Local Government and Housing Committee

Item 2 on our agenda today is the committee's work on the role of local authorities in supporting hospital discharges. We have an evidence session with the Cabinet Secretary for Health and Social Care, and the Minister for Children and Social Care. So, welcome to Jeremy Miles MS and Dawn Bowden MS, and also to officials Taryn Stephens, deputy director of social services improvement with the Welsh Government, and Shelley Davies, deputy director for futures and integration with the Welsh Government. I thank you all very much for coming in to give evidence to committee today.

Perhaps I might begin with one or two initial questions on variation across Wales. Firstly, in relation to discharge to recover and then assess, to what extent is that approach consistent across Wales, because we've heard evidence that there are very different approaches across regions, and that the implementation of Welsh Government guidance is quite inconsistent? We heard from stakeholders that a stronger directive from the Welsh Government to mandate the full implementation of discharge to recover then assess across Wales would be appropriate and useful. So, I just wonder what your response is to that, and do you intend to improve consistency and have a more standardised approach across Wales?

Diolch, Cadeirydd. The purpose of the guidance is, in fact, as you say, to deliver a consistent approach right across Wales. So, we've been clear in our expectation as a Government to the system that the guidance should be implemented in all wards in which it's relevant, and that all partners should engage in implementing that guidance. Obviously, the fundamental point of it is that it sets an expectation that the process for planning a discharge doesn't start at the point when the patient is ready for discharge, obviously, but starts very much earlier in the patient's journey. So, in order to get that consistency of approach, those relationships between the various partners operating in a way that is, I suppose, predictable, it is obviously important to make sure that that guidance is applied consistently.

I think I would accept, I would recognise, the evidence that you've received—that the guidance isn't always applied as we would expect it to be. We have undertaken a review through the NHS executive, which has asked health boards themselves to complete a D2RA self-assessment so that we can identify whether we feel, or the executive feels, that that guidance is being applied in the way that we expect, and to get a sense of how embedded, if you like, in the world of the relevant wards those principles are. So, that work has been done, that analysis has been done, that feedback has been given to health boards about what they need to do with their hospitals to ensure that consistent implementation. I think the two big take-outs from that piece of work are probably that, firstly, we saw variation between regions, which I suppose might be more expected, although obviously not desirable, but we also saw variation within health boards at hospital level as well. Clearly, there isn't a justification for that. I think one of the lessons, I suppose, from that piece of work is the need for additional training at hospital level to ensure those principles are understood and have been embedded.

Alongside that, we've been working with Betsi Cadwaladr University Health Board on a pilot, where we've engaged, if you like, two optimal hospital flow framework practitioners, which is a bit of a mouthful, but their job—. The committee, I'm sure, will know that that framework is one of the 10 interventions that we have required all regions to implement as part of the 50-day challenge, and within that framework, the D2RA principles are a key part of that. So, those champions are identifying target wards where there is the highest potential to improve flow, improve the patients' experience, make sure they are discharged more promptly, and, specifically, to try to foster a culture change, really, so that those principles become part of the early experience of the patient. The learning from that pilot will then be disseminated across the system.

Okay. Lee.

[Inaudible.]—the dissemination, then, because we already have examples of good practice that's not been disseminated, so how can we be confident that future dissemination won't fall down the same rabbit hole? Because we heard in evidence that Cardiff and the Vale is the only region currently with a joint discharge policy in place, when the others clearly know that is good practice and should be doing it, but aren't.

This is the perennial challenge, and there's certainly a long way to go, to be absolutely clear. What I would say—and I'm very confident in this proposition—is that the work that we initiated at the end of last year, the 50-day challenge, where health boards work with the local authorities in their region on a regional footprint around the things that we know—and we know the most effective ways of supporting prompt discharge for those patients who are ready to go—has, I think, been a good vehicle for not just identifying that best practice, which is the easier part of the process, isn't it, but then making sure that it is actually disseminated.

So, my view of it is that we are in a much better position now than we were, say, in the autumn. I think that isn't just in relation to those 10 interventions; I think it's started to foster a culture where that is more expected. But I'm absolutely not saying to you we are confident that every good intervention is being disseminated everywhere. What I will say to you is that, against the 10 interventions that we mandated that the system implement, we have a very robust mechanism for tracking that. And we have—Dawn and I—jointly chaired these meetings. Where we've spotted, if you like, that one region could make more progress by adopting practice from another, we've challenged them very directly to say, 'It's working here. It's a thing that you need to learn. Tell us what you've been doing to work together. If you haven't, why haven't you? What are you doing next?' And I think that's been a bit of a catalyst, really, for that better way of working to develop.

And what are the reasons they give you for when it's not working? Is there a pattern?

No, I don't think I would say there is a pattern. That's my reflection, certainly. I think that there has been—and there still is—too much of a tendency to want to develop practice yourself. So, 'Oh, it's specific to us in this region. It's particular to the needs of this hospital', and, obviously, sometimes that will be the case. There will be issues of rurality or other factors that do mean that lift and shift just isn't the right approach. But we're not asking people to do that; we're asking people to learn from good practice already in the system, actually. So, it isn't even, really, asking people to learn from other systems. The reason we've got a list of 10 things is because each of those 10 things is being done successfully in some part of Wales, and often in many parts of Wales, but just not consistently. So, I do think there's been a good level of improvement, but embedding that, I think, in what we're discussing today—but I would say, from a health service point of view—across the whole range of health service activity is the constant task, really.

And what lever do you have as Minister when there's persistent stubbornness not to adopt good practice?

Well, I think that there is a funding lever, which we have used in other contexts. In this context, I think that the very open challenge and open discussion that we've had has been a way of challenging people very openly, really, in a very constructive way. I mean, it's not a competitive sense, is it? But when you're with your peers across the system, saying, 'Well, I haven't implemented this.' 'Why?' It just creates a more openness to challenge, I guess. I think that has been part of the way we've achieved this. And also, frankly speaking, we have seen results, so it's clear that this has worked. I mean, there's much more to do, to be clear, but we can see it working. So, then, people are challenging themselves, I guess, in their own organisation, saying, 'Well, actually, we've got a persistent challenge here. It is working there. Why on earth aren't we adopting that mechanism?'

Okay. Thank you.

Okay. Siân.

Do you see—? Good morning, by the way.

Good morning.

Do you see that this inconsistency is being driven by factors beyond the health board or beyond health itself, and that there is inconsistency in the way in which care is provided in the community or in care homes, and there's inconsistency in how that happens across Wales? Does that inconsistency occur due to different issues in different areas?

Well, I don't think that that's the reason for the inconsistency in general— certainly, that's not the reason in general. I think that there is independent practice that has developed. But you are right to say that there is a variation in processes among local authorities and different systems between local councils that can be at the core of this.

So, if you look at—. Well, all health boards have more than one partner, of course, in terms of local authorities. Your region is a good example where there are many councils, and I think that the health board would tell you that the experience of collaborating with all of them is slightly different. You've heard that yourself, probably. But I see that as an opportunity because it allows us to see where the best practice is happening within that region. What I think is more difficult, to be honest, is achieving consistency between those local councils in terms of how we tackle this, because there are many factors driving those variations, as a result of systems, processes, availability and so forth, between councils.

Does the fact that we have some councils that are very rural, which makes the challenge of providing care in the community even more of a challenge, create some of that inconsistency?

I think it is part of the picture, certainly; I don't think that it explains the whole picture. If you look across Wales, you have different patterns in terms of availability of social workers and facilities in the community. So, there are various factors, but the theme that you're driving at is consistent, certainly.

Okay. Thank you.

Okay, Siân?

Yes.

Yes. Cabinet Secretary, in terms of that rolling out of good practice more generally, beyond the 50-day challenge, where you have particular structure and particular focus, where does responsibility lie for that wider spreading of good practice? Do the regional partnership boards, for example, have a key role, do you think, and how does the Welsh Government monitor progress on this front?

