Cynulliad Cenedlaethol Cymru

Good morning and welcome to the Health and Social Care Committee this Wednesday morning. Just to note, the meeting is bilingual and simultaneous translation is available from Welsh to English, if anybody requires that here today. Welcome, everybody, to this committee meeting.

The next item on our agenda is agenda item 2. We had a private session of the meeting this morning, so agenda item 2 is introductions, apologies, substitutions and declarations of interest. We have no apologies. We have a substitution, with Gareth Davies for Russell George, at the moment. Any declarations of interest? Mabon.

Diolch yn fawr iawn. Any other declarations of interest at all? No. Okay. Thank you.

Item 3 is our Health and Social Care (Wales) Bill evidence session with young people from Voices from Care. I'm really grateful to have four witnesses with us here this morning. Just as a piece of background, the committee's currently taking evidence on the Health and Social Care (Wales) Bill. With us this morning we have Rowan Gray, Rhian Thomas, Joanne Griffith and Elliott James, who have joined us, and who were part of a larger group that we as a committee spent time with this morning. I'm very grateful for your time with us here today, and for the time of others who are with us here today. It's been really powerful and informative information so far in our consideration as a committee.

We have a few questions to go through this morning, and I'm happy to take responses. You don't all have to respond on every single question, so don't feel any pressure with that whatsoever. But perhaps the first question from me is around the actual placements that children and young people who live in care are in. I just want to understand how important the placement is that children and young people live in, and for you to explain to us why that is important. Would anybody like to jump in first of all? Elliott.

As care-experienced young people, we all understand that the area of the placement is very important. We understand that we can't live very close to whoever we lived with before we came into care. This can be due to safety risks, if the young person is at risk of absconding. We all understand this, but also moving a child hundreds of miles away isn't always suitable for placements—foster placements, residential placements—and all the care-experienced young people in this room have probably had this experience. These placements can't commit to contact, they can't commit to free time, so that leaves us not being able to see our family, not being able to go and see our friends. These placements need to be able to understand that, if a child has daily contact, if they go and see their friends once a week, the placement needs to be able to know that they either have to transport, or help the young person, if it's suitable, to find the right public transport, or that they have to arrange other transport, because most children and young people in care have a social worker, and most children and young people in care have a support worker from an outside organisation.

Thanks, Elliot. Joanne, did you want to say something?

I suppose, as well, it's really important that we have a placement that we know we can stay in permanently, and that we're not going to be moved within 24 hours of living in that placement, or we're not going to be moved within a week of living in that placement. We need a placement that we know that we can call home, we know that we can trust the foster carers, we know that we can build that relationship with them, and even being able to have hugs with foster placements is extremely important, because we need to learn to build a healthy relationship around us. A lot of the time, we actually have the negativity, and that's what we don't need in our life. We need to have the positivity so we can thrive in ourselves.

Thanks, Joanne. Anyone else? Rowan.

I also think it's important to be able to match the kid that's going into these placements with the foster carers. With me, my last placement was with some people that were in their 60s, and when I was younger, I had a lot of energy and I was always wanting to do something. They did the best that they could, and they were able to take me out to go on these quad bikes and just race them around, but I also wanted to be able to build memories with my carers, but because they were elderly and they couldn't really do as many activities, they weren't able to take part in the activities I was finding fun.

Okay. Thank you. Do you want to add anything, Rhian? You don't have to. 

I think it's important, when young people come into care and they're a set, so they've got siblings, that they're kept together.

Okay. Thank you. Mabon, could I ask you to pick that up?

Being able to connect with the carers. If you have a child that's coming to you or a young person that's coming to you and they have severe mental health problems, they have severe attachment issues, they have severe trauma, unfortunately, these placements are more than likely to break down, because the foster carers and residential placements cannot cope with these. We need to be able to make healthy attachments and make healthy relationships with the people who are providing our care, but sometimes we don't know how that can be. Some young people have grown up in situations where the way that they were shown affection as children was that they were hit. So, naturally, the way that they think they're showing affection is if they hit someone, if they're verbally abusing someone. And to show the young person, without giving them a consequence to it—that, 'This isn't how you show affection. How about we do this instead, if you're happy? How about we do this?’ It's the balance of, 'Okay, we need to try and help this young person stop this behaviour, but also we need to help this young person put something in place too, so they don't go back to that behaviour.' 

