talk about what else we can be doing, integration is really key. And by that I mean between health and social services, in support of unpaid carers through the hospital discharge process. It can be absolutely transformative when things connect up well for carers and that pathway is clear to them and to the professionals that are working with them. And that does demand a more integrated approach to the funding of unpaid carer support at a regional level. I think it has to recognise those multiple touch points for carers across health, social services and third sector organisations.

To provide a positive example of what works well, Carers Outreach, a network partner of Carers Trust, has in the past few weeks been able to reinstate a hospital facilitator in the discharge lounge at Ysbyty Gwynedd. Carers Outreach is co-located in that hospital with the social work team and other third sector organisations such as Care & Repair, Age Cymru Gwynedd and Môn, and they're helping to facilitate joint working that really wraps around that patient and the carer and their wider families. So, I think being located on site means greater awareness, both for the carers and for staff, to be able to refer into that service.

Okay, Kate, thank you very much. Siân Gwenllian.

Thank you, Chair. As you know, I share care for my elderly mother, and I've mentioned this in the Chamber before today also. So, I just thought I should share that as a declaration of interest at this point. It strikes me that the assessment is important and we need to find ways to get a recognition from throughout the profession that that assessment is vitally important. I just wonder whether one of the important areas for us to get that information is from the GP. That is, an elderly person is going to see their GP regularly. The GP is going to see the unpaid carer alongside that elderly person regularly too. So, is that—? If there was some kind of requirement at that point to at least identify that, 'Yes, this person is a carer and they have a right to an assessment'—.

Because what happens if you don't do that initial work at an early enough stage, by the time you reach hospital, it is an emergency, and in the majority of cases the person caring for someone doesn't realise that they're a carer, they don't realise that they have a right to an assessment, and they've very often reached a point of crisis in the way that the care needs to be delivered from that point forward. Very often, the stay in hospital allows for planning to happen. I know there's a rush to discharge people from hospital, but in a way that period in hospital can provide respite to the family so that they can start to think how they will continue with the person's care afterwards.

So, in your—. Is that something that resonates with you in terms of your experiences with other people? What are the associated risks if someone feels that they don't have a choice, and pressure is being put on them perhaps in hospital to be discharged quickly because they need that bed space, but there hasn't been an opportunity to think clearly about what the best plan would be for them? There are big risks associated with that. I'm sorry to be long-winded there, Chair, but I wanted to contribute some of my personal experience there also.

Diolch, Siân. Okay, Kate or Rob.

Happy to let Kate go first on this one; I've gone first for all the other ones, so I'll sit out.

Kate.

Yes, happy to speak. So, to begin with, focused on GPs, previously quality and outcomes framework points were available for the recording of the number of carers that were supported. That doesn't exist anymore and hasn't existed for a long time. I do think there's a real opportunity in both GP and hospital settings to look at our record-keeping, and how we can make sure we have really good data about the number of carers that are coming through. Nationally, there's a real paucity of data in terms of unpaid carers, and this feels like a real opportunity to address that.

But I think secondary to that, and perhaps most important from an unpaid carer's perspective, is supporting GPs themselves and staff within GPs to be able to signpost effectively. Where there have been posts funded for GP facilitators, usually through the third sector, we can see real improvements in terms of signposting into services, so that carers at an early stage might be identified using language that's helpful to them. So, something along the lines of, 'Are you supporting someone?', 'Who are you here with today?', can open doors far more than, 'Are you a carer?' So, I think encouraging that professional curiosity and supporting really busy people to know where they can signpost to is really important.

When we've asked professionals within the health service, including GPs, why this presents a challenge, one of the issues that they do reference is the changing nature of the services provided by the third sector, and that is caused by the annual funding that they often receive. So, the lack of consistency in what is available feels like a really insurmountable thing for very busy workers within GP surgeries and in hospital environments to keep on top of what is available and where they can signpost to. We know that first point of contact can give a really positive experience if we signpost carers to a good first point of contact. But we also know that, in other areas, carers have reported not receiving adequate information, advice and support. And the evidence from the Association of Directors of Social Services Cymru review supports that position. So, reflecting on what can be done at GP, there is a lot that can be done, but it requires investment, and it requires the investment over the long term.

Okay, Kate. Did you want to add anything, Rob?

I just wanted to pick up on some of the points that Siân raised about choice, and this factors in to how statutory services, including local authorities, can and should support unpaid carers, through discharge but also just more generally as carers. So, the Social Services and Well-being (Wales) Act 2014 says that carers must be asked whether they're willing and able, or what, sorry, they're willing and able to undertake. But we know that—

It doesn't happen.