From a governance point of view, which is part of the question, we've actually had a system in place for some time, since before I came into my role. It's called the care action committee, which is a Wales-wide structure based on the regional footprints, which were tasked with implementing the 50-day challenge, but prior to that were tasked with working together to achieve the targets that we had set the system. We think things have moved to a different place post the 50-day challenge, so we're actually revamping that to a different structure, which I can talk about, if you like. So, that's the kind of Wales-wide structure that we have in place, and that Dawn and I use to make sure we are providing political leadership to that, and officials then work in that granular way alongside that structure.

I think the RPBs are an important part of how people are held accountable at a local, regional level. Obviously, they have a statutory footing. I think, back to the point that Lee was making, one of the challenges in this space, again, is making sure that good practice operating in one region is shared in other regions. That is, obviously, what the regional partnership boards should be delivering. They have significant sums of money at their disposal. They have about £140-odd million a year that they're responsible for discharging. I think my own reflection is what we've seen is that where we've been able to focus in the RPBs on a smaller number of critical priorities, which there is an accountability structure around, then we've been able to see progress. I think the risk is that there's a large and growing agenda for RPBs that then becomes unwieldy. So, I think that's the oversight risk, if you like.

We've done a piece of work to identify whether there's a case for putting them on a more—what's the word—I suppose giving them their own corporate entity. My own view is that that is not the right direction of travel. The system doesn't really think that is sensible anyway, but I think there is a case for, as we have been doing with the 50-day challenge, strengthening the focus on a smaller number of priorities.

Okay. On partnership working around—. If we look at what Audit Wales had to say, Cabinet Secretary, that discharge policies were largely health board only and, as Lee said, only Cardiff and the Vale had a joint discharge policy in place, if we're looking for that integrated partnership working, which is key to so much of this, we really need to make sure that it's applied far more generally across Wales. Your evidence paper referred to that strategic partnership agreement with local government partners to refresh those partnership arrangements. Could you tell us a little more about that, and how important that is to achieving this badly needed consistency?

I think this operates at two levels. I think there's a strategic level at which that partnership agreement will operate, and it deals with issues that are not limited to what we're discussing today; it's a much broader set of relationships between the Welsh Government and local government. The plan is for it to be signed in mid June, and one of the elements that we've identified is how we will work together at a Wales-wide level to support more effective discharge and more effective pathways of care. It really, I think, is there to codify what's already working well in the system. But that's at a very macro level, if you like. It's a principles level, and this is one of a number of priorities in that agreement. I think that the solution for driving that much deeper embedding of collaborative work is what we've been talking about—in our context, the care action committee and the new governance for that.

I just want to say one thing. I think it would not be fair to say that there is no sharing of good practice and no joint working. There is an awful lot of it in the system, to be clear. So, I don't think that would be a fair characterisation to say that there isn't evidence of good joint working. I think there's a vast amount of evidence of it. We went on a visit very recently to see, in Cardiff, the Heath hospital, how they've been really working in a very innovative way, I think. They have a thing called the pink army, which brings together all the services that the hospital needs to provide and that the local authority needs to provide in order to ensure safe discharge. They're co-located on a wing in the hospital, and they operate on that D2RA principle, very collaboratively, and that practice has now spread to Carmarthenshire and other parts of Wales, and we see evidence of it happening in the opposite direction as well. So, I don't think it would be fair to say that isn't happening. There is good evidence of it happening. The point I think I was making earlier, which was a response to what Lee was making, was, as always, the challenge is to make that the universal experience consistently.

Okay. Finally from me, before we move on to other matters, Cwm Taf Morgannwg have a memorandum of understanding between all local authorities and the health board on this integrated team approach. Is that something that you think is useful and might be adopted across Wales?

Yes. I think what they have in place, Chair, is a section 33 agreement, or they're developing a section 33 agreement, under the National Health Service Act 2006, and that's, obviously, an existing mechanism. This is definitely not the only example of it in Wales. We think we see it happening very often in relation to frailty services, home adaptations. So, there's a lot of it in the system. I think, perhaps, what's happening in CTM is a broader version of that. And, myself, I think it's a good mechanism, because it does allow a level of flexibility that otherwise it isn't there. So, it can allow delegation of functions from the local authority to the health board; where they have a health element, they can pool budgets. So, I think that’s a good mechanism for integrating the functions of local authorities and health boards in this way. There are other ways of doing that as well. So, we have the corporate joint committee function in the local government space, as you will obviously know, and we’ve been talking about RPBs. So, there are different mechanisms for doing this.

Okay, thank you very much. We will move on, then, to Laura Anne Jones, who, as you can see, has joined us online. Laura.

Thank you, Chair. Good morning, Cabinet Secretary, and Minister. In terms of the length of delays target, your evidence paper says that one of the three targets set in the 50-day challenge that you mentioned was to reduce the total number of days delayed by 20 per cent, but this has not been achieved; there's been a 12 per cent reduction. Can you talk us through why you think this target couldn't be met, and any further action you wish to take to address this issue? Diolch.

Certainly. As you know, two of the targets were exceeded. So, the total delays and the assessment delays target were exceeded, and the net effect of that has been—. We were looking for an output target, if I can use that term, for the 50-day challenge, so that there was a measure we could sensibly apply. So, we tasked local authorities—health board regions—with targeting, if you like, the 25 per cent of patients with the longest delays, and making sure they have been discharged. And the net effect of hitting those targets—or exceeding them, actually—has been that 88 per cent of that cohort have been discharged. So, I think that’s very positive, and the 12 per cent that remain are the ones with the most complex needs, so you’d probably expect to see that pattern.

We haven’t hit the total delays target, although there has been a variable level of performance on that within the course of the year. I think, even with that, though, there's been—. I would say there’s been significant progress, even against that measure. So, the most recent figures that we have, the March figures—. We’ll be publishing the April figures in a few weeks, and I’m happy to share those with you, Chair, when those are public, but the March 2025 figures, compared to March 2024 figures, in terms of the number of days delayed, show that there were 9,000-odd fewer days delayed this year than there were last year. So, I think there’s been quite a lot of progress in that space as well.

I think some of those challenges have been in relation to some of the more complex patients, or patients with more complex needs, sometimes with quite complex mental health or learning disability needs as well. So, we’re looking at some data in that space. We’re looking at how we are coding the experiences of those patients, so that we have better data to understand what more we can do. Some of it is around court of protection challenges, and often that is outside the hands of—. Well, it is always outside the hands, in a sense, of health boards and local authorities, but, again, we’re trying to code differently there, so that we understand whether there is more that we can do to facilitate that process. I think it will be one of the areas that we absolutely will want to focus on in the year ahead, in relation to the number of delays delayed, given that we want to obviously hit that target as well.

Thank you, Cabinet Secretary. Just picking up on something you said there, you said that results are still variable. Why do you think that is? Diolch.

I meant variable over the course of a year. I think that’s probably seasonal. There are points of the year in which it’s more challenging to discharge. I’m looking at some figures in front of me here, which show the health board delays, and I think there’s some variation there as well. But I think the main issue is a calendar year issue—at different points in the year, it’s more challenging to discharge, effectively.

Diolch. Data on the length of delays has clearly been collected, from the evidence that we’ve already received, but it’s currently not being published alongside the other pathways of care delays data. What is the reason for this, please, Cabinet Secretary, and can this be rectified? Would you commit today to publishing that data to give us a fuller picture of the situation?

Yes, I’m happy to do that; there’s no problem with that. We have that data, and we use that data. I’ve just been giving you—. It’s the total days delayed figure. So, we publish the headline figure, if you like, but there is more that we could provide, and we will commit to doing that. So, we’ll need to see what is management information and what is verified; that’s obviously important for us to do. But I’m happy to do that.

