Cynulliad Cenedlaethol Cymru

Yn ôl i Chwilio

Y Pwyllgor Cyllid

Finance Committee

07/03/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

David Rees AC
Jane Hutt AC
Mike Hedges AC
Neil Hamilton AC
Nick Ramsay AC
Simon Thomas AC Cadeirydd y Pwyllgor
Committee Chair

Y rhai eraill a oedd yn bresennol

Others in Attendance

Carol Shillabeer Prif Weithredwr, Bwrdd Iechyd Lleol Addysgu Powys
Chief Executive, Powys Teaching Local Health Board
Gerry Evans Dirprwy Brif Weithredwr, Gofal Cymdeithasol Cymru
Deputy Chief Executive, Social Care Wales
Joseph Ogle Gwasanaethau Cyhoeddus Cymru 2025
Wales Public Services 2025
Vanessa Young Cyfarwyddwr, Conffederasiwn GIG Cymru
Director, Welsh NHS Confederation

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Catherine Hunt Ail Glerc
Second Clerk
Georgina Owen Dirprwy Glerc
Deputy Clerk
Joanne McCarthy Ymchwilydd
Researcher

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

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

Dechreuodd y cyfarfod am 09:02.

The meeting began at 09:02.

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions and declarations of interest

Bore da, felly, a chroeso i gyfarfod y Pwyllgor Cyllid. Croeso mawr i bawb. Gwnaf i jest atgoffa Aelodau i dawelu unrhyw ddyfeisiadau electronig ac, wrth gwrs, mae cyfieithu ar sianel 1 a'r sain wreiddiol ar sianel 0. Wedyn, rydw i wedi derbyn ymddiheuriadau gan Steffan Lewis. Hefyd, a oes angen i unrhyw Aelod ddatgan unrhyw fudd neu ddiddordeb yn y materion dan sylw? Pawb yn hapus, felly.

Good morning, and welcome to the meeting of the Finance Committee. Welcome to you all. I just remind Members to put any electronic devices on silent and, of course, interpretation is on channel 1 and amplification on channel 0. I've received apologies from Steffan Lewis. Also, are there any declarations of interest in the issues at hand? Everyone is happy.

2. Cost Gofalu am Boblogaeth sy'n Heneiddio: Sesiwn dystiolaeth 1 (Conffederasiwn GIG Cymru a Gofal Cymdeithasol Cymru)
2. The Cost of Caring for an Ageing Population: Evidence session 1 (Welsh NHS Confederation and Social Care Wales)

Os felly, gwnawn ni droi at y tystion ar gyfer ymchwiliad y Pwyllgor Cyllid i gost gofalu am boblogaeth sy'n heneiddio. Croeso mawr i chi gyd. Os caf i jest ofyn i ddechrau eich bod chi'n datgan eich enw a'ch swyddogaethau jest ar gyfer y cofnod, os gwelwch yn dda—gan ddechrau gyda Carol.

If so, we'll turn to the witnesses for the Finance Committee inquiry into the costs of caring for an ageing population. Welcome to you all. Could you please introduce yourselves and your roles for the record? Thank you. Starting with Carol.

Diolch. Good morning, I'm Carol Shillabeer, and I'm the chief executive of Powys teaching health board.

Hi, I'm Vanessa Young, I'm the director of the Welsh NHS Confederation.

I'm Gerry Evans, deputy chief executive of Social Care Wales.

Diolch yn fawr ichi am hynny, a diolch am y dystiolaeth gynhwysfawr iawn rŷm ni wedi ei derbyn gennych chi hefyd. Os ŷch chi'n hapus, byddwn ni'n mynd ati yn syth i holi cwestiynau ar sail y dystiolaeth honno.

Os caf i ddechrau, serch hynny, fel Cadeirydd a defnyddio tipyn bach o hawl y Cadeirydd, dim ond i roi ar gofnod ar ran fy hunan, yn Aelod sy'n cynrychioli Powys hefyd, wrth gwrs, ond mae'n siŵr o ran aelodau'r pwyllgor hefyd, ein bod ni'n ddiolchgar iawn am y ffordd mae gweithwyr yr NHS wedi ymdrechu drwy'r tywydd garw yn ddiweddar a'r holl ymdrechion sydd wedi eu gwneud i barhau â gwasanaethau. Beth bynnag yw'r dadleuon gwleidyddol rydym ni'n eu cael o bryd i'w gilydd ynglŷn â'r gwasanaeth iechyd, mae ein diolchiadau yn fawr iawn i'r aelodau staff. Mae'n siŵr y byddwch chi'n cyflwyno hynny'n ôl i'ch aelodau a'r bobl yr ŷch chi'n eu cynrychioli hefyd. So, diolch am hynny.

Os gwnawn ni droi at y dystiolaeth, os caf i ofyn i ddechrau, mae'n amlwg o'r dystiolaeth bod y galw am wasanaethau gofal cymdeithasol wedi newid—natur y galw—dros y blynyddoedd a bod hyn yn ei dro wedi effeithio ar y ddarpariaeth a'r ffordd mae'n cael ei darparu ar ei chyfer. A fedrwch chi jest amlinellu sut y mae'r galw yna wedi newid a ffordd rŷch chi wedi gorfod newid y gwasanaethau neu newid y ffordd rŷch chi'n darparu neu'n dosbarthu arian i gwrdd â'r galw yna?

Thank you very much for that, and thank you for the comprehensive evidence that you've already sent to us. If you are content, we'll go straight into questions on the basis of that evidence.

Could I start, as Chair, and use a bit of the Chair's prerogative, just to put on record myself, as a Member representing Powys, of course, but also for other members of the committee, that we are very grateful for the work that NHS staff have striven to do in the inclement weather recently and the efforts to continue with services. Whatever the political arguments we have about the NHS, we are very grateful to staff. I'm sure you would like to relay that to your members and the people that you represent. So, thank you for that.

We'll turn to the evidence, and can I ask to start—? Clearly, from the evidence, the demand for social care services has changed—the nature of that demand—over the years and this in turn has affected the provision and the way in which it is provided. Could you just outline how that demand has changed and the way that you have had to change services or the way that you deliver funding to meet that demand? 

09:05

Shall I start? Yes, thank you very much for your comments around the weather and the efforts that not just staff but communities have made as well—pretty tremendous. I think it relates in particular to the subject area that you're examining, which is around care for largely older people within your terms of reference.

I guess the change in demand over the last few years can be described in a number of ways, really. What we're very clear about is that older people do not want to go into residential care primarily; they would like to remain at home as long as possible. That was one of the key messages that we had, certainly in the Powys regional area, from our population needs assessment. Therefore, the push continues to be on what are the alternatives to residential care when people become frailer.

So, we all know about the population projections, there's plenty of that in the evidence that's been submitted to the committee. But a couple of important points—one is about choices. As we get older, people do largely want to stay in their own home but we've seen the development of other types of accommodation, supported and assisted living, and they're offering a real opportunity for people to stay in their own communities but in an environment that has got enhanced support. I think there's much more progress to be made in ensuring that that type of accommodation and that type of care support is available throughout Wales, so there are areas that have been able to move forward on that and others that are in a bit of catch up.

We've also seen the demand for domiciliary and residential care change, particularly because of the further development of community services. So, from a health perspective for a moment, we've been able to support people in the community who in previous decades may have been cared for in residential care but, because they've chosen to stay at home, we've been able to invest in community services to enable that to happen.

You may be familiar with developments such as virtual wards, where people who would ordinarily have perhaps gone into hospital are now being cared for at home with that intensity of package. What that actually means is that we're trying to break into the chain of admission into an acute hospital—which does add dependency to people, particularly in the over-85 age group, with a greater likelihood of requiring longer term care—we're breaking into that, but what we are seeing therefore is the demand switching between residential care and domiciliary care and that support at home. I know that we're going to have lots of discussions about domiciliary care.

The thing that I must stress, though, and we've had these discussions at the regional partnership board that I chair, is that there will always be a place for good-quality residential care. What we have seen is the pattern of that change over time, where people who are accessing residential care with nursing are much more complex than they may have been, or there are more patients of more complexity than there would have been, say, a decade ago. So, making sure they're well staffed and well provided for is a key element of the whole package of care. But it's been very clear to me, to our region, and to the NHS and social care partners that the pattern is needing to change. The pattern's already started to change but there's much more for us to do. 

Do you want to add anything to that, particularly on the challenges that that gives rise to? 