Yes. So, we know that, by and large, that isn't the case, unfortunately. This has a massive knock-on effect, and the risks that you alluded to earlier I think are really stark. So, we did some research last year, and found that 64 per cent of current and former carers surveyed in Wales said that they had no choice but to care—that was their only option. So, that's a pretty high number, if we're honest. In some further research last year, 27 per cent of carers who care for somebody who had been discharged from a hospital setting in the last 12 months said that they were involved in those decisions and care planning—so, one in four. And only 12 per cent of carers were identified in medical settings. So, the scale of the challenge is vast.

The risk in terms of carers having no choice but to perform that role, I think I want to point out, immediately, will have a disproportionate effect on women, because the vast majority of unpaid carers are women. So, there is an equalities angle, which is just staring us in the face. But, equally, it's completely juxtaposed with any sort of Government initiative around economic growth. The amount of carers that we speak to who have had to retire early or who have had to give up work altogether and rely on a now-diminishing welfare state and system to provide care—. They're saving the Welsh Government £10 billion every year with the care they provide—that's how much it would cost to replace that care—and the thanks they get for it is poor mental health and having to be pushed into poverty because they've given up work, and that strips away their identity as well. Anecdotally, if I had £1 for every unpaid carer who'd said to me, since I started this role, 'I'd love to go back to work but it's just impossible'—. That's the risk. And hospital discharge is a critical part of that. If you're being launched out of hospital to try and avoid bed blocking, and having to have unpaid carers pick up the pieces, who are having to try and balance work and care, that is another dimension to this that I think just isn't really appreciated in the grand scheme of things. So, I just wanted to pick up on those points as well.

Thanks very much, Rob. Siân.

The support services available to carers are so important, therefore, aren't they? Because if we don't protect that huge cohort of people—including a high number of women—the entire system will collapse. I don't think that we really realise that as a society—there's still this presumption that families will continue to care for their loved ones. And of course, we all want to do that, but working patterns are changing. In your opinion, therefore, is there enough emphasis put on the support services for carers? Is that the way to maintain this cohort of people? Or are we moving away from using members of the family and unpaid carers—is that the way that society will go in the future, which will create a huge pressure, then, on all the statutory services?

It's the $1 million question, isn't it, I think. To caveat everything I'm about to say, this problem is never going to be easier to fix than it is today. The trajectory that we're on as a society, with developing complex care needs, an ageing population, means that this is only going to get more difficult to fix the longer we wait to take action. And I personally feel—and everything that we hear from unpaid carers tell us—that this isn't achieving a sufficient level of priority at multiple layers of Government and successive Governments as well. So, I think, in terms of the direction that we're going, I don't know, is the honest answer, where we are going, but the facts are stark that more people are going to need care for a greater period of time and in more complex ways as we get into the future. I don't see an alternative where that isn't inherently reliant on unpaid carers to step in and do that, otherwise we're talking about, again, £10 billion-worth of replacement care to do that via statutory services. I'm not sure that's ever really going to be a realistic option for anybody.

So, it's multifaceted in terms of the way that we need to address this and start to build a health and social care system that's fit for the future and addresses these needs, whether it's through discharge or everything else. There needs to be greater flexibility for carers to be able to balance employment, work and care, because, again, anecdotally, lots of carers who otherwise would be able to work want to do that, but there are barriers in place to stop them from doing that, and that's to do with the welfare system, but that's also to do with employers and supporting employers to be able to support carers. But I think, equally, unless we have a support system in place via statutory services that is able to recognise carers' needs on a local but also a national basis, and plan adequately to support carers, we're going to be back here again in a year's time, scratching our heads, thinking about, 'How has it got to this point?' again. And while we're doing that, the trend for carers' health and well-being is heading in just the most alarming way. Between 2023-24, in our State of Caring survey, there was a 36 per cent increase in the number of carers reporting poor mental health. The surveys are always bad; the findings are always, always bad. We read them every year; they always make for stark reading, but last year's was just so alarming, and paints a picture of things going the wrong way. That's not in spite of will; there's lots of good work going on, but I don't think, if we're honest, that it's anywhere near to meeting the scale of the challenge.

Okay, Siân. Kate, did you have anything to add to that?

Yes, please. I think Rob makes some very stark points, and I'd like to note that if we do not invest in the support that carers need, we really do risk doubling that pressure on the health and social care system. It's going to see higher rates of failed discharges, it's going to see those readmissions that we don't want to see, and that couples with the potential for carer burn-out and need for more intense intervention moving forward.