I think the reason—. Just to give you the context for it, really, we've focused very much on the pathway experience of patients. So, the focus has been on making sure that the individual pathway works effectively and therefore gives that individual patient the best experience that they can have, the least delay that they need to have in the system. We implemented a new data reporting system a couple of years ago, which gave us more granularity on this. And that's been kept—. That's been kept—. That's evolved, if you like, in light of experience—pretty constantly, actually; so, we've been constantly adjusting the data sets that we have. I think what's become clear as we've got that further data, more data, is our ability to be clearer about the total days delayed and how that's affecting the availability of beds. So, I suppose it's a question of the maturity of the data that we collect, but we definitely are at a place now where we use that reliably and therefore can make it available to you.

Thank you. The Association of Directors of Social Services says that, in local authorities' view, the pathways of care delays data collection is flawed, as recording a delay 48 hours after clinical optimisation is unreasonable, particularly for people with more complex needs. What is your response to this, and do you agree that changes are needed to the current data collection set?

I don't agree it's unreasonable. I've heard the argument and I'm very familiar with it; I'm afraid I just don't agree with it. So, we started the session today talking about the D2RA guidance. What that guidance tells us is that the process of planning for a discharge should begin at the point when a patient is admitted. That's the entire purpose of the guidance, to start that process early. So, the system ought not to be, and I don't believe, generally, is, starting that process at the point when a patient is clinically—. The term that we use is 'clinically optimised'. What that basically means is ready to go home from a medical point of view. So, the system should not be commencing the planning at that point. Clearly, it is not possible to do all of that planning in 48 hours, but that isn't the measure. The planning should have started as soon as the patient was admitted, and what that 48-hour period gives you is a notice period, if you like, to activate the care package that you've been planning on since the patient has been in the system.

Now, I absolutely understand, and we've talked about it already, that that isn't being applied consistently, but that's the rationale for having a 48-hour window. In a sense, it would be the easiest thing in the world for me to say, 'Well, actually, let's make that a 72-hour window, or a 96-hour window.' What that would do is suppress the figures that you're holding me accountable for, and I don't think that would give you the level of transparency that you would expect from us. So, by having a 48-hour trigger, if you like, for the inclusion of a patient in these figures, it gives a fuller picture, and then enables us to be clearer about the data that we need for each individual patient to make sure they're getting the right support and they're being able to be discharged safely. So, I don't think it's an unreasonable approach. Obviously, with these things, we're constantly looking at how best to capture the data, so that will continue, but I hope that broader context is useful.

Thank you, Cabinet Secretary. It's quite a strong thing to say, for them to come back and say that that data collection is flawed. Why do you think that they're saying that?

They don't think the 48 hours is a reasonable period to measure. It's just a difference of opinion. What we're discussing here is transparently how the data is captured. So, different opinions can be shared. The version of the data that I'm sharing is the largest data set, and therefore the most transparent. So, it enables us to have a more informed discussion about where the challenges are in the system. What we're not saying to directors of social services is, 'You have 48 hours to safely discharge this patient.' What we're saying is that that should start very much sooner in the process. We recognise, clearly, it will not always be possible even to activate that set of arrangements in 48 hours, but we should be clear about where that challenge is so that we can understand how to address it.

You think it's probably a communication problem then, in terms of what you think and what they're thinking. And do you think that—? How would you go about creating that consistency? Again, you mentioned that word. Thank you.

Well, we don't need to create consistency. This is the data that we're collecting, and we have a difference of opinion about whether the 48-hour window is the right window. My view very, very strongly is that it's better to err on the side of having a larger data set so we understand the individual needs of all those patients than having a smaller data set where there would be patients whose experience, by the way, would be no different, but would be out of sight from the discussion that we're having today.

Thank you. Thanks, Chair.

Okay. Peter Fox.

Good morning, all. I'd like to look at intermediate and step-down care, and, obviously, with the pressure in the system, there is a desire for patient flow. But I would argue at what cost, because most of the evidence that we've been taking points to the fact that some of the initiatives we have are driving that desire for patient flow, where it needs to be focused, really, on outcomes for the individual.

So, there are significant concerns, for instance, around inappropriate intermediate care, where people perhaps are being freed up from hospital but are being driven into care settings, into residential care settings, perhaps prematurely. And we've heard that the standard residential care is generally being used as that intermediate step-down care and it's not recovery focused. So, temporary placements end up becoming permanent, and that independence is lost prematurely. So, I wonder, do you recognise those concerns about the current sort of practice—driving for flow, if you like, and putting people in, perhaps, the wrong settings? And if so, how do you intend to address that?

I'm not sure I would agree entirely with the way in which the point has been put to you, from what you're describing. I mean, I do think there are two things at play here, if we're being candid. The most important thing is to make sure that the patient has a pathway of care that supports their needs and does not involve them being delayed in being discharged when they are medically fit to go home. I think that's very important; I'm sure we all do. The reason it's given, I think, less weight in the discussion than it should is because of a sense that, well, actually, patients are, you know, fine to be left in a hospital bed; they're safe there. Everything we know says that when you are medically fit to go home, the last place you should be is a hospital bed. We never talk about that openly, because it's quite a difficult, nuanced conversation. But every hour you spend in a hospital bed when you're fit to go home has a significant impact for many patients—on mobility, on confidence. It's called deconditioning—I'm sure you'll have heard this evidence from others.

So, the main reason we're doing—. It's to make sure that that doesn't happen. We know that patients who leave with a level of deconditioning struggle, if they can, to achieve—you know, to get back to the level that they were at. So, that is a bad outcome for patients. That's the main driver. As you say also, though, clearly the system needs for that flow to be working so that the system can work as well. And the reason the system needs to work is that there are patients waiting to come into those beds who also need and deserve a good experience. So, there are two things at play here. I don't think—. Well, what we strive to make sure of across the system is that what you're describing doesn't happen.

So, one of the key things that we did at the end of last year was we increased the funding available for reablement facilities. There wasn't sufficient capacity in the system, and we know that that is a key solution to what you've been describing, really, that intermediate care. If you can also provide that reablement support in that setting, that will help patients. There are also fantastic step-down facilities right across Wales, which are really providing excellent intermediate care. So, you know, it's the patient's individual journey that matters. We obviously want to make sure that they get the care that works for them. I don't know, Dawn, if you want to come in on this.

Yes. I was just going to say that a lot of the work that we've been doing over the pathway of care delays has been about talking with local authorities about how they build their community capacity, to do the two things that you've been talking about, which is, working to develop services in the community that prevent hospital admission in the first place. But also, once the patient is medically optimised, they're in a position to have their care package and be discharged to the place of their choice, whether that is at home—and that would be the preference for many people, that they get home, they have their care package, they can live safely at home with a care package, with their reablement services—or, for some people, it is discharge into a care home. So, building the capacity of care home availability has been one of the things that we've been talking about as well. And you'll be aware, through the budget process that we've just recently been through, that we are now investing an additional £30 million, very specifically to deal with the building of that community capacity, to help deal with those very issues that you've just been raising.

Yes, but is it recognised, though? So, the desire is—

Yes.

—about bringing outcomes, but is it recognised that perhaps patients are being stepped down into inappropriate places, really? And that may be because there aren't enough appropriate places.

Sure. And I think that that's been part of the discussion, that's been part of the work that the Cabinet Secretary was talking about through the care action committee, about the good practice, about what should be happening as opposed to what is happening. And that is the shift that we're now beginning to see, and why our focus, through the work of the care action committee and through our budget allocation now, in terms of building community capacity, is to make sure that the good practices—again that the Cabinet Secretary referred to earlier on—become the norm. But you can't build that capacity overnight. We know that this has been a long-term area of concern for local authorities in particular, that they don't have that sufficient capacity.

So, this is about making that shift towards that community capacity not just being somewhere where you discharge to, but that it's also used as part of the prevention to prevent admission in the first place. We know that there are too many people, particularly elderly people, being admitted into hospital at a time when they really could be cared for successfully either at home or in their care home location.