Thanks. Joanne.

I suppose, from the point of view of a lot of young people, a stable placement would be somewhere we can call home, someone that has the correct mental health training, disability training, and we know that if we have an issue, we can go to the foster carers and we're not going to get stigmatised because of it, or they'll know the correct way to comfort us. Because that's extremely important when it comes to young people who are coming into care, that they have the correct support and that they know the foster placement have received the correct training that the young people may require when living with them.

Thank you, Joanne. Do you want to add anything, Rhian?

I think comfort is key for a young person, especially when they're coming into care, because I find that's the hardest transition of all. Although transitioning at the age of 18 is hard, I feel like, when you first come into care, that's the hardest part of it all. And having your siblings or having someone you're familiar with around you would help you.

Thank you. Rowan.

For me, what was important when I was in care was the location of my placement, because, when I was in care, I was out in the middle of nowhere, where I didn't have anyone around my own age that I could build friendships with. All my friends were all in the town where my high school was. And that was like 10, nearly 11 miles away from my house. So, I couldn't build any lasting friendships.

To add to that quickly, a situation that I like to use is if you have a backpack and this backpack is full of rocks, going into care, these rocks represent trauma, they represent hardship, they represent friendships, they represent education. Going into care, these rocks get taken away. Well, people try to take them away, but, in actual fact, they're not. A lot of young people, especially if they come into care with absolutely nothing, have the clothes on their back and that is it. In my experience, and in my personal experience, I was very attached to what I had when I came into care because I didn't have a lot. And then when my foster carers threw these items out, I was so upset because it was the only thing I had, it was the only memory I had of home. And these rocks—. Unfortunately, the system thinks that, as soon as we enter into care, all of our problems are solved. They haven't been. We are still deeply traumatised young people who need care, love and support, and, unfortunately—. If people have moved around placements, unfortunately, these first placements aren't picked out very well, meaning that these young people are getting moved on and moved on and moved on, until a suitable placement can be found. Why can't we be placed in a suitable placement the first time round? We understand emergencies happen; we may need to go to into an emergency placement for a couple of days. But also letting us know when we're going into care. I was told when I was coming into care—. An hour and a half before I came into care, I was told that I was going into care, and I didn't even know where I was going. I got into a car with a duty social worker. I didn't know this woman, I didn't know where I was living, and I feel if we can understand these young people, understand that, just because they've put into care, their trauma isn't going to be taken away—. 

Thanks, Elliott. Before I bring Mark in, Gareth, do you want to say something?

Yes. Thank you, Chair. I was just wondering, on the back of that—obviously, because local authorities, Government, obviously, because we're more broadly looking at the health and social care Bill—what do you think that local authorities, being the providers of foster care, can do better in that regard in terms—? Can it be more training? Can it be better provision? Is it more inspections, more reports, more accountability? What do you think that local authorities can do to step up and make sure that those needs are being met better than they currently are? 

If a young person is coming into care and it's a planned move, or if a young person is moving placements, the needs of the young person, whoever is providing the care, whether that's a residential placement, so you have residential support workers, whether that's foster care, whether that's kinship care or adoptive placements, these people need to be trained in what the young person's needs are, because, in my case, my ASD, nobody was trained in how to deal with my ASD, meaning that I was always left to suffer by myself because nobody knew how to help me with my behaviours, and, in actual fact, that my behaviours weren't behaviours—they were me showing symptoms of my ASD.