I guess the changes, as Carol said—it's just the quantity of demand is growing at a pace. The complexity of that demand is also increasing with the multiple morbidities that people have. As Carol said, what people want is also changing; their expectations of care are growing, which is perfectly to be welcomed, really. Similarly, the pressure is then to try and maintain people in their homes for as long as possible. We know that's what people want, or—as Carol again says, there is a need for good-quality residential care, for that to be provided, again, within people's own communities as much as possible. The implications of that are, particularly from our point of view, for the workforce and the skills—well, the number of staff required to start with, the skills levels of those staff and their understanding of how to work with people—to work alongside them—which is in the Social Services and Well-being (Wales) Act 2014. So, it's a multiple change in that sense, and the volumes tend to get a lot of the attention, but the complexity and those trying to work out how you work with people to meet their needs in new ways is the additional element of it.

09:10

Just to build on that point, when we take evidence from the Cabinet Secretary for Finance, usually he tells us that, within the NHS and with spending on health in Wales, one of the difficulties, as things are changing, is to maintain spending on your current services, if you like—your acute hospitals—and some of the problems that arise are from people perhaps being inappropriately in hospital, for example, older people, but then trying to maintain that spending whilst trying to innovate and bring in new spending. You've been trying to do that, particularly in the last five or six years, at a time of cuts, generally described as austerity budgeting. Has that produced a particular challenge as well in terms of meeting this need and developing the new servcies that are needed?

Yes, absolutely, it has. I think the other thing, just recognising the ageing population growth and the fact that we have a higher rate of increase in life-limiting illnesses in this country as well compared to the rest of the UK, means that the pressure on social care is potentially greater and that has a knock-on impact then into the hospitals. So, you mentioned, obviously, the challenges that the NHS and social care faced in the last few days. If I just refer to the figures for December, we had the highest number of A&E attendances and, of those, we had the highest number of patients aged over 85 needing admission. Those patients tend to need to stay longer and then also need social care packages to be able to be discharged. So, we need to look at it as the whole-system impact of the ageing demographic and the reliance that we have between us on the pressures that we're trying to address together.

We're just at the moment looking at all the directors of social services' annual reports and that is a theme that is emerging—the difficulty of moving to new patterns of services when there are constant and growing pressures on existing services. That is a theme that emerges from directors. Similarly, we know that transferring or supporting the third sector in some of those initiatives that improve local provision for people is also under pressure at the moment. So, putting all of that together, yes, it is creating difficulties in terms of moving to those new patterns of service, which we all want to work towards, really.

Thank you for your extensive evidence, and also can I add my words of thanks to all those who worked in social care as well as the NHS over the last weekend? It's been extremely pressurised. I think it's interesting, as you say, in terms of social care and support—Gerry, I think you mentioned quantity and complexity of demand changing, and of course, circumstances like the last week's increased pressures can actually throw everything in terms of trying to move to a longer term solution and work through those patterns of change. Of course, once you're in a hospital, it's harder to then move back. But can we just focus for a moment on current cost pressures on the providers of social care—residential and domiciliary? How are providers reacting to these pressures?

If I start on that, I think they're probably different in the different parts of the sector. So, if I just talk about residential care for a moment. The evidence—and I've seen evidence from others submitted to the committee—I think is pretty clear that there are significant cost pressures around the workforce. The introduction of the national living wage is to be welcomed, particularly in this group of workers, but it has caused some pressures. But I think that's been compounded in particular by the workforce recruitment and retention challenges. I'm sure Gerry will give a bit more detail on this, but when some domiciliary care providers are seeing between a quarter and a third of their staff turn over every year, the sheer efforts of trying to recruit and retain do take up a huge amount of effort and energy.

On residential care and recruitment issues, particularly among the registered workforce—registered nursing—we know that, right the way across the UK, there is a shortage of registered nurses. The independent sector is not isolated here, and the costs are considerable. There has been dialogue with the sector around the true cost of care and the allocations made from both local authorities and the NHS, but we are seeing home closures. There are no two ways about that. I know that particularly north Wales are under a lot of pressure. I've seen a couple of small homes in Powys—. And it particularly affects those where the critical mass of beds is not there—so, the smaller, more independent homes, which often are those more local homes to people rather than the big 60-bedded areas.

To just make some reference to the older people's commissioner's report, 'A Place to Call Home?', she's pushing very hard, rightly, that we see from the NHS and the local authority that the sector is part of the whole and total offer. So, I sense that there is more that we need to do collectively on workforce planning to support the residential sector, because the costs are actually increasing, not just on the workforce but primarily on the workforce challenges that they've got.

The sector becoming smaller is a real problem for the NHS, and when we talk about the increase in the numbers of people over 85, while that's to be celebrated of course, in many ways it is completely the wrong place for people at that age to then therefore be spending weeks, if not months, in an NHS environment. So, we do need to find a strategic solution to these problems in the residential sector.

09:15

I suppose the question is: how are providers—. They need the space and, given the pressures they're under, how can we enable them to actually move in those kinds of directions that would be more effective for older people?

There are a couple of things in particular. I've heard that there are some real challenges around capital costs for the development of new buildings—that they're simply not able to raise, or feel confident enough to raise, the capital for that—and then, secondly, there is the work that I know Gerry and colleagues are undertaking on the social care workforce and the value placed on that, and their professionalisation, which you may want to touch on, Gerry. How do we ensure that as a country we're valuing—not just saying the words but that the actions are matching the words on the value of this part of the sector?

Can I, if I may, just ask for a little bit of clarity? You talked about capital costs. We're talking mainly about private investment here. Some of them are social enterprises as well, of course, but are there any schemes that Welsh Government has that open up support for capital costs? We've taken evidence on the financial transaction capital, for example, which is investment and payback. Again, there is an income stream potentially here once you actually get it up and running. Are there any examples of that or is this an outstanding issue, if you like, that is unresolved at the moment?

Going back to Carol's point about other alternative forms of housing and supported housing and things like extra care, in the past, extra-care facilities have been funded through things like social housing grant, so local authorities have entered into partnerships with registered social landlords. That has become more challenging over recent years, but there are still examples. There's an example in Bridgend, where they're building a couple of extra-care homes, and they've done that through partnership with an RSL. I was working there at the time and it was difficult to align the funding mechanisms, the capital, in a way that ensured that the RSL was able to have a secure income stream in the future that was sufficient to cover the capital costs of the investment. So, it's how you try and bring some of those options together around the capital funding that is available within Government and beyond to facilitate those kinds of partnerships. And it also involved sharing of the land owned by the local authority. So, there are ways to do it, but we could certainly make it easier, I think.

Yes, from the domiciliary care sector, I think perhaps the most worrying symptom there, in terms of how providers are responding, is the numbers who are now returning their contracts to local authorities, saying that they cannot provide at that fee level, which I think is a matter of significant concern, really.

As was said, staffing is a critical issue here because there is 20 per cent to 30 per cent turnover amongst domiciliary care workers, and the costs involved in recruitment in itself clearly have a knock-on impact for providers. Not only is it just replacing existing staff, but it's the fact that, over the next 10 years, we need another 20,000 care workers in Wales. The challenge that that is posing is pretty daunting, I think, for providers.

So, a whole atmosphere of some concern, I think, does exist. As Carol said, we are trying to do some work around the recruitment end, but actually it's a long-term process of actually getting this workforce to be recognised for the complexity of the work that it does.

09:20

Could I ask Neil Hamilton and then David Rees—just quick follow-ups?

Anybody who has ever had any experience of residential care—I'm sure we all have, with elderly parents and so on—is amazed that people are prepared to do the kind of job they do for the money that they're being paid. I presume that it's pay, conditions and the combination of the hours people have to work, and the intensity at which people are working the whole time, that cause this great churning of staff. So, the answer to the problem is probably higher pay, but then the other end of the equation is who is going to pay for that and what's the funding mechanism. So, am I right in that analysis?

Yes, I think. The evidence we've got—and the University of Manchester, I think, did a piece of work for us—actually reflected the fact that care workers actually really enjoy the work that they do and get a sense of reward from it, but it feels now as though things have reached a point where they feel, actually, too much is being asked of them for too little. So, yes, certainly pay and the terms and conditions of employment, particularly those that are now being looked at, like zero hours and travel time, are critical in all of this. That sense of them feeling valued and not being exploited is central. Otherwise, actually, as a career, it is one that people do value and do want to go into, and we know that there are younger people now who want to go into that, if we can provide a clear career framework. So, pay is critical. It is a complex job these days, with significant challenges and risks that staff undertake in the nature of the work that they do. So, pay, yes, but, over and above that, there are some positives to be built on to demonstrate that this is a valuable career that people can make for themselves in this sector, but, without addressing the pay, it is going to be a challenge.

I just want clarification on the churn and turnover, just for my purposes. Is that churn and turnover actually people leaving the sector or simply transferring to different employers within the sector?

It's a mix, actually. Some people come into it and leave fairly soon, I think, finding it's not for them. Others, and particularly once they become qualified—we're encouraging qualifications amongst all staff—they'll look to other places to work. In part, that means going to the NHS, because the pay will be better there. Others do move within the sector, but the sense you get is that that's more limited actually. Other people stay, and a significant proportion stay for very long periods of time, it has to be said. So, within that 20 per cent to 30 per cent, there is a whole mix of issues there.