Could I just bring Siân in briefly, Peter? Siân.

You mentioned that either in a care home—you said it once again at the end there—either in a care home or in the community, in their home, with a care package. But we're talking about something in-between both things here, aren't we? And that lack—

Yes, yes.

—that lack of capacity that there is for someone who isn't quite ready to go home to be cared for at home; that step-down approach. Could you mention some of the good-practice examples so that we can understand whether we're talking about the same thing when we're talking about that intermediate care?

Yes, I take your point; you're absolutely right in that. And the reason I did mention care homes is that, you know, quite often, care homes are being used as that step-down facility. So, you know, when I'm saying about people being discharged into care homes, that could be for two reasons. One is as a permanent placement, and that is where they will have to live, but also, you know, a lot of those places in care homes are commissioned for that step-down approach, so it's the intermediate—

Not a lot—

—approach.

There aren't many of those places.

There are not many, because, as you've already identified, Siân, you know, there are pressures on the care home system as they stand. So, the work that we've been doing is about acknowledging and addressing that. And as the Cabinet Secretary said, there are some good examples, and we've got a couple of examples—. There's Marleyfield in Flintshire, and—[Inaudible.]—in Swansea, which are good examples. And our mission, if you like, is where we identify those good examples, is that we say, 'Well, if this can happen here, it can surely happen elsewhere.' And it's about—. You know, it's about upscaling the good practice.

But sitting alongside that, of course, we absolutely understand that there needs to be investment in that as well. And, you know, we absolutely understand the pressures that local authorities are under financially and so on. And so, you know, the point I made to Peter Fox was that the specific focus on our budget—following our budget—the specific funding, is aimed at addressing that particular gap in the provision that we currently have; and that would include the step-down facilities where they're needed.

Do you want to—?

Yes. Am I on?

Yes, that's okay.

Just to say a little bit more about those examples, so Marleyfield up in Flintshire and the model that we've got down in Swansea, and there are other examples where we're investing capital in terms of helping build some of these specific facilities linked to care homes. So, Marleyfield has had quite a significant capital injection through the integrated care fund and now the integration and rebalancing capital fund in terms of our capital funds, and then wrapping around revenue support through things like the regional integration fund to create what they've called the DART team—so, it's their discharge and recovery team—that wraps around the care home to give that rehabilitation, that recovery, for six to eight weeks, to help people then step and move home. So, we've got some really good examples of those across Wales that are giving some really good results, and what we’re looking to continue to promote is that good practice. So, it’s really important to understand that, when people are being discharged into a care home, it’s with a clear care package that is about promoting their independence to allow them to leave at the time that's right for them.

Chair, if I may, one of the other ways in which we're trying to alleviate the pressure, if you like, in that part of the system, is by making sure that care at home is more available, obviously. So, one of the things that I think we've been most pleased with is the reduction in waiting lists for domiciliary care, which have gone down by about a third over the course of the last year or so, which I think is quite significant. And as I touched on earlier, there have been very significant increases in reablement capacity as well. So, that's not a direct answer to the question, but it's about how you provide options, I guess.

Okay, Siân? Peter.

If I can just move on to the commissioning of step-down care. Some of the evidence we've had has been quite powerful, saying there's insufficiency of the right type. Professor Bolton, for instance, made it very clear that there's insufficient capacity, basically, in the system. He and many others stress that intermediate care facilities should be commissioned for the purpose of recovery, and it's essential that they have access to therapeutic and nursing input, and focus on that aim to return patients home, which I think, as you said, you really want to do. Do you recognise a need to commission intermediate care perhaps differently and increase the provision of appropriate recovery-focused care rather than just pushing to care home beds? And I know you've talked to that a bit already.

Yes. So, it's just building on what I was already saying. So, the starting point, really, is that the regional partnership boards, in conjunction with social care services, develop their plans around population needs, and that will include all of the community provision that's required. And that will be part of that process, making sure that there's sufficiency in the system, that there's capacity in the system to deliver the appropriate type of care, whether it is intermediate care, whether it is care home provision, whether it is domiciliary care. All of that is done through that process.

What we have and what we have had is a commissioning process and commissioning procedures that the local authority will work with the health board to develop what is needed in the community, how much that is going to cost, where we are going to put it, at the right price, in the right place and so on. But we have introduced a new commissioning process. The national commissioning for care and support was introduced in November of last year. The theme today has been about consistency and good practice. The national framework for commissioning care and support is about developing that good practice and that consistency right across the country so that commissioners are in a position where they know that they are looking to commission something, not just based on cost, but based on need and on quality of care. And that will mean that there will be variation in costs across the country, but the process in which that is commissioned and how that is done will be very transparent, and there will be a process that everybody will feel that will be consistent. Although, as I said, some of the charges for some of these services will vary according to local need.

Thank you.

Okay, Peter?

Thank you, John.

Lee Waters.

I want to ask about some of the barriers to joint working, and information sharing is one of them that's come up in evidence, not least the parlous state of the digital landscape. We're still getting evidence of fax machines being used. I can remember nine years ago, in a committee, being shocked that fax machines were being used, and think how much the digital capability has shifted in nine years, and we're still getting evidence of fax machines being used. It beggars belief, really. But paper systems too. There are examples of good practice where there are modern systems being used, but, again, so much unevenness. What is it that you're doing to make sure that this is addressed?

So, in terms of data and then systems, in terms of what data is being captured, I think our experience, as a consequence of the 50-day challenge—but that’s one example—is that there has been some inconsistency in data capture, and that is getting better. I’m not saying it’s in the right place, but it is definitely getting better. I think the experience that we’ve had post the COVID pandemic, when we restarted the process of capturing this data, I think that’s on a good path to making sure we have the level of granularity that we’re comparing apples with apples, and all those things. So, from a data category point of view, I think that’s heading in the right direction, and there’s definitely progress.

On the systems point of view, I think that is a much more challenging space, bluntly. We had the Wales integrated community care system, which the committee will have heard about. That has required consistent data standards and protocols for interoperability between social care and the health system. That is now being replaced. So, there’s an opportunity in the system that we’re putting in place to align the digital systems, both from a health and a social care point of view. It’s clearly a huge task, not least given where we’re starting from.

The ambition of the Connecting Care programme, which is what the successor programme is called, is to build an interoperable digital data system that enables data stored in different parts of the system to be accessed and shared with other parts. The ultimate goal is for there to be a single integrated care record for individuals. There are two elements to it. One is a local government-driven business case, if you like, which we have approved, and that will set out requirements for consistent data standards, but also a single specification for procurement and a co-ordinated approach for procurement between local authorities. That, I think, is positive. That will lead to that greater consistency.

We’ve recently had the health element of that through Digital Health and Care Wales, and that’s currently being considered by officials. I’m hoping that we’ll be ready to say something positive about that in the next few weeks. The objective of that is to have a similar alignment of systems across the piece. But that’s where we are on the development of that at the moment. The timeline for doing that is quite short. I don’t have the note in front of me, but we can let you have the details about the timeline as well.

It’s tempting to pursue that area, but I’m going to resist. But just to note that the big bang approach that you suggest there was something that was tried with the Welsh community care information system, and failed. So, whether or not it’s wise to be continuing to follow a one-size-fits-all, once-for-Wales, system-wide solution, given the track record of the system to deliver that—. Here we are 10 years on and it still hasn’t happened. I am trying to restrain myself. Perhaps I should give you a chance just to respond to that before I move on.

If I may. I want to make sure that my point has been clearly expressed. The key point is that it's a single specification, so that every procurement of the tool is a shared specification.

Okay. Common standards.

Well, standards, but also a specification for the system as well. So, it addresses the point that you've made, hopefully. That's the intention.

Okay. Well, there's a further conversation to be had. Thank you.