And I think also understanding that every young person suffers with something different. Two young people can be on the spectrum but they display it differently. Two young people can have the same behaviour but different causes for it. Two young people can go through the same trauma but display it differently, and it goes on and goes on and goes on. But understanding that, yes, there are going to be times where the foster carers, residential workers or whomever we're placed with are going to struggle with they don't know what to do, but putting the support in place not only for them to get training, but putting the support in place for us as well as them, having someone that these carers can go to to ask, 'Okay, what's my next step? How can I get help to deal with this behaviour?', rather than the local authority thinking, 'Okay, this placement can't cope with this young person's needs any more, we are going to move them on.'

Thanks, Elliott. Anyone want to add anything to Gareth's question at all? 

I suppose, in my opinion, it's doing compulsory training, because a lot of the time in foster care in the private sector, in any sort of care setting, they do a lot of non-compulsory training. So, it's up to that individual foster carer whether they attend it. So, in my opinion, I reckon there should be compulsory training and unnotified visits so that they can see the setting of the house. Because a lot of the time you'll find a young person can be in foster care, but the foster carers, when they know the social workers are due to come out, they'll make everything look perfectly fine, whereas, if they'd done unannounced visits, they would actually see the setting because the young people or the foster carers won't actually know they're coming. And, that way, they can judge the setting and know whether that young person is generally safe in that setting.  

Okay, thank you. Anything else? 

Again, I think, obviously, the training is really important, but, as a young person, I don't think it's taken seriously, because I lived in a foster placement and they'd been fostering for 15 years—I hadn't lived with them for 15 years. So, she had a letter come through the door saying about training, and it wasn't mandatory. And she said that, where she's got three kids of her own and she's been fostering for 15 years, she doesn't need that training. But she couldn't take care of me the way she should have with the mental health problems that I have.  

Okay. Thanks, Rhian. One second, Joyce. Rowan.

With me, there needs to be improvement in all areas that you mentioned, but there are two areas that I think need a massive amount of improvement: training and accountability. Because, if my local authority had actually done what they'd said that they were going to do, I wouldn't be sat here; I would be currently in Bristol, living with my mother. But, because there was no accountability within my local authority, they went back on their word, which they'd given to my mother, and I ended up in long-term foster care.

Okay. Thanks, Rowan. Mark, do you mind Joyce coming in here? Joyce.

If I can ask you this, you've talked a lot about training foster carers or care providers: have you experienced where they have asked for extra training themselves and they haven't managed to get that? And particularly, Rowan, you talked about that accountability.

Yes. One of the RSWs that currently works in my residential placement, she was given more training with mental health, neurodiversity, eating disorders, even, working as an assistant additional learning needs co-ordinator in a school rather than as an RSW, and I think private care-providing companies and the local authority and the council do need to take accountability for the fact that they're not providing these carers with the right support and training. But then it also falls, under the accountability, that I feel as if the care-providing company should also be fighting for this training. It shouldn't be ultimately down to these carers; it should be the companies that they're working for that should be pushing, pushing, pushing, pushing, but they're not pushing enough.

Okay, thank you. Mark, I'll bring you in now.

If you looked at the statistics of the amount of profit that's taken from a profit-gaining company, every £10 that's given to support a child in care, £3 of that is already profited. My social worker recently disclosed, for a standardised residential placement that hasn't got any high-tariff behaviours, the company that the child is with is being paid £5,000 a week. If £3 of profit was taken for every £10, that's £1,500 a week that's been taken off this young person, for the support.

We understand that there can be possible consequences to taking profit out of care, because the money is the incentive for these private care-providing companies. If you had a look at the young people that these private companies are providing care for, they are high-tariff behaviours, they have severe mental health problems, so they are taking on more complex young people. And we understand that possibly taking these profit-gaining companies could mean that these young people are stuck without a placement. But if the local authority is willing to pay that much for a young person to be placed in these profit-gaining homes then they should be paying for the training for a non-profit organisation.

Okay. Thanks, Elliott.