Could I just come back on the point about fee levels? Over time—and I recall, when I was Minister, we helped develop toolkits to have more equity across Wales between local authorities in terms of their fee levels—the toolkits have come and gone. I'm not sure what the latest state of play is in terms of guidance to local authorities in terms of their fee setting, but it does vary very much, and that must have an impact on the job market as well as actually accessing residential care.

Yes, that's certainly a comment made by providers—that particularly where they provide across more than one authority, it has become very complex in terms of the negotiations and the differentials there.

In terms of a toolkit, there is one currently under development for the care home sector, and that's being developed by Professor John Bolton with the sector. As far as I know, that's a trial one, and the thinking was that that would then progress to looking at domiciliary care.

I think it's worth us looking into that further. Can I just ask you perhaps, Vanessa, a couple of questions from your evidence? You clearly recognise, as I think we all recognise—and the parliamentary review has recognised—how important the effective interface is between the NHS and social care. That's been crucial, you say, even in the ways it has been able to develop, perhaps, over the—. You know, the pressures mean that it's very difficult to keep that interface going. But can you give examples of how you feel we can progress in the short and long term on that interface with health and social care and how it's working at the moment?

09:25

Yes. So, certainly over the last few years, and with the help of things like the integrated care fund, health and social care have been able to put in place some new models that have helped with that interface, and when we're thinking about that interface it's about how we help to prevent people needing to enter the health system and how we help them leave the health system as quickly as they can. So, there are a number of examples of how we've worked together to help prevent admissions by providing support to people in their own homes, how social care has helped us to improve the patient flow through the hospital in terms of facilitating faster discharge and more appropriate care packages, and really it's also about primary care working more with social care in the community so that we understand the patient's or the client's needs and are providing the support that they need to keep them well so that they don't need to access secondary care.

We have been doing a lot, but, as Simon was saying at the start, the difficulty is that, when you're trying to create new models of care while you're also trying to deal with the level of demand that we're seeing in our hospitals currently, particularly from the elderly population, we are constrained just by the nature of the resources that we have in how much we can invest our time and energy in that. Also, we have significant workforce pressures across health as well as social care, so there's a very practical obstacle about resourcing new models as well as providing the resources that we need to maintain existing ones. 

So, as I say, things like the integrated care fund have been very helpful. The transformation fund that the Cabinet Secretary has announced will also help support some integrated working, so that will be helpful too. And we are as NHS leadership really working very much more closely with the social care leadership now. So, an example of that would be Social Care Wales working with the new Health Education and Improvement Wales to develop an integrated workforce strategy, and that comes on the back of recommendations from the parliamentary review. So, that would be an example. And we are working with colleagues in the Association of Directors of Social Services Cymru and the Welsh Local Government Association to identify mechanisms that we can put in place to help us actually really deliver that seamless system. But so much of that is about the good practice that we're doing already and scaling that up so that we're doing that everywhere. But resources are inevitably—both financial and staffing resources—a real obstacle.

It's interesting that a relatively small funding stream, the integrated care fund, has actually had such an impact, I think, from your examples and your evidence and what you're saying today, in actually enabling that interface to—. 

I think part of what that is is that it removes the tension about problems in the different arrangements that we have in health funding and social care funding—the different accountabilities, the different ways in which we access funding, having the conversations about—. Fundamentally, we are dealing with a system where demand is higher than the capacity that we have, and so having funding where we don't have to argue about how much each is putting into that pot and how much risk we are each bearing enables us to more easily progress new ways of working.

I'll just say in passing that one of the better examples of a budget agreement between two parties is the intermediate care fund and one of the ones that has been sustained way past the original budget agreement as well. So, that's good to see. And you're quite right that it's evidenced in a lot of the evidence that we've had as a committee that this is a fund that's been punching above its weight, in effect, in its effectiveness. I'll invite David to say something now.

Just based on what was said—in a sense, this is meant to be my question later on, but I want to ask it now. You've highlighted the issue of the parliamentary review and how it's proposing a change of models, yet you've still highlighted that obviously there are issues in being able to deliver what you've got, plus this change. Is it actually a question of funding or is it more, actually, a question of resources to be able to do it? Because if you haven't got the resources to be able to initiate it, there are going to be problems. 

09:30

It's fundamentally both, and the parliamentary review does acknowledge that they weren't asked to look at the funding envelope, but they've recognised that it is an issue. If you look at the Health Foundation report from 2016, 'The path to sustainability', in there it identifies what the forecast funding requirement is for health and social care, and Welsh Government has met that requirement in respect of the NHS, but actually has not been able, due to austerity, to meet that commitment for social care. So, there's a fundamental mismatch between the resources that I think everybody recognises social care needs and the funding available in the system to help support that. So, that's a fundamental point.

Then there is also the issue about do we have the headroom capacity within our workforce to be able to spend time developing these new models of care. So, that's a workforce issue. And then there's also the issue that, when you're investing in new models of care, quite often you need transformation/transition funding so that you can dual-run those services before you're able to withdraw one service to provide another. So, it's those three component parts. The fourth thing I would say is of course we need to drive the greatest value we can from the resources that we already have. So, between us we have a considerable part of the Welsh Government's budget and we need to make sure we're driving maximum value through that, so that's also about tackling efficiency and effectiveness through the way in which we conduct our business. So, I'd say it's those four things.

Of those four things, if you haven't got the resources, you fall down, because you can't deliver.

Arguably without each of those components you fall down. So, they're all very important.

So, if you have the funding—. Let's say you get the funding—austerity disappears and you get the funding. Do you have, does the country have, the workforce available to deliver?

It depends which part of the workforce you're looking at, doesn't it? So, if you come back to the point that we were just talking about, about the relatively low wage for the social care workforce, if you were able to invest more, then you would be able to attract more people to come and work and to want to have a career in social care, which would inevitably be positive for the health and social care system. If you're looking at more specialist services, in health we do have real workforce challenges that we're trying to tackle over the short to medium term through our workforce planning and development and recruiting overseas and trying to train and develop more within our own country. It's a mixture of factors that we need to work on, but there's no simple solution.

I think there are some limiting factors here. I, if you like, speak from the ground. If you don't have the resource, then you can't put in a new service. When we're designing a new service, we have to be really mindful of where the workforce is going to come from, because if you can't guarantee you've got a workforce stream then you can't put that type of service in. What it is making us do is to think very differently about the different types of care that can be provided that are less workforce dependent. So, you've got some really positive examples of the use of technology and technology-enabled care now coming through, which means that they are less labour-intensive and you can manage services in a slightly different way. The parliamentary review raised this. We've got a long way to go in terms of really maximising that. I'm not sure we know what we don't know, even, at this stage—we don't know what we don't know at this stage. But there's a sense that there are some areas that have been able to push forward on that.

So, I think if we're wholly reliant on a workforce-based transformation, in the current model I think we are going to struggle. We are already seeing different types of workforce roles coming forward, and that is important. They do have to be properly remunerated, and there has to be a proper long-term plan, which is why HEIW and Social Care Wales working together is critical. What I guess we would like to see is this career pathway—that people can come into the social care sector. Many people will want to spend the rest of their careers in that sector, and that's very important, but we also want to be able to offer a progression through to other parts. It's a very rich world, the care world, to give people those opportunities, and what we are seeing is people are leaving to go and work in retail, for example. So, there are a number of important factors that we need to place down, and, as Vanessa says, if you start to remove one of those important building blocks, then it's going to affect the pace of change.

If I could just add a comment on a bit around the hearts and minds of the health and social care system. I think it's important to say that I think we've seen a shift over the last few years. The Social Services and Well-being (Wales) Act 2014, particularly Part 9, which is the regional partnership boards—they've given a new and fresh impetus to partnership working. I think that that's why the fund has helped, because we're not trying to rob Peter to pay Paul; it was a new stream. I think there are some challenging issues, but there's a high level of commitment to sort through things like fee setting under the regional partnership board, under the commissioning for care homes, for example. There will be some tough times ahead because the pot's too small for the demand, but nonetheless, I sense, having spent a long time in the service, a sea change. The whole system can only succeed if the whole system succeeds. So, we're in a different place to—

09:35

It can only happen if it happens, and if it doesn't happen, it never happened. 

Because there's a sense of—don't let anyone play that back now—a sense that we can't have a successful NHS without a successful social care system and vice versa. So, I think there's a complete acceptance of that, but there's a sense now of 'What are the shared issues and the building blocks to get to that success?' I'm going to use that term, thank you for that.