Another little quirk that's come up in the evidence, which I find quite disturbing, is that where there is an effective electronic referral system, in Cwm Taf, neighbouring local authorities will not accept these referrals. So, that's not about digital systems; that's about the system playing nice. So, again, what can be done about that?

I will need to look at that and come back to you separately.

Okay. Well, I'd be grateful if you would, thank you.

Just to move on again to targets, you can't win on targets. If you don't introduce targets, you're criticised for not mobilising the system, and when you do, there are obviously risks of distortions and unintended consequences. We've heard examples of a couple of those. There are two I just wanted to mention to you. One is where preventative and early intervention services are not being funded to the extent that they should be, because they're not being measured on that, because they're measured in acute hospitals. That is a sub-optimal consequence of the target.

A second is around deconditioning, which you mentioned earlier being a bad thing, where nursing home places are being commissioned—spot purchasing in order to get people out of hospitals—where there is no therapeutic support service available, and those patients are then less likely to leave that nursing home because their condition deteriorates. So, there are two separate examples there of a similar theme of unintended consequences that are militating against your overall strategic objective.

I think that I'd accept the thrust of what you are saying, for sure. We all know that we have a system that mainly measures outputs from a secondary care space. It's waiting times, it's access targets and those things. And, obviously, a system responds, generally speaking, to the targets that are most publicly measured; that's how systems work.

It is, I think, more challenging to be able to capture the experience of those people who have not engaged with the system and have not therefore required intervention from the system because something else has happened downstream to give them a better experience. It's just inherently more challenging to do that. It's a more diverse field—all the obvious things.

However, we absolutely do recognise that, and we are looking to see how we can develop a clearer understanding of the benefits to the patient and the system of that. It's obviously beneficial, but how can we develop a more granular way of understanding and measuring that, to some extent?

On decommissioning specifically, we are working on some tools that, I think, if we are able to succeed in that, will help us measure deconditioning in the patient more successfully. I think that will be genuinely innovative. I don't think that it's been done anywhere else in the UK, certainly. And that, again, will give us a more detailed understanding of what that deconditioning has meant, so that we can then make sure that the services are there to be able to respond to it in the way that you are saying.

But this is deconditioning happening in care homes, where people are being moved out.

Yes.

Okay. I'm just mindful of time, so I'll just move on to one final point, which is around the disputes that are occurring around funding and people guarding their little pots of money, but specifically around the NHS continuing healthcare theme. We heard from Care Forum Wales, and it said it seems to be a deliberate tactic by some health boards to underassess nursing needs to protect their own budgets.

Then, we've heard similarly from local authorities, saying that these CHC panels are gatekeepers and don't respect multidisciplinary teams, which is creating a wedge between health and social care. And we've heard from the NHS itself—complaints about local authorities. So, this seems to be another example of where real system tension exists. Again, is there any work specifically to unknot this knot?

Yes, there is. I won't go into the broader challenge of integration. We could talk all day about that. So, specifically on this, clearly, the most important thing is that it is not good for the patient. That's the most important aspect of this.

We have discovered in the care action committee discussions—I keep referring back to that, but it has been useful—that here have been, definitely, parts of Wales where they have, I think, been very proactive in trying to resolve that and taking a patient-first, money-second sort of approach. We'd hope that was universal, but there's definitely good practice in the system. Powys and some other health boards have put together a joint budget to support initial discharge. So, that takes some of the pressure off the initial work.

There is a framework in place that sets a clear set of expectations around how CHCs are assessed, and we're looking at how we can better measure performance against that framework at the moment. There's an internal review going on into that. There's a tool that we've developed that should, if applied consistently, lead to more consistent outcomes. So, that would be positive.

Where the needs are most complex, we already have a complex care joint forum, which does actually enable us, for the most complex cases, to spot some of these issues and try and resolve them. So, there is definitely work under way. It's a subset of a larger issue, when you've got two systems working together, separately funded, separately accountable for their own budgets.

Thank you.

We will move on to Laura Anne Jones.

Diolch, Chair. There's agreement that social workers need to be involved early in the discharge process, as has been said already today, and co-located in acute hospital settings, with reports that there has been a reduction in this since the pandemic. BASW also says that named social worker protocols should be developed. Do you agree with those calls, and if so, how can the Welsh Government drive those forward? I'd also be interested to know if you think there is sufficient capacity of social workers to deliver these measures in hospitals across Wales. Diolch.

Thank you, Laura, for that. The starting point here is that we absolutely recognise that social workers are key members of the multidisciplinary team, and they need to be involved at the earliest point as part of the discharge process, and it's absolutely right that they are. We do see excellent models. We've talked about good practice. There are excellent models around that, where health boards are involving social workers at a very early point. They are co-located in the hospital. We're seeing this in Cardiff, for instance. This is very much part of the work that hospital-based social workers are doing with the pink army that the Cabinet Secretary referred to earlier on. They're working very much hand in glove.

I think there's something about having the right people in the right place at the right time, and I absolutely agree with that. It is right that we deploy social workers to be dealing with some of the most complex cases associated with discharge. That's why we're also trying to develop the trusted assessor model that the Cabinet Secretary referred to earlier on as well, which is trying to embed in the system somebody that can take responsibility for those fairly low-level cases of people that can be discharged that don't have particularly complex needs, they just need to have a comprehensive package of care that will enable them to go home and live safely and securely on their own. So, building that into the system then will release, and does release, the social workers to deal with those more complex cases. So, I'm basically agreeing with the premise of your question.

In terms of the capacity in the system, what I would say is we recognise that is a challenge. There is, and has been for some time, and not just in Wales, a challenge across the UK. We've seen some quite innovative projects that local authorities have employed to try to deal with their social work capacity. You may be aware of the international programme that Bridgend County Borough Council have employed, where they've gone to Africa and to the USA and recruited social workers from abroad and brought them here to fill those gaps in their sufficiency. So, we see some good models, some innovation around that.

We are doing a lot of work through Social Care Wales to develop the social work capacity. I think we had about 4,500 registered social workers in Wales last year, which was an increase of more than 200 on the previous year. So, we are seeing some successes around the process that we're putting in place through the workforce development plan, our work with Social Care Wales, the work on the social care bursary, the support that we're giving to social workers coming in to undertake their degrees, both undergraduate and postgraduate support that we're putting in place.

Laura, I'm just going to bring Siân Gwenllian in for a moment.

Thank you. I completely agree that there's an important role for the social workers within hospitals when people are ready to leave and go home. But, in the bigger picture, is there not a role far before that, in some cases, where the social worker could be brought in by the GP, for example, when we have very elderly people in our population by now? Once they reach some kind of level of need, the GP will acknowledge that and know this person will soon need a care package, or whatever. And perhaps doing that far earlier would prevent people from having to go to hospital, because, very often, families are in crisis when an older person reaches hospital and have had no contact with social services before that.

I’ll come in on that. You’re right, one of the things that we've introduced is a scheme with funding for GPs to look at, I think, the top 0.5 per cent of people who are most likely to develop more intensive needs, as you described. Often they'll be older people, but not always, and then they can provide specific care to those people and signpost them to other services as well, in the way that you mentioned. We think that that will make a difference.

And the other thing that we're doing—we've just started it in April—is to try and re-establish consistency of care for people who have the most intensive needs. It's a quality improvement approach, so practices can bid to be a part of it in order to see how we can build it, and then target, if you like, that core of people who have the most intensive need for consistency of care, so that they don't have to wait to see who they'll get when the call the GP; they'll know it's that GP that they will see. Now, it's going to take some time to ensure that it's available generally, but I think that it is important that we do that. It's important for the individual, but I think it is partly at the core of the pressure on GPs in general. So, that will tackle the issue somewhat.

Okay, Siân. Laura Anne.