The Social Services and Well-being (Wales) Act 2014, I think, is really ambitious, and I would applaud Welsh Government in their policy direction for unpaid carers. There is a clear strategy, real intention to deliver for unpaid carers, but there is an implementation gap, as we've already discussed. We know that community-based support for local carers is truly preventative, and it is an essential component of well-being provision that local authorities and regional partnership boards need to commission for their population, but they can do a better job of commissioning that, and it's important, I think, to reflect on recent guidance through the national commissioning framework, which I think often isn't met across parts of Wales.

I wanted to reflect very briefly on some good examples of national approaches and learning that we've taken from them. We know that poverty is a significant issue for unpaid carers, and poverty alleviation is a key priority for Carers Trust, therefore. We have been fortunate to be the national delivery partner for Welsh Government on the carers support fund, which is designed to provide emergency grants for unpaid carers, meeting the most urgent need of those at the sharpest end of poverty, but also to support income maximisation. These have been really effective schemes, but it's surprising to me that almost half of those that are accessing the carers support fund have not previously had access to any other support. So, when they join that service or request something to support them with heating, with eating, with having a bed—not replacing a bed, but purchasing a bed for themselves because they do not have one—they are not already connected to statutory services or commissioned services, and that has been a consistent finding across five years of delivery. When we ask unpaid carers where they would go for support without that carers support fund, a common answer is 'loan sharks'. So, I don't think we should dismiss the level of poverty that we have amongst our caring population and the impact that can have on their ability to flex and meet new needs as somebody might be discharged from hospital in a different condition to that in which they went in.

I would also like to reflect briefly on the national short breaks scheme, which, again, we are the national co-ordinating body for. Eighty six per cent of people who fill in a survey after the break they receive through this scheme tell us that they have not had a break in the year prior to that, and that dropped slightly to 75 per cent for young carers. To me, seeing three quarters of young people who are providing support not having had a break in a year feels very stark. So, these schemes are making headway; they are creating flexible and person-centred short breaks in a really place-based way, but we're still finding, year on year, that those accessing this essential support that will prevent carer burn-out aren't connected into wider support. So, again, a little bit of a theme of the evidence I'm providing today is that integration, signposting and a clear pathway for carers are so important. That no-wrong-door approach that we've discussed so many times has never been more applicable.

Diolch yn fawr, Kate. Thank you very much. Lee Waters.

Thank you. Yes, we've discussed discharge quite a bit. I just wondered if there was any particular good practice you've been able to identify that you think should be scaled that the committee might recommend.

I'm happy to speak on this. In terms of hospital facilitators and hospital officers, we know that co-location is really important. If we have those experts in carers' rights and carers' needs at a place where they're accessible to healthcare professionals to support their learning and be there to take on that role, it is not the role of the hospital doctor or the hospital nurse to provide that hand-holding or advice to the unpaid carer, but to have somebody within a hospital location that they can signpost directly to is quite important. Also, to pick up those that haven't been identified—a stand on a concourse, a hub within a hospital, really, really helps to capture those unpaid carers who might not self-identify or might not have been identified whilst the person they care for is in hospital. The co-location with local authority social services teams has also been a really positive example of how we can join things up effectively.

And I think finally, to note, I've already said it, but multidisciplinary team meetings: it surprised me within a Carers Trust network to see, in some areas, carer officers, carer hospital facilitators sitting on multidisciplinary team meetings, and in other areas them being told they can't—'GDPR says "no".' So, what is the answer, and what guidance can we provide to health boards and carer services to take a consistent approach across Wales that prioritises getting the right people in the room to advocate for and connect with unpaid carers?

Thank you. That's clear. Carers Wales says in the evidence, in terms of the challenges around discharge from hospital, that a system of fast-tracked direct payments to enable families and patients to purchase the support they need to short-circuit the system would bring benefits. Can you tell us whether this has been tried? Is there evidence of this?

So, the practice massively varies on direct payments, no matter how you look at it. I think a lot of this is through co-production of evidence with carers. So, when we ask them what would be good in that respect, that's one of the things that comes through to us. But I would also just add a caveat around direct payments that there is a bit of a postcode lottery around that. This definitely isn't a silver bullet; I think it's one method by which we can help to support unpaid carers. And also, with direct payments, there's that element of choice and control, but the services have to be in place for the carers to be able to commission and pay for as well, and we know that that's patchy too. So, I think it's an option; it's something that we need to look at in more depth and detail, but there are pitfalls as well.

Just so I'm clear, at the moment, it's a concept rather than the existing practice anywhere?

Yes.

Okay. Thank you.

Okay. Diolch yn fawr, Lee. Laura Anne Jones.

Diolch, Chair. I was just wondering, considering what you were just saying about the carers saving Welsh Government lots of money, of course, by what they're doing, what are your views on the effectiveness of the Welsh Government's strategic approach on hospital discharge, and what further action do you think is needed at a national level to tackle these delays? Thank you.