Obviously, we know there are going to be many risks doing this, but a lot of us young people will say that we aren't in the care system for people to profit off us. We don't choose to go into the system; the system chooses us. And, obviously, why should people be able to gain money in their back pocket and spend it on whatever they want, when, in actual fact, the money should be going to support the young people, so that we can thrive, so that we can do education, so that we can receive the correct support. It should be in place that it goes all towards the young person. Obviously, yes, we get that companies need the money to run, but there are alternative ways for them to do that. It should not be coming from the young person; that should be purely for them, so they can do what they want in their lives.

Can I had add on to something with Jo? If the Bill isn't passed to ban profit from care, there need to be stricter guidelines on where the money is going. If you're paying for a residential placement that specialises in mental health, that specialises in neurodiversity, then where is the support for these young people? If you asked, say, 100 young people in Wales at the moment that are in residential placements that say that they're a mental health home, they're a neurodiverse home, you would actually find out that that is just a label. The companies providing the care can say that, because, yes, their staff may have slightly more training than a standardised residential placement, but that doesn't mean that the young people are getting the support and care that they need. And we understand that this Bill may not be passed, but, if it isn't passed, we want stricter guidelines on how much a company can profit off us, because, at the moment, companies are profiting off us, and we are not for sale. They are taking the money, putting it in their back pockets, and then they're investing in more homes, therefore profiting off more young people.

Anybody else want to add anything?

I think, obviously, with the cut or the reduced profit from care, it might help young people stay in placements for longer. Obviously, there might be more of a chance for siblings to be together, and for them to be kept close to their comfort and in their community, rather than just put wherever and left to deal with what they've got to deal with on their own, because that's what it feels like.

Okay, thanks, Rhian. Rowan.

I agree with the Bill—I so heartedly agree with it—but my biggest concern, if and when it does get stopped, if it does, is that all these companies are just going to end up packing up and just going elsewhere, because they no longer are able to profit off us, and that's going to cause a lot of problems for all the kids that are being looked after by all these different companies.

Okay, thank you. That's a good point. Happy, Mark? Yes. Thank you.

Time flies, and we've been really, really grateful for what we've heard from you here and in our time before. John, I'm just wondering perhaps if you could wrap up with a final question for us.

Yes. Diolch, Cadeirydd. I'm just wondering if there's anything that you haven't yet told the committee that you would like to mention that's relevant to this legislation that would take profit making out of the system.

It's not just about the profit—it's about the care of young people as a whole. A lot of young people are being let down by the system currently. A lot of young people, their local authority won't pay for specialist care for these young people when they desperately need it, therefore letting these young people be placement hoppers, meaning that they're going to different placements, which could be 10, 20, different placements in a week. And we understand that this is going to happen, there are going to be placement hoppers in the system, and that's unfortunate, but, if the local authority is happy to pay £5,000 for a residential placement, why aren't they happy to pay for a specialist care placement, therefore saving them money? And if the Bill is passed, it would actually save taxpayers money, because these companies would not be profiting off these young people. These companies would not be profiting off the young people, therefore, taxpayers wouldn't have to pay as much as they are, because, in all fairness, taxpayers aren't paying for our care—they're paying for the companies to stay open.

And also, with the care of young people, threatening these young people with DoLS orders, which are deprivation of liberty safeguards orders, threatening them with secure units, also doesn't help the situation, because, if you have a young person that's showing a behaviour that's a trauma response, if they're lashing out, threating them with a DoLS order or a secure unit just means that they're going to react to that, which pushes them to more likely be placed on a DoLS order or be placed in a secure unit.

So, what you're saying, Elliott, or what you said to begin with, is that money that's taken in profit by those profit-making organisations at the moment should be actually ploughed back into provision and services and training?

Yes. If we have services that we could access as young people—. We talked about this at the second national summit; we would like a service that is purely for care-experienced young people, that they can access the support that they need. But, with the amount of money that's being paid into care currently, we're not getting the right support that we need. We're waiting three, four, years on waiting lists for child and adolescent mental health services, we're waiting four, five, years for neurodiversity assessments. I'm pretty sure the adult mental health waiting list is six years, currently. And we're waiting for these diagnoses, but, if we're constantly being moved, we're constantly being moved between health boards, which means different CAMHS practitioners, and we're being put to the bottom on neurodiversity waiting lists. We need the priority on these waiting lists, and we don't think that we should be bumped down the list just because we've moved placement and we're under a different health board.