Diolch. We've heard evidence—Siân Gwenllian is quite right there—that that early intervention, again, and that information, could prove vital. We've also heard that the make-up of hospital discharge teams varies widely by hospital, and also we heard about the enormous benefit it would bring if professionals, representatives, social workers, as Siân just said, housing, third sector representatives, were involved and are not always involved for various reasons. But should the Welsh Government be more directive about who should be involved in hospital discharge teams as a minimum, so that all that information and all that communication can be shared and come together to get the best possible package for that patient? Diolch.

I think the task is to try and eliminate what they call unwarranted variation—so, variation that you can't explain by good reasons. Clearly, every patient is different, so you will expect variation. There's a patient-to-patient variation, there's, to some extent, ward level, hospital level, regional level variation, arguably, depending on the context. So, if you have a patient—. That is why applying the D2RA guidance fully is so important, because, actually, along that path you will have identified, 'Does this patient have a supportive family that's able to provide some level of care and support for them, or do they not? Do they have a home they can go back to, or do they not?' And so that will tell you, 'Do I need housing officers to be part of the discussion? Do I need some third sector organisations to be part of the discussion?' And the guidance we have is clear about what expectations, if you like, the Government has about what should be considered when multidisciplinary teams are brought together, but I think you have to say that that is, ultimately, a question of professional judgment based on the circumstances of that individual. We are clear about what the expectations are of the things you should take into account, and obviously that will vary based on the individual circumstances of a patient.

Thank you.

Okay, Laura Anne. Siân Gwenllian.

Laura has already touched on this a little, namely housing issues. Stakeholders have been telling us that not enough priority is given in the discharge process from hospital to needs in the home, as it were, and that that could lead to delays in the process. How do you think we can change that focus? One part of the solution is that those housing officers are included in the process much earlier on, but is there more that can be done to put the focus on that?

I think I'll answer this one, Siân. Basically just to say that I think most of the issues around housing and homelessness, and even being involved in the discharge process, are probably questions better answered by the Cabinet Secretary for Housing and Local Government, because it is about housing policy as well as just the discharge process, but I will answer your question, so I will answer your questions.

In 2019, of course, housing representatives became statutory members of the RPBs, so they do sit within—

That's high level.

It's high level, but they sit within that level that determines policy around how we can move towards developing the right housing solutions. And they're responsible for quite a lot of funds, including capital funds, that go into developing housing solutions. So, there's the housing with care capital fund, of course, which is the big one. And I might ask Shelley to say a little bit more about that, because each regional partnership board does have a 10-year capital fund, which is about developing housing solutions for people in all aspects of the care sector. So, as I say, Shelley can say a little bit more about that.

The Cabinet Secretary has now set up a task and finish group, reporting on ending homelessness. A national advisory board has been established, which is, again, about discharging into homelessness. So, there is a significant amount of work going on to deal with the issue of housing as it relates to discharge. So, the issue of housing about the appropriate level of housing that somebody is discharged into, what type of housing, and most notably, avoiding discharge into homelessness. Because what we can't do—. And you will have probably heard the Cabinet Secretary and the previous Cabinet Secretary saying this on many occasions, that hospital is a very, very expensive and inappropriate way to keep people once they are medically optimised. And keeping people in hospital because they have nowhere to go is not the appropriate thing to do. The appropriate thing to do is to make sure they have somewhere to go.

So, there is the task and finish group that has been set up to report on that and how we can make sure that we avoid those delays due to homelessness. And that's going to be reporting, I believe, later this year, Shelley, I think. I don't know, because we're not the local government Ministers.

I understand the point with regard to the services on the homelessness side of things. I understand that. But I'm thinking of that lack of focus on the need to make adaptations in homes soon enough, to put the handrails in and to do that work. If those housing officers aren't there in those multi-agency meetings, then an assessment is made of the home, and, 'Oh, we've forgotten that the home needs to be accessible to the person who is returning from hospital.' That happens all the time. It happens right at the end of the process, and then, 'Oh, the house isn't ready', so it means that there are five or six additional days to wait before they can return home.

Yes, sorry—

I understand the point with regard to homelessness as well, of course.

Yes. Homelessness is a big factor in all of this. But I absolutely get the point you make, and I'm sorry I kind of missed what you were saying at the outset. But one of the things that we are looking to do, and what the home first approach is looking to do, is to make sure that that is absolutely what is happening, so that when somebody is admitted to hospital, the talk about discharge and what they might need to go home happens actually on the day of admission, and not on the day of discharge.

It doesn't happen now though.

So, as soon as somebody is admitted to hospital, the conversation starts taking place with them and their families about what discharge is going to look like. Because one of the things that we identify very early on, and you'll be aware of this, is that quite often families are very reluctant to agree for their elderly relatives to be released from hospital, despite the fact that all the evidence shows that being in hospital is not the best place for them. But quite often families feel that that is the safest place for them, the best place for them, if they haven't got the care package that they need to be safely discharged. So, we're trying to shift that focus, so that when somebody is admitted to hospital, that conversation is taking place right at the outset, with the family as well as the patient.

I get that in theory, but in practice the hospitals are so busy, there is so much activity happening that the families are quite often forgotten, and the need to start the process of discharge disappears. And you can understand that because the pressure is so enormous on the staff, on the front line, in the actual hospital, that maybe they don't think, 'Oh, I should get social services involved here now.'

I will ask Shelley to come in on this because I don't think it's a question of—. It is a relatively new process about—. Somebody once talked to us about the fact that hospitals quite often have what they call a 'cwtch culture', where the hospitals themselves feel that it's the right place for people to be and have them there, and want to keep hold of them and make sure that they're okay and so on, when, in reality, we know that that is not the case. But the home first approach is something that is not fully embedded yet, and I take that point, because it has to become part of the normal practice of admitting somebody that this starts immediately. And again, there are good practices out there—the pink army is an example of that in Cardiff. But, Shelley, did you want to say something about that?

Yes, I think there are a lot of different factors here, and as you said, we've got some really good areas of good practice and other areas where there's still variation; we need to build that. I think that point about having multidisciplinary teams, bringing together people like occupational therapists early, who will help to determine what actually somebody needs in their home, the model in Cardiff where they've got the pink army. I think in Powys they have Powys Association of Voluntary Organisations community connectors very involved in conversations about people's care needs, trying to tap them into then what the community has available to support them for that planning.

And then, of course, we have the joint equipment stores, which are effectively funded off and through section 33 agreements, to make sure that health professionals can access the resources and materials that are needed. We have care and repair services, which are funded broadly from regional partnership boards, local authorities, to make sure that they have people with the right experience to go in and actually make the adaptations happen. I think you're right, in some cases, it could be happening sooner and that's the big drive we've got on home first, but there are examples of where that is happening in a very timely way, to help people make sure they've got the right arrangements at home.

And just picking up on the Minister's earlier point around the funding that we do put into this, we have the housing with care fund and the integration rebalancing capital fund, which are funding a range of projects, ranging right from home adaptations—so, making sure that we can create accommodation-based solutions for individuals to meet their, perhaps, changed needs—through to extra care, supported living and even residential care facilities. So, there's a range of different capital investments to make sure we've got the right accommodation-based solutions for people, so they can be where they want to be and as independent as possible.

Okay, Siân.

The next question is to do with the role of the third sector—the essential role that they play in providing services from hospital to home—but they all feel very frustrated that they're at risk of closure every year due to the lack of stability in terms of funding. What could you do to help move that along more smoothly, so that there is long-term funding available to some of these charities? For example, I know that in Ysbyty Gwynedd the Red Cross have been providing transport services straight from hospital to home on discharge. That service is coming to an end. I don't know why exactly, but that was a very important service and I don't know how that's now going to be done, to be honest. But that long-term funding, that's what we need, isn't it? How can we move towards a situation like that?