Can I just add quickly, on the workforce issue—? Because there is some good news there I think. International work that's been done on the skill requirements for the future, across the world, indicates that care, and the skills associated with care, are going to be one of the top areas that can't be wholly replaced by technology. And therefore we are able to say to parents in particular, 'Actually, your children could have a good career here', if we just create the right sort of circumstance around that role to enable them to come into the sector. Work we're currently doing with job fairs indicate that interest is there if they feel that it's an appropriately professionalised role with that career structure in place. 

I just wanted to—. I should have asked this question earlier on, but you did earlier on say—I think all of you—that it's about expectations and changes and people want to, if possible, remain at home and have access to domiciliary care. Can you just say: is that having an impact on cost pressures? What impact is that having in terms of the increasing emphasis on providing care at home? 

I'll just start by saying—I think it's in the evidence that was submitted—that actually, the amount that's being spent on older people by local authorities in Wales seems to be going down, which suggests that more is being targeted at the more complex needs end, which might suggest that there are more people actually at home now not receiving the same level of care that they might have had, say, five years ago.

The data is very hard to find—it's another one where you don't know what you don't know to some degree. But there is an indication there that the cost pressures will be having some sort of impact there. The other evidence I saw was relating to carers, family carers, and is there more burden—not the right word—but is there more being expected of family carers now, which may also have a knock-on impact down the line. So, it's a complex area to see exactly what's going on in some family situations at the moment. 

Can I just—? I know that Nick Ramsay had questions here, and we've strayed into the questions that he had, I think. But Nick, do you want to—?

My voice is not going to last, so I'm pleased you did stray before I had to ask them. One question I think that—. You were talking about the workforce; how reliant are the elderly on unpaid or voluntary carers and how sustainable is it?

So, we've put some numbers in our evidence, which shows that there are 370,000 unpaid carers in Wales, which, I think you'll agree, is a really significant figure and surprising. Certainly, when I read that, I was surprised it was that high.

It's 370,000 unpaid carers. And actually, a couple of the issues there are that our population is ageing, and so too is our carer population, and that's going to add to the pressure on the overall workforce. We were saying thank you earlier to the NHS and to social care, and I think about how people have coped in the last few days and weeks, and, actually, a big thank you also needs to go to that huge group of people who have helped to support people and continue to do so.

The other issue is that we in the UK—across the UK—depend on informal carers for a significant number of hours a week, and probably more so than evidence from other countries. Those carers are saying to us that the more hours that they're having to do places more pressure on their own mental health, so we really need to be very mindful of the burden that we are placing on this significant group of people and the key role that they play in helping us to support the population.

The other issue is about the conversation that we need to have with the public about looking after themselves and working with their families to keep well, to stay well, to again help the overall system—which isn't about caring, but it's just about recognising our own role and our own opportunity to look after our own health and well-being. 

09:40

I'll just add, yes, there's a huge dependency there, as Vanessa said. It's among the highest levels in Europe as the figures quote. I think what we've got to recognise, if you're moving from a model of care homes to domiciliary care, where there isn't 24-hour cover, somebody is picking up some of those gaps there, or people are being left on their own and becoming very isolated. So, in moving to that model, which is what people want, we've got to acknowledge the role that the informal carers, neighbours, et cetera, are doing, and provide the necessary support to ensure that it's not at the expense of those individuals that that is happening. 

Just to add that I know that for regional partnership boards, carers are a key priority—they are for the one that I sit on. And really, just the understanding that if we don't support the carers in the totality of them—as an individual, but also with offers such as respite care and appropriate sitting support—that the cared for will inevitably end up either in residential care or in hospital. So, this is an important area both at a human level, but also at a cost level—

Completely. And that's very plain for everyone to see. So, carers, particularly, have been singled out as a priority in many if not all of the regional partnership boards, so you'd expect to see each region in Wales have a plan for how they're going to be supporting carers. There are already some fantastic schemes, I've got to say, and some very good third sector organisations who provide tremendous support. But, is there more that we should be doing? Absolutely; particularly in access to respite and enabling people to recharge their batteries. I'm always impressed by people that I meet, very humbled by their being a carer, who don't quite see the role that they're fully taking on. So, some of the challenge is offering the support that might be of benefit to them when they're not feeling they need that help and support, but we've got to have it there for when they do. 

And, actually, I think one of the impacts of the reduction in overall funding to local authorities and both their wish and their need to protect statutory services means that things like respite services have come under real pressure, and we're seeing those services reduced as a consequence. That, obviously, doesn't help to support the preventative agenda and look after our caring workforce.

The other point is that the average spend on adults in social care has fallen by around 14 per cent since 2011-12, I thinkFootnoteLink. You'll probably hear from others that that is at least partly a consequence of an increase in the eligibility criteria, as Gerry said. With that, again, we are really committed as a system to investing in prevention, but actually, austerity means that we're really finding that difficult to do. So, we're saying one thing, but we're having to do another. 

09:45

Family carers are probably the major source of care, but what you've got is family carers ageing and they reach a stage when they can no longer provide care. The great medical advances in the 1960s and 1970s left a lot of very severely disabled children who are being looked after by their parents, and their parents are reaching an age now, and are likely to reach it even more so in the next 10 or 15 years, when they are no longer able to provide that care. What happens then? Are we in a position where we're able to move in and deal with that and provide the care that these children need? Well, I say 'children'; they are now middle-aged adults and their parents reach a stage when they can no longer provide that care.

And I think that we see some of that evidence, particularly in groups where people have a learning disability, for example, and there is a lot of anxiety as parents age, and people with illnesses that may have limited life much earlier are now living into their 50s and 60s and beyond. Whilst the thrust has been around supporting people to maintain a life and develop life skills, there is that risk that a more institutional type of care may be required for some, and that would not be the wishes either of the family or the practitioner. So, I think it's a very real issue.

I think, as Vanessa said, the average age of carers now is increasing and I think there are real vulnerabilities around that. Equally, there are some very good volunteer schemes that have been developed in a couple of places in Wales, where people who have been carers and then are no longer carers because their loved one has died, are supporting other carers and are getting a lot out of that. I know that the Royal College of Nursing in their evidence to you are suggesting that people who have been carers are a very valuable source of expertise and maybe we should be working with them more in spreading that through. So, there may be some other options that we need to push forward on in that regard.

Another point that we haven't touched on is about loneliness and isolation and I think the parliamentary review talks a bit about that, and that part of the response is how we mobilise communities and use community assets more effectively to support people, so even before a need for social care arises, if we can invest more in tackling things like loneliness and isolation, we can help people to stay well for longer.

I think there's a strong tradition from the living with disability sector of work, particularly between housing associations and those providing care and support. And those models, I think, are still with us and offer some promise for the future—perhaps not just for learning disabilities, but we're talking about extra care and other things. So, there is the beginning of a sort of synergy between the whole agenda in that sense, about how you accommodate people with long-term care needs in their own communities without moving to institutional models. The danger is that we start comparing what's being spent on learning disabilities against what's being spent on older people and it all starts being seen as a bit of a competition, I think. There is a joint agenda there that we could usefully develop, I think.

The last question I've got is: we look at health and we look at social care, but I don't think we look at the whole person enough. What you've got with the health service is the backstop—if all else fails, they end up in A&E. We keep on pumping money into A&E and the health bit, but without trying to stop them getting there in the first place. Is it any surprise that people who have poor lifestyles, who live in inadequate housing and who are lonely end up in hospital, when they are also receiving very little care at home and they just end up being ill? Shouldn't we be trying to do more of trying to stop them being ill? The whole debate on health is about pumping more money into the health service so that it can treat more people. Treating more people is considered a success. Surely, having fewer people going into hospital is a success.

09:50

Thank you so much; that's just the question for me. You're absolutely right in that the NHS is a national health service, not a national ill health service, and I do want to give you some reassurance that the focus on well-being, the focus on prevention is absolutely there. And in terms of having an integrated approach to the health service, which we've had since 2009, that is one of the benefits in that, for example, I'm the accountable officer for the health service in Powys, and it's for the whole population. It's not just those who are accessing hospital care who are primarily in the thoughts.

The issue for us, and this has particularly come through in the regional partnership boards and the integrated care funds, is how we make sure that we're doing enough focus on well-being and early help and support. That was the really key thrust of the Act, and I think, locally, we're absolutely taking that forward. I'm happy to send it to you, but in Powys we've published our long-term health and care strategy, which does just that: it focuses on the life course, but focuses on well-being, early help and support as well as then the joined-up care elements and tackling the big diseases that limit life. So, I'd like to give a greater level of reassurance that the eye is across the system and not just on the secondary care elements. The challenge is how you move money around the system to enable that focus on well-being, which is where the integrated—'integrated' now; it was 'intermediate'—care fund has come in and has been so helpful, because it has provided that additional focus.