Thanks, Elliott. Anybody else want to add anything in terms of anything else we want to—?

I suppose, from my point of view, and a lot of young people's, is, 'Put yourselves in our shoes.' You probably wouldn't want to be profited off, so why should young people in the care system, in private sectors, be profited off?  

Thank you. Anybody else?

And the pay for—. If you actually had a look at the pay for a standardised residential support worker, it is shocking—it’s minimum wage in most companies. Why are these carers being paid minimum wage when they are dealing with high-tariff behaviours, they are getting hit on most days? Yes, we understand that companies want to make a profit, otherwise they wouldn’t open companies, they wouldn’t branch out, they wouldn’t open more homes, but, also, there's the fact that these residential workers, these foster carers, deal with so much. Why are they being paid pittance money when the companies are profiting off their misfortune, as well as ours?

Thank you. Okay, we're going to have to draw things to a close there. Can I just say: Rowan, Rhian, Joanne, Elliott, thank you so much for being with us this morning and for sharing your information, and to everybody else who spent time with us this morning as well? I'm really grateful for it. We're going to take a short break for five minutes now to prepare for our next panel. Diolch yn fawr iawn. Thank you.

Thank you all very much.

Welcome back, everybody. We'll continue our meeting of the Health and Social Care Committee here in the Senedd. We're moving on to agenda item 4, which is an evidence session with organisations supporting children in care, as we continue to consider the Health and Social Care (Wales) Bill. I just want to provide a welcome. I can see Helen Mary Jones from Voices from Care Cymru; Sharon Lovell, the chief executive of NYAS Cymru; Rachel Thomas, head of policy and public affairs, Children’s Commissioner for Wales; and we've got Rhiannon Beaumont-Walker, chief executive of TGP Cymru. So, welcome to you all this morning. We really appreciate your time. We have around an hour together. Don't feel that you all have to answer every single question. We'll take questions from around the committee as we go along. 

I shall start off, in the first instance. I'm interested in your view of the main changes needed in terms of placements for children in care and what this Bill would do to address those. Who would like to kick off?

I'm happy to start, if that's okay. 

Sure, thank you.

So, I managed to catch some of the evidence session that you've just had and, as we reflected in our evidence and the young people spoke about, it's the importance of the links for them to their home community to maintain family contact, and that sort of thing. So, whilst there are some technical parts of the Bill that I know, no doubt, we will get into in due course, I think it's important to see this Bill as a necessary step as part of that wider transformation of children's social care, and so the ability to bring children and young people back closer to home so that they can maintain their links in the community, their links with their family and their support networks—. We know that the most common destination, for example, when young people leave residential care at 18, is to go back home, and so we need to make sure that we're not just sending them back to somewhere that doesn't really feel like home to them because they've been living so far away and their support networks are all somewhere totally different. So, the importance of securing the changes in this Bill, as far as we're concerned, is about that wider transformation to support those outcomes for children and young people. 

Thanks, Rachel. Helen.

I think we'd say that the provisions of this Bill are necessary but not sufficient to achieve the transformation. There are two elements, and our comments are based on what young people have told us, both before the previous Senedd election—because this was a call in the manifesto that Voices from Care Cymru presented on behalf of care-experienced children and young people before the previous Senedd election—. So, this is for our young people. It's something that they've asked to be delivered by their Government, and that's significant.