So, this has long been a campaign, hasn't it, of the third sector in particular around longer term funding? I think we absolutely understand the pressures that are on third sector providers that are developing their projects, their services, and never know from one year to the next whether the funding is going to continue. But there are two aspects to this. Firstly, I think it's important to say that anybody that attracts funding through the regional integration fund—. Of course, that's five-year funding; that was something that was a recommendation from Audit Wales when they looked at third sector funding initially. They made a recommendation around the need for longer term funding, and that was when they did the assessment of the integrated care fund, which you'll remember. They looked at the assessment of that, and one of the recommendations was longer term funding, and so what we see with the RIF funding is that that does fund five-year programmes, in particular. On a wider level—. But not every organisation is developing, necessarily, integrated care projects, so they wouldn't necessarily qualify for RIF funding. The kinds of organisations you're talking about would primarily be accessing the sustainable social services grant, and that has been longer term for the last few years. So, the sustainable social services grant is basically on a three-year rolling funding programme. That comes to an end next year, the sustainable social services grant, and we're already in discussion with the sector about what will replace that. And that kind of multi-year funding is a key element of that.

But one of the things that I'm very keen to do, and the discussions that I've been having with the sector, is that, where we are identifying very good practice in the third sector, delivering programme for government objectives and commitments, we shouldn't be short-term funding that—we should be looking to how we mainstream that. And, similarly, I don't think we should be looking to have short-term funding for projects that are limited to small geographical locations. If they're delivering projects that absolutely fit with the programme for government, then we should be seeing that available to anybody, in any part of Wales.

So, my view on that, and the conversation with the sector and with officials, is that, where we are identifying those good practices, we need to be saying that that should be rolled out across the country, and that, when organisations apply for funding in future around the delivery of a programme for government commitment, then I would want to see that being delivered on an all-Wales basis and not just on a geographical basis. Now, that may mean that more than one provider has to deliver it, because not all third sector bodies operate right the way across Wales, but different providers across Wales provide the same types of services.

Okay, Siân?

Fine. Thank you.

Lesley Griffiths. Diolch.

Thanks very much, Chair. We've heard evidence, and I know you're very well aware of this, that there's huge inconsistency across Wales—I would actually say inequality—around commissioning of care fees. If you look at the table, it's literally thousands of pounds difference between north Wales and south-east Wales, apart from—. I think it's Conwy that doesn't fit into that. We've got the national regulatory standards, we've got the national regulator. So, why is this happening? What are you doing about it? How are you encouraging all parts of the sector to come together when they're looking at care home commissioning fees?

In some ways, it's a mystery to everybody, isn't it, why we have this situation. But the starting point is that it's the responsibility of the local authority and the health board to agree on the social care needs of the population. They're the commissioning authorities, and they have to deliver this, and they agree what the fees are. Now, we started with—and I think I was talking about this earlier on, in response to a question to Peter Fox, but we started with—. In 2018, we commenced the 'Let's agree to agree' process, which was the guidance and toolkit to support commissioners in helping them through the fee-setting process. That hasn't quite worked in the way that we would have wanted it to work, because of the sorts of disparities that you're talking about. It is a framework; it is a toolkit. It was intended that that would bring some consistency into the process of commissioning, but I'm not sure that it worked in the way that we wanted it to do. But we have now introduced the national framework for commissioning care and support. That was only introduced towards the end of last year, and so that's got to work its way through the system. And that really does require commissioners to understand the cost of delivering care and setting fair and sustainable fees. It doesn't mean that the fees will be the same everywhere, because there are local circumstances, but it does mean that the process that will be followed will be consistent, it will be transparent, and the whole fee-setting process and commissioning of care will be based on the quality of the care that's commissioned, as opposed to just looking at the cost. Because we want to ensure that we have not just consistent processes and, where we can, consistent fee setting, but, actually, consistent service and consistent quality right the way across the piece. So, there will be differences in the fee rates; I don't think we can avoid that. But how those fees are set will be much more transparent under the new national commissioning for care framework.

So, just on that, do you agree with me that it is inequality across Wales that we're seeing?

I would say inequality—. It seems—. I don't know whether it's inequality; it seems to be inequity, which is not quite the same, but there are certainly large variances that are sometimes difficult to explain. What I hope will happen is that the national framework will make it much more transparent—the process will be much more transparent—so, where we do see disparities in fees, or what are apparent disparities in fees, we will be able to look back at the commissioning process and see how that has arisen. Because, as I say—I will be absolutely clear—the national commissioning framework is not about insisting that everybody sets the same fees, but it is about ensuring that we have a consistent approach to how fees are set.

So, you mentioned the system that we had in 2018, you didn't think had worked in the way that Government anticipated it would. Is the framework to replace that? Do you think the framework, once—? I appreciate—. I think you said in your answer to Peter Fox it came in in November.

Yes. So, it's still quite new.

So, it is quite young, and I think Care Forum Wales, in their evidence to us, accepted that, but how—. I think they used the words 'frustratingly slow'. How quickly do you anticipate we will see an improvement? Because 2018, that's seven years ago. So, you've brought this system in six, seven months ago. How quickly do you think that will—?

Well, in some areas, the health boards and the local authorities will be able to move immediately to this new process; in others, they're not quite ready to do that yet because of where they are already in the cycle. But they will have to publish annually what they're doing. So, it will give us a picture of what is happening in commissioning right the way across the country on an annual basis, and they have to publish that as well. So, it's not just about having a report to us; it's about making sure that they publish that.

And we also have commissioned some research around the feasibility of creating and putting into place national fee methodologies. This is part of the work that we're doing towards delivering a national care service. So, phase 1 of that work was—. You will recall this, Siân, because this was part of the co-operation agreement on the delivery of a national care service, that we were going to deliver in three phases, and the first part of that was to commission some research around fee methodologies and how we could apply that to a national care service. But I think the principles that come out of that are something that we could apply through the national commissioning framework. We haven't yet got the outcome of that research; that's being undertaken now. But I certainly see that we will have a clearer picture within 12 months of what is happening.

Are you monitoring it? You're not just waiting for the annual report.

We will be looking to monitor it, because it's something new, so we want to see how this is being adopted and adapted by local authorities and by local health boards. We've had several sessions with commissioners so that they understand what is expected of them. There is a toolkit that's available for commissioners, which is being developed and updated as we go along. So, even though it's still early on, we're already getting feedback from commissioners about what more they feel that they need. So, that's a moveable feast, and that's an ever-evolving set of recommendations and guidance for commissioners. But I don't know whether Shelley or Taryn have got anything to add to that.

I think it's just important to note. So, the national framework for commissioning came in in September 2024, last year. We anticipate that that will take some time to embed. What's important to note, however, is that that is the commissioning framework for both health and social care, which is a significant development in terms of that framework.

The research that the Minister shared earlier that's being undertaken by the national office for care and support will allow us to look at what standardised fee methodologies look like, which will then build upon having the commissioning framework standardised fee methodologies, which will support us moving forward to ensure that there's a fair and transparent system for care home fee commissioning.

Okay. Thank you. Care Forum Wales were also critical about regional partnership boards and the way that funding went out—particularly capital funding, I think. So, one of the examples we were given was that Carmarthenshire County Council are building a new care home at a cost of £19.5 million to increase community capacity; meanwhile, there are homes within that county council with beds. So, why are they building, you know, a brand-new home, using all the funding in relation to that? Why aren't they working more closely with the independent sector to improve capacity there? So, would you—? You know, what's your view on that? Have you got any other examples of any other areas in Wales where that's happening?

Yes, I think that those would be the kinds of issues that both the Cabinet Secretary and I would recognise in some areas. The regional partnership boards, of course—. You know, it's their responsibility to actually deliver what is the requirement within their area. So, we would expect all of that kind of planning to have taken place, that there would have been research on that. This is what I talked about earlier on: the population needs assessment, all of that, should have been informing the delivery. So, I don't know the specific detail of why we are in a situation where that is being commissioned in that particular area when there is sufficiency in the system. I don't know whether Shelley has got anything that she can add to that, but—.