The parliamentary review talks about triple integration. So, when you talk about the whole person, and I feel very strongly about this, it talks about triple integration, and that's primary and secondary care, so how you join that up; mental health and physical health, because we don't have just one or the other these days; and health and social care. So, if our focus is on the person, all of those things have got to come together, and ideally in much more of a place-based home-type setting. 

The sense of the transformation fund that the Cabinet Secretary announced a couple of weeks ago, certainly the impression I'm getting is that the link to the parliamentary review is to really push us much more firmly in that direction and to try and give us the headroom to do that. So, I'm a little more optimistic. There are weeks like this where the NHS and the social care system are under huge pressure that indicate more than ever that we do need to try to provide an alternative to what is a hospital-driven response at the moment to the care particularly of older people. That's where we need to be pushing.

I'll bring you in, David, but just to say that I want us to have a couple of questions on paying for all this as well.

Powys health board doesn't have a district general hospital, and therefore you actually have a different scenario and the way in which you're looking at health may be different to other health boards. Have you had discussions with other health boards to ensure that this is an approach that's going to be across Wales, because you're working in a different situation?

We say we've got about 244 acute beds for Powys; they're just not in Powys. [Laughter.] I know how many patients there are. I think the benefit of not having a district general hospital and them being so far away is that we've had to really focus on trying to support people in the community, because we know that miles matter to people and it is a very long way. So, if we can provide a service that focuses on keeping closer to home, then we will. Equally, of course, we work very closely with the rest of the NHS system, because the experience for our individual residents moving through very busy and congested hospitals at times is a poor experience, and we know that time's under pressure. 

I think that there is a recognition—I'll try to speak on behalf of all my chief exec colleagues now—that we do need to change the system, because it can't really continue in the way that it has been: the demands, the numbers—we all are aware of that. It's how we get that headroom. That's why I feel more optimistic in the work that the NHS and social care, as two sectors working together—that there is that commitment moving forward. What we'll need to see now is the response from the parliamentary review—how that can be matched with resources that give us the headroom, and then those deliverables that you would expect to see as a result.

09:55

Well, I'd say two things. Carol said that the strategy in Powys is very clearly articulating that direction of travel. And, actually, if you looked at the other health board strategies, you would see the same direction of travel. So, individually, within organisations, there is a recognition of the need to change the model and the milestones about how we go about doing that. But also, at a collective level, NHS chief executives and chairs come together frequently to discuss and debate how we need to redesign services at a level that's above individual health boards to support that agenda, and also what we can learn from each other to actually drive that improvement, or that change, to the new model more quickly across the whole system. We are working very closely with Government—as a group of chairs and chief executives with Government, the Association of Directors of Social Services, Social Care Wales and the Welsh Local Government Association—to really try and co-produce what is the response to the parliamentary review, which will identify some ambitious opportunities for actually being able to shift that system more quickly. But resourcing, obviously—both finance and staff will continue to be part of that equation.

Let's move on, and I'd like to invite Neil Hamilton to ask his questions.

It's obvious that, as the proportion of elderly people grows within the population, the costs of supplying their needs is going to increase by more than the economy is likely to grow. The long-term growth rate of the economy is sort of 2 per cent, and health and social care-related costs are likely to increase by 4 per cent or more for the indefinite future. So, unless other areas of Government spending are going to be squeezed, we're going to have to find extra money from somewhere. You say that the amount spent per person in social care has fallen by 14 per cent. The corollary of that is likely to be that needs that were previously met are no longer being met. So, it's not actually a more efficient service or a more productive service, but it's just that it doesn't actually do as much because it can't afford to do it. So, how do we get more money into the system?

The NHS Confederation has, I think, very bravely said that Governments need to consider alternative funding models for the health and social care sector in future. My own feeling is that there's very limited scope for increasing the amount of money raised from general taxation, and over long periods of time, whichever party has been in power, it's proved very, very difficult to raise more than 35 per cent of national income from general taxation. So, we can't do that. How do we find the extra cash that, inevitably, we're going to need. So, perhaps you could explain your own ideas on this.

Well, I could make a couple of points. The first is going back to your point about the fall in spend per head. Partly, I think it's to do with an increase in eligibility criteria, but it is also partly through improved efficiency and effectiveness, and a kind of rightsizing of packages—a review of existing packages of care and just making sure that people are getting what they actually need. So, I think it's a mixture of both.

The NHS Confederation doesn't have a position on what the solution should be to the funding gap. We recognise that there is going to be a gap and that needs to be funded, and there are a range of options that Government could consider about how that's done. Actually, there was an Ipsos MORI poll done by the King's Fund in November 2017, and that showed that two thirds of people—adults—would actually support an increase in taxation to fund health. So, there is, potentially, an appetite, a willingness, to recognise that the costs—. If we want a high-quality health and care system, we need to be prepared to perhaps spend more on it than we currently do. The mechanism for doing that, whether it is general taxation or a social care levy, or a social insurance model put forward by people like Gerry Holtham—all those different options have their merits and their weaknesses, I guess, but the confed isn't in a position to say which one we think should be the model that we pursue. It's more about saying we do need to have that debate, and we need to have that debate with the public, and we need to have that debate with politicians, because we can't stick our head in the sand and pretend it's not going to happen. All the evidence that you've heard this morning shows that if we don't do something, we're going to have a really significant problem on our hands.

10:00

I think these opinion polls need to be treated with a degree of caution and scepticism. It's very easy for you to answer an opinion poll to say, 'Yes, I would pay more.' It's a very different situation actually signing the cheque.

Exactly. But what I do think is probably right is that people are prepared to pay for something where they see a direct return for the money that they're paying—a kind of hypothecation, if you like. The national insurance fund, of course, was set up over 100 years ago with precisely this aim in view. It was looted by Governments almost immediately, and the annual payments in were blown on current expenditure. It's become a massive Ponzi scheme, in effect. We have a fund in name only, but nothing in it apart from pieces of paper that have 'IOU' on them. Who owes the money? Well, we owe it to ourselves, because it's already been spent by Governments. Gerry Holtham's idea is similar to that, but if we do set up such a fund, then it will have to be inviolable and not open to Governments—profligate Governments—simply to raid it in order to square the annual circle of how to pay for all the things that they've promised the voters.

So, I was wondering if we could move on to that, because this is a specific proposal, and it's one of the Welsh Government's ideas as a possibility for one of the new taxes that we're able to introduce as a result of the devolved powers that have been given to us. I'm personally quite favourably inclined towards this idea, if it's properly constructed. We know that we're all going to have to pay, ultimately. People my age, perhaps, have even greater interest in this subject than most, because we're nearer the point of needing these services ourselves. It's how to make this both palatable to the public and effective in operation over a long period of time—these are the key issues for me. The NHS Confederation, in particular, I think, could play a very pivotal role in devising a system that is going to be, if not popular, at least accepted by the public as a means of providing for needs that otherwise would go unmet or would be inadequately met.

I guess I would say that the confederation and health and social care leaders, together, recognise the importance of an engagement with the public about the scale of the challenge that our population as a whole is going to face over the coming years, and through that process of engagement, helping the population to understand that challenge and the options that we need to consider to be able to address it. And so that’s the starting point. We need to get to a point where the public actually accepts that there is a need to do something different, and then it’s critical to test the appetite of the public to the different options that might be available, as to which would be the most palatable to them. And inevitably, there’s a huge amount of politics in all of that too.

So, for us, actually, in thinking about all of the conversations we’ve had about needing to transform the system, the critical part is about how we engage the public in recognising the challenges and responding to them. And that, then, brings you to look at things like the way in which we deal with public health and how we support public health. There was another survey in February that Public Health Wales conducted called Stay Well in Wales, and when asked about public health issues and looking after yourself, two thirds of the population or more recognised that they actually have a role to do that for themselves, and that would help significantly. Half thought that the NHS should spend more on prevention, and 88 per cent said that schools should invest more in education around living well. So, it’s all part and parcel of that conversation that we need to be having with the public before we get to the point where we jump to, ‘And now you need to pay more.’

I think I'd just add one point, which is that, currently—and I think, the Competition and Markets Authority highlighted this—the current system for funding the care home sector in particular is pretty inequitable, really, and does provide a disincentive for saving into old age. And that's probably going to grow, so potentially an offer of something that is seen as being more equitable is something that people might welcome, because I think it is a growing issue in terms of people recognising the care costs they might be facing down the line. The other dimension to that, I think—and we're just doing a piece of work on it—is about the economic value of social care, and it's actually—. It's early days, but it looks like it's about the seventh main contributor to the economy of Wales, and if you look at the growth in the numbers, then it's going to be a significant player. Add that to the NHS. So, these are significant contributors to our Welsh communities and perhaps don't just need to be seen as a burden and taking things out of those communities.