This, by itself, is not going to completely deliver all the transformation, as Rachel said, that we know is necessary, but there are two things that I think young people would want us to raise. One is the principle, the idea of being sold off to the lowest bidder on a website, which is what happens to children—and our call partly came from a young person who actually witnessed that. She was left in her social worker's office, and she saw the different companies putting in lower bids for her care, and you can imagine how that makes you feel. So, that principle of not being something that is bought and sold. For us, there are issues here around the United Nations Convention on the Rights of the Child, and particularly the right of a child not to be economically exploited, and it certainly feels to young people that they are. It's clear that the levels of profit that are being taken out of children's care are excessive. The previous UK Government acknowledged that and had actually set up a working party to deal with those issues in England. So, there's that issue of principle, that it's just not morally right. We don't buy and sell our healthcare. If I end up with lung cancer, I'm not buying and selling my care. My need isn't being sold off to the lowest bidding hospital to provide me with that care. 

But also there's the issue of the amount of money that comes out of the system. Now, some companies, of course—and we would never want to characterise it that all of the care that's currently done in the private sector is dreadful and all the care that is currently done in the public sector is good; that simply isn't true. But the truth is that companies are taking 25 per cent, 30 per cent profit. And as one of the young people worked out for us, that means that, for every £10 that the Welsh taxpayer is paying to look after a looked-after child, up to £3 of that is going straight into the pockets of shareholders. And we don't believe, and our young people don't believe, that that's a very sound economic prospect for the Welsh Government. 

One other thing that we would say, though, is that young people have issues, some issues of trust, with local government in Wales, and if these responsibilities are to be, as the Bill suggests, completely transferred to local government, young people are asking for the Welsh Government to be really vigilant about how all of this is delivered, to ensure that it's delivered consistently across the whole of Wales and that we don't end up inadvertently going down to the lowest common denominator. 

Thank you, Helen. Does anybody else want to add—? Sharon.

Thank you very much. In principle, NYAS, the National Youth Advocacy Service, supports the Bill. We have experience of providing statutory advocacy to children and young people in care, where we know that they've come for advice and advocacy representation because there are questions around them remaining in their placement or having to move, because of the financial arrangements in place. So, we know that, financially, there's been a motivation sometimes as to why children and young people have had to have advocacy cases. But we are concerned with the implementation of the legislation. We think that there needs to be a really clear time frame in place. We believe that consideration of extending 2026-27 for implementation needs to be reconsidered, because we believe that there are some fundamental issues that need to be addressed still.

One of the things we're concerned about are children and young people. We believe that there will be 500 children and young people in residential homes, and 1,000 young people in private fostering placements that will need to come into the local authority arrangements, and at this stage, we know there's huge transformation work taking place with the radical reform inquiry work last year, and the transformation programme for social care, which—. There's a huge amount going on, which is very positive, I have to say, but I think this work is so big, and we know that many children and young people who are currently going to be affected do not know this is happening. So, I had the privilege of meeting a young woman in north Wales last week who is 12, 13, in a private fostering placement. She's had many private fostering placements and residential homes before, and she said to me it's first time she now feels settled with her foster carer, who is a private foster carer. And I was thinking, this is going to affect those two, and they know nothing about it at this stage. So, I think a very clear communication plan for our social care staff, our local authority staff, third sector providers, but more importantly children and young people is critical. And I do think there's a real vulnerability to some of our most vulnerable children and young people. I know that through the provision we provide in NYAS Cymru, we work exclusively with young women and girls who are pregnant in the care system, and those foster placements, private foster placements with mother and baby, and baby homes with mothers, are critical. And so that is my ask: having a real clear plan to support those placements, but more importantly, having care plans individually for children and young people based on their views, wishes and feelings. Thank you.

Thanks, Sharon. Perhaps before others come in, I know, Gareth, you want to ask a question—just one moment, Gareth. Just in terms of the comment you made there, Sharon, around the knowledge or the engagement that young people currently have or do not have about the impact of this Bill, you described that there should be a clear communication plan to help young people understand how this Bill might impact them. Are there any other things that should be done to ensure that young people are aware of the potential impact of this Bill, do you think? Is there anything else that should happen?