I think anything that talks about hospital discharge, as a general rule, often doesn't give adequate consideration or recognition of the role that unpaid carers play in that process. Just to give an example of this, I think the recent—. Is it a 50-day challenge that happened recently? I would encourage Members to go and look at that. I wasn't able to find any mention of unpaid carers in that, despite the fact that the success around hospital discharge inherently hinges on unpaid carers' ability to provide that care once people are discharged.

We all agree that the vast majority of people that are in secondary care settings don’t really want to be there. It’s also the most expensive point in the system, so it’s in all of our benefit and interest to have people out in the community, but there has to be sufficient support in place to do that. And to make sure that happens, we need to see that clearly communicated from the very top, and I don’t think that that is done adequately with regard to unpaid carers at the moment. I think there are examples of good practice more generally with unpaid carers, but in relation to hospital discharge not nearly enough priority is put on unpaid carers or recognition given, I would say.

Diolch.

If I can come in there, I would agree it's really notable that Welsh Government's 50-day winter challenge, which was only published in November, and the 10-point action plan to support people to be discharged from hospital sooner, did not include a single reference to unpaid carers. It really was a missed opportunity to bring together existing Welsh Government-funded work streams, which includes the £1 million allocated between all health boards annually to support unpaid carers through hospital discharge.

Okay. Thank you. That's very useful. In terms of preventing avoidable admissions, we've heard today that there needs to be a more proactive approach in the community to support frail older people at risk of falling and preventing them to need to go into hospital in the first place. Is a similar approach needed for unpaid carers, who are struggling to cope, where there are risks of carer breakdown? What are your thoughts on a more a proactive, preventative approach and how that can be progressed? Are there any practical steps that you could perhaps suggest? Diolch.

So, for me, in terms of prevention, we know that our third sector organisations, those local carer organisations across Wales, do an amazing job at being that preventative force, and they do do so in a way that's really dynamic in terms of generating funds to expand services. We know it's a difficult financial environment, and the third sector are incredibly lean and incredibly good at generating match funding to do the things that matter to their communities. That co-productive approach that is really embedded in what local people need and where they want to receive that service is really strong. But statutory funding remains really inconsistent, and whilst things like the regional integration fund should be providing funding over five years, that isn't the experience of our network partners. Some are receiving in-year funds, 'Please get this spent in the last six months of the year', and others are waiting until the end of March to find out if they still have the funding for those important preventative services in the next financial year. So, the plea from me, really, would be to look at that, how we are commissioning our third sector as important partners in that prevention journey.

Thank you.

I would echo all of what Kate has said there. And just, again, to reiterate that point around prevention, what the Act sets out to achieve, I think, nobody really broadly disagrees with. It is the implementation gap that is the issue here. The Act is in and of itself inherently slanted towards prevention, but the fact of the matter is that, at the moment, everything is just hitting crisis point and we’re having to deal with just consistent firefighting. And obviously, you can’t just drop that to then focus on prevention, you have to get that mix right and balance between the two and try and shift away from the firefighting towards preventative approaches. But, again, I just don’t get the impression that this is of sufficient priority within the agenda of successive Governments, and, again, that’s at local, devolved, reserved level, to meet the challenge—the scale of the challenge.

In our 'State of Caring' report, again, the numbers of carers who tell us that they’re worried about their ability to provide care in the future increases year on year, and we’re talking—. I think it’s nearly three quarters of unpaid carers that we surveyed last year who said that they’re worried about their ability to continue to provide care. And if they can’t provide care, people are going to be admitted into hospital and treated again in the most expensive part of the system where their needs, often, will struggle to be met and carers will again feel guilty about burn-out, and it’s just a self-depreciating cycle. So, I think a greater emphasis on priority is what we would call for in addition to all of the things that Kate’s spoken about there with regard to commissioning services too.

Okay. Thank you. So, your key recommendations to the Government in terms of your absolute priority actions—. What would you say those are, on top of what you said—or reprioritising?

Close the implementation gap of the Act, if I can give it in a nutshell.

Well, it's useful to be that clear. Thanks, Rob. Kate, did you want to add anything at all?

I would absolutely concur with Rob's point: close the implementation gap. The legislation is good, the strategy for unpaid carers is good, let's deliver on that.

Okay. Well, Kate, Rob, thank you both very much for giving evidence to committee today. You will be sent a transcript to check for factual accuracy in the usual way. Diolch yn fawr.

Diolch.

Thank you.

Item 5 on our agenda today is papers to note. We have one paper: additional information from the Welsh Local Government Association regarding our work on housing support for vulnerable people. Are Members content to note that paper? I see that you are.

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