In terms of the models, yes. The insurance model, I always—. I'm out of my comfort zone. I always thought you needed a long period of time to build up the pool of funds to achieve that, and the problem we've got now is because this issue hasn't been resolved, that huge demand is facing us very quickly and there won't be time to develop that. So, that may mean we're looking at different models or multiple models, really, to get us through that period of time.

10:05

I think that's right. There is going to be a tension here as well, in as much as NHS care is provided free whereas social care isn't. I had this with my mother in the latter years of her life where she had multiple needs. She actually qualified for continuing healthcare, so we didn't have to pay the nursing home fees in her case because of the complexity of the treatments that she needed, but if only one element in that complicated equation had been missing, then we would have had to pay very, very significant sums indeed, and there's an inequity involved in that as well. But are there any international models that we might profit from, in your experience or knowledge, in order to try to square the circle that you, Mr Evans, have just referred to? In as much as we all know where we want to get to—getting there is very difficult. We can't just afford to ring-fence a large sum of money for use in 20 years' time, because we have needs to pay for today. Is that a conundrum that is solvable at all?

The confed hasn't done any specific work on options around potential ways of funding social care in the future. I mean, obviously, looking at different healthcare systems, they are funded in different ways across the world. And, actually, if you look, there was a report, the Commonwealth Fund's fifth report on healthcare systems, which covered 11 countries, ranging from Australia to Norway, Sweden, Germany, Canada, France and the UK, and what they found was the issue of poor healthcare was less to do with the model of funding and more to do with the way in which systems work together—the health and care systems work together. So, their conclusion wasn't that there's a better way of funding it to help support a sustainable system; it's more about what you do with the money when you've got it. So, I can't really add any more to that.

So, that means further integration of health and social services.

Yes. It's about how you make the component parts of the system work effectively on their own and in connection with the other parts of the system.

Our understanding is that many of the international examples are based on insurance-type schemes, long-term insurance-type schemes. But I think that issue, as you raised, around the NHS being free at point of delivery, social care not, is perhaps not unique to this country but actually throws in a very different dimension to it that needs to be examined very carefully.

Just to add, briefly, there are at least four reports that I've read over my years, on a UK basis, around funding social care. I think Andrew Dilnot, if I get the name correct—a huge amount of work on the commission there. So, my sense, when you stand back and look, is that this is a shared problem across many parts of the world. I'm not sure anyone's quite saying they've cracked it, so there's probably no perfect system, but we're going to have to move into something because we know the problem and it's not a problem just of the future—it's a problem of now—and so, inaction, really, is one of our greatest risks.

I think we will need to conclude there, remembering that Dilnot had some very real proposals, and that was over seven years ago now, and nothing's been done since. So, this inquiry hopefully will shed a little light on some of those from the Welsh perspective. I'd like to thank you very much for your evidence this morning. There'll be a transcript for you to just check if you've got any figures or things that might have been misspoken or whatever, so that's just for veracity. We're very grateful. Diolch yn fawr iawn i chi.  

10:10
3. Cost Gofalu am Boblogaeth Heneiddio: Sesiwn dystiolaeth 2 (Gwasanaethau Cyhoeddus Cymru 2025)
3. The Cost of Caring for an Ageing Population: Evidence session 2 (Wales Public Services 2025)

Bore da. Good morning. If you're happy to start, could I just ask for your name and who you represent—just for the record, that's all? 

My name's Joseph Ogle, and I'm from Wales Public Services 2025. 

Okay. Well, a couple of committee members will be back—they're getting refreshments; they'll be back shortly—so we'll start if we may. Thank you for your very comprehensive paper—some fascinating facts and a mine of information to follow in there. So, if you're happy, we can start with the questions. I was very interested in the different trends of spending per head compared to spending per service user and how that emerged in the paper, and the way different local authorities had looked at that. Are you able to give us a sense of where you think that has emerged and why it's emerged in that way? 

Yes. It's a bit of a conundrum in a sense. I can't definitely give an answer to it because there are a few data issues. As I allude to in the paper, the number of service users has been measured in one way between the period we looked at—so, starting in 2009-10 and then up to 2015-16 it was measured in one way, and then the Welsh community care information system came online in 2016-17, so in that year we see that it's been recorded in a different way and the numbers of service users spike. So, making a real comparison is quite difficult.

Having said that, the legislation does permit a degree of flexibility, as you're aware, which means that—. And anecdotally there has been a suggestion among service chiefs that eligibility criteria have been somewhat squeezed in order to concentrate on those with the highest needs, so focusing resources. So, I don't know if that answers your question—

It chimes with the evidence we have. I just wanted—. I suppose the other way of looking at this is whether, in looking at the trends over a longer period of time—which you've been able to do—you're able to ascertain the decision making that's led to these changes in spending. Is that something that you're able to pin down or is that still complex and hidden behind the data? 

I'd say that's complex and hidden. I think, as we alluded to several times in our submission, the main thing that we lack in this area is a comprehensive, representative, longitudinal survey within which to track an individual over their life course, see how they interact with the care system, see how individuals with like life-limiting conditions are treated by the care system at different time points, therein which you could measure the policy decision and say, 'Oh, it appears then that this type of person would have received care in 2009-10 and they aren't now'. And, whether that's a good thing or not, we're not in, really, a position to know. So, that's the real stumbling block that we have at the moment. 

Does that also mean that it's difficult to tell whether some of the resources that we are told are being spent on preventative steps are actually having the effect that they're supposed to have?

10:15

Yes, absolutely. There's a really interesting report by the Royal College of Occupational Therapists where they say they looked at right-sizing packages, which is something that was alluded to in the last session. I think it saved Cardiff Council in that year roughly £400,000. So, you could see why certain preventative initiatives, right-sizing initiatives, would ultimately lead to perhaps a flatline in terms of spending over the period. I think also a key point to make is that the demographic shift is in its early days. So, just because people have crossed the line of 65, it's leading to this big decline in spend per head, but what that means in service terms is really anyone's guess. 

Is there sufficient data to give us any sense of how this spending, however, does vary across Wales, in different parts of Wales—different decision making by local authorities perhaps, different interpretations of eligibility criteria and so forth being taken? Is that discernible in the data?

Yes, to an extent. I think one thing that is very much achievable and we could do now is a simple survey of local authorities and their practices, but certainly the variation is discernible in the data. So, nine local authorities cut their spend per head by a fifth or more. In many authorities, it was pushing something like 30 per cent. In others, there are small increases. We haven't really looked at the key question of what explains that variation. We haven't really looked at that. Obviously, there are the data issues. Looking at a simple, naive correlation, taking the Wales index of multiple deprivation, it does appear that there does seem to be some association whereby more councils with high levels of deprivation appear to have cut, on a per-head basis, the services more. It was a correlation of 0.6 or something like that. That's an interesting finding. What it means practically, I'm not too sure. Obviously, those are the councils that have seen a larger cut to their Welsh Government grant support over the period of austerity, so it maybe shouldn't be surprising that they've also seen bigger cuts relative to others.

You've already touched on the Welsh community care information service in terms of the difficulties of reflecting on previously reported figures, but how do you see the Welsh community care information service in terms of this system, which is a more integrated system approach on the future provision of social care services for older people?

I must say, it's not something I've thought about too much. Obviously, the system's in its early days. The figure of the reported number of service users I think was about 62,000, and that was absent two councils that hadn't been able to contribute to the system in the first year. It's certainly very interesting. I've had a glance at the data that is available from that, but, in terms of the questions that we've been considering regarding what the effect on people's health and well-being has been of specific policy changes, it would be difficult to make some very specific inferences from that data source about the effect of policy.

For the future, it may be more helpful. You also mentioned—well, you suggest that the Welsh Government should consider a longitudinal study like the English longitudinal study. Can you just say something about how you think that could improve the evidence base?

Yes, sure. I think there are many options to bring best and existing models—irrespective of whether you take them on to something like the national survey for Wales. But I think how it would improve the evidence base is that, as I alluded to before, being able to follow an individual over their life course, over their own lives, using a representative sample, you can see how they interact with the local care system, and, if you incorporate a panel element of that so you include informal carers, loved ones close to them, how their interaction with local services impacts on their health and well-being. That's only something you can tease out in a longitudinal design; it's not something that a cross-sectional study such as the national survey for Wales could tell you. As a halfway house, more questions on social care could be incorporated within that study, but, really, to understand cause and effect and thereafter make policy based on that, you need the longitudinal design.

Thank you. There's been quite a bit of evidence given to us about the Daffodil system. Of course, that was developed by the Institute of Public Care for Welsh Government. Obviously, it's designed to help with potential need for care over 20 years. You've got comments on the Daffodil system. Can you tell us about the system and its application for the provision of social care services?