Yes. I think what—. So, in terms of the investment we have through the integration and rebalancing capital fund, that is specifically looking at building capacity in our market that will help us rebalance the market. Research that we did a number of years ago was showing there's that 80:20 split in terms of the adult residential care market—80 per cent independent, 20 per cent in that not-for-profit public sector space. And there's something about being able to rebalance that so that actually, where you've got more provision that is spread across those sectors, you've got greater choice and opportunity for people in terms of where they want to be located. But it also really helps commissioners to be able to have facilities—. So, for example, if a local authority has got a care home, they're able to perhaps move more quickly or have more flexibility about how they create placements for people with specific needs, whereas, when you're commissioning from the independent sector, there's a different dialogue that takes place. So, getting that rebalance is one of the specific aims behind the IRCF programme, and perhaps why that's been flagged by Care Forum Wales.

That said, all of that investment is being underpinned by these 10-year strategic capital plans that RPBs are having to do; providers are represented in the RPBs as part of that process. And when they're doing their 10-year strategic capital planning, they need to be looking at their population needs assessment, their market stability reports, which they have to produce, and their area plans to make sure that the capital investment is addressing the needs that are specifically identified through those other strategic assessments.

So, there—. You know, on a region-by-region basis, there should be a really good rationale as to why that particular investment is needed, and they'd have to be submitting that as part of the really robust business case process we have around the IRCF.

Do you think the new framework will help with this as well?

It will help in terms of having the consistent approach and the ability to work in a consistent way with consistent processes, and transparency within the process that we will be able to see. So, it is a framework that is about how we deliver quality outcomes in the most cost-effective way. If it wasn't going to have any impact, then I would be disappointed, because, you know, the whole—. It is the framework for the whole of our national commissioning and care process, both in local authorities and in the NHS, so I would expect that to be driving the way in which all of our care services are commissioned.

Okay. I know we have very, very little time left, but I wonder if we could just deal with two further questions that Siân Gwenllian has, on unpaid carers.

Thank you. Unpaid carers play an essential role, of course, and we're looking today at discharges from hospital, and unpaid carers are often a very important part of that package that allows that care to move from hospital into the community. Ten billion pounds is saved to the public purse from the work that these unpaid carers are doing, but we need to think about how we're going to make this sustainable for the future. The assessments that are a right of unpaid carers—many unpaid carers aren't even aware of them, but they can be a very good way of identifying not only the pressure on carers, but also the needs of the person receiving care, which could lead to identifying those needs earlier on in the process so that the process of going into hospital doesn't even have to happen. So, they have an absolutely essential role. So, how are you going to raise that emphasis on these assessments?

And also, if I may ask one question related to this, respite care can also be essential to retain carers for the future, but there's very little respite care available in some areas. I don't know if it's inconsistent, but certainly, in the area I live, you can't get respite care, so the pressure on unpaid carers is even greater, and sometimes, in some situations, people do end up in hospital because that's the only way for unpaid carers to get any respite. So, I just wanted to make that point, and about the assessments, more than anything.

Sure. Well, first of all, can I say I absolutely agree with you, Siân, in terms of the importance of unpaid carers in the social care system, not just the financial benefit, you know, in terms of the savings that you identify, but actually the care that they're providing? I mean, I think you said yourself that you're a carer.

One third of my—. My two brothers help as well.

Yes. And, you know, I went through something similar a few years ago with my dad when he had his stroke. He was living quite a way away from me, but mum and I were trying to do the best we could, back and forth and so on. So, I do absolutely understand, but for some people it's 24/7. It's absolutely 24/7, and there's no kind of break from it.

You'll know that through the ministerial advisory group we commissioned the Association of Directors of Social Services to do a rapid review of carers, and that was primarily because of a long-standing concern that had been raised by carers about inconsistencies of approach. We've heard that word come up a lot today, haven't we? The inconsistencies of approach in terms of carers getting the appropriate assessments and so on.

So, we set up a task and finish group, and ADSS are on that group, as are the third sector, as are unpaid carers, and that was about looking at how we can improve access to information and advice and support for unpaid carers. So, we're in the process of doing that work, but we're not not doing anything while that work is going on, because I think it's very clear to me from the discussions that I've had with unpaid carers directly and with organisations that represent unpaid carers that there are gaps in the kind of provision for unpaid carers.

So, the thing that concerned me the most was the inconsistent approach from local authorities towards offering carer assessments. So, I was very keen to understand how a local authority identifies an unpaid carer. I was very keen to understand why there were so many inconsistencies around the way in which care assessments are undertaken, and what support is given to a carer once that assessment is undertaken, and what work local authorities are doing to ensure that unpaid carers are aware of their statutory right to have an assessment.

And the other thing that I was quite keen to ensure happens is that carers are assessed in their own right, and not as part of the package of the person that they care for, because they will have their own independent needs that are very different to the needs of the person that is cared for. And again, we have seen examples of where the same person is undertaking the assessment for the carer and the cared. Quite often, in those circumstances, it’s the person being cared for whose needs seem to be prioritised against the carer. I think they are different, but they are equally important, and so it’s probably important that we have different people doing those care assessments. So, we’re working on a number of those points with a view to, again, introducing that consistency across the way in which this operates.

It's important to say, around the support for carers, obviously, there’s the carers allowance, and there was a very welcome increase in the benefit for carers allowance that we saw announced by the UK Government last week. From a Welsh Government point of view, in addition to the respite services that are offered by local authorities, and taking on board the point that you are making that that, again, is not consistent and is not always sufficient, we have put an awful lot of money into the short-break scheme, which provides tailored respite for carers. I see you shaking your head there, so I think it is a question of: is enough known about that? Is that being publicised well enough? Do carers know about it? Because, certainly, in the discussions that I have had with carers' organisations and unpaid carers, those that have been recipients of the short-break scheme say that it is absolutely transformational in terms of what they can get, because it is not a standard offer, it is a bespoke offer to the carer for what they need. It could be a short break, but it could be a visit to the theatre, it could be anything, whatever it is that they need. So, that is in the system, but I absolutely accept, I think, that we have a way to go around making sure that people who have rights are aware of those rights.

Just to add, underneath the task and finish group that sits underneath the ministerial advisory group, local authorities have been asked to undertake an assessment on how they’re meeting the needs of carers and conducting carers assessments, and there are two workshops that are set up, on 15 and 22 May, where Welsh Government will be meeting with senior local authority officials to look at that information and next steps.

Okay, thank you very much indeed. Thank you, all four of you, for coming to give evidence to the committee today. We have one or two other questions we’ll write to you about, and, of course, you’ll be sent a transcript to check for factual accuracy. Diolch yn fawr.

Diolch yn fawr iawn.

Diolch.

Okay, the next item on our agenda today, item 3, is papers to note. We have a letter from the Finance Committee in relation to the Welsh Government's draft budget for this financial year; a letter from the Cabinet Secretary for Housing and Local Government regarding Cornerstone Place, an organisation that provides infill housing solutions; paper 5 is a letter from the Cabinet Secretary for Housing and Local Government on building safety, in response to our letter following correspondence from the Welsh Cladiators; paper 6 is a letter from the Cabinet Secretary for Housing and Local Government with additional information for our inquiry on housing support for vulnerable people; paper 7 is a letter to the Petitions Committee from the Cabinet Secretary for Finance and Welsh Language on a petition regarding giving neighbours their say when holiday-let owners start applying for licences; paper 8 is the Welsh Government's response to our report on the provision of sites for Gypsy, Roma and Travellers; and finally, paper 9 is a letter from the Cabinet Secretary for Housing and Local Government in relation to our report on the Welsh Government's draft budget for the current financial year. Are Members content to note those papers? I see that you are. Thanks very much.

Item 4 is a motion under Standing Order 17.42 to resolve to exclude the public from the remainder of this meeting and for the meeting on 22 May. Is the committee content to do that? Yes. We will then move into private session. Diolch yn fawr.