10:20

Sure. So, my use of the Daffodil system has been very limited to the extent that it is based wholly upon the existing data on Stats Wales, and it simply reflects adjustments using Office for National Statistics population projections of the existing revenue outturn data and projecting forward based on those numbers. In that sense, for our own work, it hasn't been particularly useful because we have access to the Stats Wales data. It hasn't been able to really give us a good indication of social care need in the sense that you're always using an arbitrary benchmark—you're always saying, 'Okay, at this point, this amount of people are receiving services; if the population grows at this rate—or the old adult population grows at this rate—we expect this amount of individuals'. Well, we need to maybe first ask the prior question of, 'What quality of service do we want? How deleterious to health are intensive forms of informal care provision?' These are things that aren't reflected in those numbers, and it's a real stumbling block of many of the projections that we have—our own basic ones and also the Health Foundation's projections as well.

I'll follow on, if that's the case. The concern I have perhaps is that when we talk about projections for the need for social care in the future, as you say, there seems to be a very simplistic blueprint. The reality is that we're probably moving the age range of people who start needing care to later in life, but as a consequence—people are living longer, but they have more chronic conditions and multiple chronic conditions as well, so the demands, actually, are changing, they'll be more intensive in one sense. Has that figured into your analysis of where the future demand will be? Plus, on top of that, of course, younger people come through who have more conditions, who are now, again, living to an older age, so there's another population coming through in the underage range. So, have those factors been considered in your—?

Yes, you're absolutely right. Let's compare two projections: if you compare some very simple, 'Let's maintain a level of spend per head’ and project that forward, that would, as you say, be the equivalent of saying, 'Let's take the'—I don't know—'class of 2016-17 and just project that forward; let's just double the population and we'll double the amount of spending'. As you alluded to, that wouldn't be correct, because that class of 2016-17 will get more chronic conditions, they'll live longer and therefore you need to spend more on that fixed group. So, if you do some very simplistic analysis and just project forward based on population projections then those things are completely missed. The Health Foundation's 4.1 per cent figure, which has been quoted widely, does incorporate those changes in age-specific chronic illness prevalences. So, they are modelled into their numbers, thus explaining the £480 million, £460 million rise that they think will be needed by 2030-31.

Do the Health Foundation—? Obviously, I'm assuming you think the Health Foundation data is the best set of data that you can use in that case.

Yes. It doesn't incorporate changes—policy decisions like the change in capital threshold; it basically takes an English model and just applies Welsh population data. But, nonetheless, because those additions are relatively minor as compared to the demographic pressures and the illness pressures—

And you mentioned the informal care, particularly the intensive informal care—

Which are excluded by those numbers.

Which, I would suggest, 11-plus hours—if you have someone living with you with a condition, it's not 11-plus hours; it's nearer 24-hours a day, basically.

Absolutely, and I think that's a really arbitrary point that they use, but—

But has also consideration been taken into account—? Because many people will be required to work for longer in their lives, so when they do intensive care, sometimes they do it when they come home from work, so there'll be an older population, obviously, also offering care in that sense. Has that been taken into consideration in the analysis?

So, there's quite a gap, in a sense, of how policies are affecting the outcomes that may happen in years to come. 

10:25

Certainly. So, you could probably say that the Health Foundation's projection, which, as I said, is probably the best one—even if it were met, you would still likely see some deleterious impacts of that informal care pressure going forward. 

Notwithstanding the fact that you don't have the longitudinal study here in Wales—a specific Welsh study—based on the data that you've looked at and the evidence you've presented to this committee, do you think we have sufficient and sufficiently reliable data to make some of these predictions around future spend? Obviously, as a Finance Committee, we're looking at what is likely to be, and we hope this inquiry will lead us to some answers around what is likely to be the future demands, and to then set challenges for the Assembly and the Welsh Government about how they might meet those demands. Do you think we have the evidence—sufficient data and reliable enough—to do that? 

Unfortunately, it's a bit of a yes/no answer. As I've said, I think the Health Foundation projection is pretty robust, so meeting that target from the perspective of the committee might be something that you'd work towards, and thereafter you would speak of things like the Gerry Holtham suggestion. Again, though, it's all based on an arbitrary starting point. So, thinking more critically about the level of health and well-being that we wish to achieve in Wales, which really chimes with the parliamentary review's aims—the quadruple aim that they set forward there—if you're actually trying to fix a certain level of health and well-being, then we don't have the data within which to make any reliable projection. 

But nevertheless, the Health Foundation that was mentioned—you'd be content for that to be used as a planning tool. 

Yes, certainly more than maintaining, for example, a specific level of spend per head. 

As you say, it's about the base point from which you start, acknowledging that there are factors that have to be added to that. 

This is a question I asked earlier as well. It's about the informal care for people who were young children but have grown older. Their parents are able to look after them up to a certain point, then through age, infirmity or death the parent then stops being able to look after them. That's something that happened. There were huge health gains in the 1960s and 1970s. Those who came through then and, I think, thankfully, survived much longer than anybody ever expected—now we're at a stage where the informal care provided by parents is reaching a stage where it's no longer able to be continued. Do you recognise that, and do you see it becoming an increasing problem as these parents, who were parents in the 1960s and 1970s, are now reaching their seventies and eighties? 

Absolutely, it's a problem. It's a problem in a number of respects. There's an equity issue with regard to the 'can and can only' test within the latest Welsh legislation, in the sense that a council might legitimately restrict access to council-provided social care when there is access to a child living nearby, or a spouse, whereas they wouldn't in another case. So, there's an issue of perhaps burdening people without giving them the support that others would. I think the demographic pressures would clearly suggest that informal care is likely to become more prevalent over the next few years. I don't know if that answers your question.  

It has been said of economists that they're very good at predicting the past, and we also know that in the nineteenth century somebody said that by 1940 or 1950, the streets of London would be so many feet high in manure, from the horses, which would have grown exponentially. That didn't happen because we had things that happened in the meantime. How often do you update these projections? Because a major flu epidemic or a breakthrough in cancer would have a huge effect on not only life expectancy, but it may well have an effect on the morbidities of people who are unwell. 

Yes, certainly. I think these numbers tend to be updated on an annual basis, based on new data coming through. We updated our numbers based on the new revenue outturn figures that came out in October of this year. So it's on an annual basis that you update these numbers. In terms of piles of manure on the streets, or whatever the example was, I think, realistically, that's not going to happen. What seems to be the general trend is that, if nothing were to happen, councils would just constantly increase their council tax rates in order to fund services. 

10:30

I attended a pension fund meeting on Monday, and the Office for National Statistics have started reducing life expectancy predictions. I was disappointed to see my life expectancy going down by 1.3 years. The rest of you in this room may not be that disappointed, but it's the same figure for you. But you're having these changes, aren't you? That's the first time I've known the ONS to take down life expectancy—I would say in my lifetime, but certainly while I've been following it.

Yes, there was a small decline. I think it was commented by Michael Marmot as well several months ago. But it won't represent a huge—it won't be much of a dent in the cost pressures.

Well, if everybody was to live 1.3 years less, surely that would affect the last 1.3 years of their life—the cost pressures.

But not the increase in the care that they need in those final years—it's exponential, isn't it?

That takes us on to—. I wasn't going to raise it, really, but you've raised it, so I'll raise it as well. Figures that I came across—this is going back 20 years, so you can tell me I'm out of date—show that people's need for both health and social care is really substantially largest in their last two years. It's slightly different for people who've got morbidities that are coming through, but the average person, i.e. most of us in here—our cost to both health and social care will be in the last two years of our lives, rather than throughout the period. So, if my last two years are 100 to 102, or 80 to 82, it's the last two years that matters, not how long I'm going to live.

Yes, that's absolutely right. 

Based upon the updates, is the Health Foundation going to be looking at perhaps considering some of those factors we talked about as it progresses its data, not just as it collects new data? Might it actually look at different factors and different features that it might wish to include in consideration of the projections?

I don't work for them so I don't know, but what I could say is that they adapted the Personal Social Services Research Unit's model. There were really spurious data out there on informal care, so I think estimates of the replacement cost of certain amounts, certain quantities of informal care vary widely. So, I don't know how exactly you'd really incorporate that well.

'How do we pay for all this in the future?' is the key question of the moment, isn't it? There's a limited number of options available. At the moment, the costs of social care are falling disproportionately upon local authorities, and local authorities are under extreme pressure because their grant funding has significantly reduced—16 per cent in the last seven years. Council tax has increased by 20 per cent over that period. There's a limit to how far we can push up council taxes in future. It's a highly regressive form of tax generally, so it would be undesirable on public policy grounds anyway. So, what scope is there, in your opinion, for local authority-based funding to help to square this circle? Is there any role at all, or no role?

I think there definitely is a role. I think, as you alluded to, council tax, as everyone knows, is a highly regressive form of taxation. The local government finance working group I believe made some proposals to the Welsh Government. I don't know what's happened to those, but they were generally to do with changing the ratios between the bands. That's something that doesn't need to be revenue neutral, so I don't know how popular that would be, but that's something that could be done immediately that might increase revenue, or might be a sustainable way of increasing revenues, without it taking such a regressive form. But if we do nothing it will just continue in its current form anyway. So I guess that's something that could be done, certainly, at local authority level.

What is your view on the scope for using devolved taxes to help to square this circle? We know Gerry Holtham has come up with interesting suggestions for a social care levy. The Welsh Government has included that as one of its options for using the new devolved tax powers. The product of a penny on income tax in Wales is about £200 million a year. So, what do you think about this?

It's a very interesting proposal. It comes down, as you alluded to, to the difference between a pay-as-you-go versus a contributory and funded system. Obviously, the latter has many advantages over the former. There is still that issue that I keep coming back to, however. For example, in Professor Holtham's modelling, he takes one of our very simple numbers, which is a per-head measure, as the amount of money that you'd need to take out of the fund in the first year in order to pay the recurring costs of care in the initial stages. It's an arbitrary figure. How much you really need is, as I've suggested, something we need to evidence much more. That actual figure was, perhaps, slightly underestimated, because the Health Foundation's figures would have been a better basis, which would suggest that much more would have been needed to be taken out in the initial stage, which would mean that the growth projections that are in the initial working paper that Gerry Holtham put forward perhaps need to be revised. That's probably as much—. The technicalities of implementing it are something that are beyond my expertise.

10:35

That's basically the point—. I don't know if you were in the previous evidence session when Gerry Evans referred to this in answer to a question from me about setting up the social care fund: you would need to capitalise that very significantly in the early years in order to provide the long-term funding benefits that you need, and so ring-fencing a fund to that extent is likely to increase pressures, rather than to reduce them in the short term. So, the practicality of this as an idea depends, crucially, upon how much money you've got available to put into the pot at the start.

Because you're trying to do two things: both pay for current needs and provide for future funding streams.

And there is a suggestion that, perhaps, that amount of money is more than is written in the paper, but, as I say, it's not something I'm particularly knowledgeable about, unfortunately.

Can I just ask on that, though—? You said there's a suggestion that, realistically, it would need to be more than Gerry Holtham has, at this stage, sketched out. Obviously, we will be taking evidence from Gerry Holtham, so we'll be able to explore some of this with him. But, do you say that on the basis of other evidence that you've seen or other suggestions from other commentators?

By juxtaposing the Health Foundation's number with our own. It's simply that the numbers that we put forward don't reflect the changing—they refer purely to demographic pressures, nothing to do with—

So, they don't reflect the other discussion we had a little earlier about the Health Foundation's additional aspects of this.

Yes, and they're completely agnostic to any ideas of informal care. 

Thank you for that. Is that okay, Neil? Okay. David, have you got any further questions?

Following on from that, obviously, the care levy, as you say, is more of a pay-before-you-need, rather than a pay-as-you-go. Royal London has talked about a care pension, which is the same principle—pay beforehand, but add a new element that goes towards future care needs. Has anything like that been tried in other countries across the world to see if that works? I understand it's long term, because you can't start it off and expect to get it tomorrow morning, for example. But have other countries actually got similar schemes such as that that work at the moment?

I can only give a short answer on it. My own understanding is that Gerry's paper was based on a Japanese model. That's where he took the inspiration for his model that he proposed from. Other than that, I'm not too sure. Most of our work has been trying to measure the impact of changes to how much resource is given to social care and perhaps trying to measure changes in eligibility criteria. 

Do you think the care fund or care pension would actually deliver that resource, or will there still need to be support elsewhere?

Well, as we alluded to in the previous question, it depends on the amount of money you put into it, and how much money you take out at the start, which has major implications for how much you tax now or how much people have to pay now if they're in their later years. That's a real challenge.

Can I just go back to informal care for a moment? Because I think it was in your paper—you mentioned there's the informal and the intensive informal, and that you tend to find that where there are many informal, there is less intensive informal, which surprised me a little bit, because I think there's a mix between an understanding of what they are—in some people's minds, not yours—or maybe in the carers' minds themselves. But with the situation in Wales where we have a large proportion of informal carers with a lesser proportion of intensive informal carers, are you seeing a change in that?

10:40

I haven't tracked the data. There was a paper, which I quoted, in the European Journal of Public Health, where they just compared across European countries; they didn't look at a time series of that data. But if you're comparing countries, just to repeat the kind of phenomenon that you suggest, there appears to be—. Where there is a crowding in of the state in the intensive end of informal care, you do tend to see more people providing two or three hours of informal care, so in the—[Inaudible.]—states, for example, there is quite a high population prevalence of providing a limited amount of informal care—perhaps partners or loved ones. But at the intensive end, that's where the state provides much more.

The UK ranks sixteenth out of the 20 European nations surveyed in terms of its prevalence of intensive informal care. So, it does appear to be something of a trade-off. It seems to be something that other countries have, perhaps, considered more than we have here in terms of the funding and the eligibility criteria as well.

Because the other issue you highlighted is that those who deliver intensive informal care are more susceptible to mental health problems of their own— 

—which has a knock-on consequence, because that means the health service system has a consequence, to support those individuals.

It's the full gamut of impact—productivity, health impact and their future care needs as well.

Exactly, but it's not something we can currently measure in Wales, and how changes to local government finance have impacted on that is something we can't tell at the moment.

And to be specific, the comparisons you made were UK comparisons, so even the general comparisons don't drill down to the Welsh level, where, in the earlier evidence session we had, it was of the prevalence of informal care being higher in Wales, potentially, but, again, this data aren't completely clear, but that wasn't able to be extracted from the data.

No, not in those Eurostat data. I know that there are Welsh-specific estimates that do show that it tends to be higher than the English average.

Exactly. So, we are higher than the English average, then you compare the UK figures with the European ones, so, I suppose, from a statistical point of view, we're getting very weak here, but there's a kind of story there that you might be able to discern.

Yes, and I think if you think of a local authority trying to balance their books, if you're in an area where there is less out-migration, where you've got families living in close proximity and perhaps high levels of deprivation, you can see that it would be quite an attractive option to rely more heavily on that informal care. Perhaps that explains why you have seen higher deprivation councils feeling able to make greater cuts than those in other areas.

You might also infer that those areas, perhaps, in Wales that have had high in-migration of retired people, who don't have family connections, in turn, might put slightly higher pressure on local authority spending, in terms of quite intense care towards the end of their lives.

This bears out anecdotally with what we find as Assembly Members, but I suppose, as a researcher, you wouldn't necessarily put your life on that. But it's to be inferred from some of the figures that we've seen—yes?

Just for the record, Neil Hamilton very rightly said an increase in income tax by 1p. Can we just, for the record, maintain that that's increasing the rate by 1p, not everybody paying 1p? Because a lot of people seem to think that if everybody pays 1p, it will raise huge sums of money, whereas, in fact, 1p a week would raise less than £10 million a year. We use our own language in these things and sometimes it gets misinterpreted by those listening. 

Duly noted.

There are no further questions, in which case I'd like to thank you and your colleagues for the paper. It is very comprehensive and very thorough and a lot of help to us as we pursue this inquiry, so it's been very useful to us. Again, we'll share a draft transcript so that you can check for any words that are missing or lost, or whatever. Thank you again. Diolch yn fawr iawn.

Thank you very much. If I may make a brief final comment—

There was a bit of an oversight that we missed in this paper, which is that there is absolutely no mention of the care workforce and the lack of data on the care workforce as well. I do understand that the Minister has said that care workers will be registered as of 2020 and 2022. I think that there's a very good case for taking action now in terms of how that data could be used to inform the aims of the parliamentary review in the future, and for there to be, maybe, a survey element to that as well.

10:45

Okay. That's duly noted. Thank you for that. We'll speak to you again.

Not all care workers—I'm not sure that domiciliary care workers have yet been recognised, so I think there will be a question on that point.

Yes. Again, we'll have the Minister in and we'll be able to pursue some of these questions.

Brilliant. Thank you so much.

4. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o weddill y cyfarfod
4. Motion under Standing Order 17.42 to resolve to exclude the public from the remainder of the meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

If I can invite the committee to consider a proposal that we go into private session, under Standing Order 17.42. If you're happy to do that—lovely. Thank you very much.

Diolch. Awn ni i mewn i sesiwn breifat.

Thank you. We will go into private session.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 10:45.

Motion agreed.

The public part of the meeting ended at 10:45.

Eglurhad/Clarification:

Spending per person has fallen by over 12 per cent in real terms over the period from 2009-10 until 2015-16.

Archwilio Cynulliad Cenedlaethol Cymru