Absolutely. I think if anybody was told within two or three years, 'You are potentially going to have to move from where you currently live'—we have to give due regard to the care plan and placement of each individual child and young person. So, that is why I think a phased approach, one that has full regard for clear time frames, clear communication plans for children and young people—. I've been told that many social workers don't know this is happening. And who are going to be the individuals informing children and young people of this transformational change? So, again, in principle, I absolutely support this Bill, but my concern is the time frames in which we support children and young people for the practice of the outcomes of this Bill.

Thank you. Rhiannon.

Following on from Sharon's point with regard to the needs of young people in this situation, as an advocacy provider, the discussion around the development of the active offer for advocacy was to include points of transition for young people, and this is obviously a major point of transition for young people who are going to be affected by the Bill, and so we've called, TGP Cymru—I'm sure NYAS would support the call—for the reintroduction of the active offer specifically for these young people.

I think it's taking into consideration as well, as Sharon said, that lots of social workers currently don't know about the situation, and those people that are close to the young people, their current providers, are affected by the situation, so they're going to be involved emotionally, financially, and aren't best placed to support those young people through their situation. So, to ensure that young people have got an independent voice and are heard in the transition and that their needs are met.

Okay, thank you.

I think those are really important points about young people's individual needs needing to be taken into account. I also think it's important that there has to be a transition period, but also a cut-off point, because a transition period where the transition period just goes on and on creates more uncertainty. It would also be remiss of us to allow the committee to believe that the current, predominately private sector provision, particularly when it comes to care homes, provides stability, because it doesn't. For some young people, they're really fortunate and they find the right place the first or second time, and that's brilliant. But because most of the children who are in the care home system rather than fostered are the children with the highest needs, if those needs don't get met, they do find themselves being moved around and, very unfortunately, if some of those placements become too expensive for the provider to provide, because the child's needs are so high, then that can cause instability as well. So, I wouldn't want to leave you with the impression that the current system is stable for those young people. What we want to do, I think, is to make sure it doesn't become even more unstable.

Thank you. Rachel.

I agree with what Helen Mary was saying there. I think the information that's out there at the moment is—. Because there are some transition points, but there are still some gaps in what the picture looks like and what happens to young people who are in placements currently, so it's just a bit more information to provide some certainty, and that would be for all the relevant stakeholders here. So, obviously, children and young people as the primary stakeholders, but then social workers, advocates, care home providers and everyone else that's involved. I think there's perhaps still an element of people waiting to see what's happening with it, and that's why a clear end point and plan need to be in place, so that this can then be implemented.

We've seen very welcome investment in new regional accommodation for children with complex needs through the regional partnership boards, but that's been happening since 2018, and is still rolling on and people will get there when they get there. There are a lot of complexities to that around capital purchases and so on, but even still it's taking a long time for those beds to become available, and so, for everyone, I think the certainty of an end point is probably what's missing at the moment and will help with a lot of the messaging that needs to follow then.

Thank you, Rachel. I'll bring Gareth in briefly, then Mabon, over to you after that, if that's okay.

Thank you, Chair. Hearing the evidence that you're giving this morning, I'm just curious to know why, in your professional opinion, we've come to 2024 and we're looking at a health and social care Bill that is intended to be implemented within the next few years. Given that we've had an NHS system nationally for the past 76 years, social services run by local authorities for decades, why do you think that children's services in this regard are so delayed in taking profit out of care, which has pretty much been nullified from a health point of view? Why is it now the case that children's services took so long to, perhaps, catch up in that regard? I'm just curious to know why that seems to be the case, because we've had Governments of all hues over those decades, both UK and Welsh Governments, so it's a bit of a question as to why now and what have been the potential barriers and delays to that over those ensuing periods.

Next, Helen.

Well, I wouldn't wish, Chair, to bore the committee with a history lesson, but I could provide one for Mr Davies if he wants one—

That's what I'm after. Go for it.

—but I think two things happened in the late 1980s and early 1990s. One was the Waterhouse scandal of child abuse in very large public sector children's homes, particularly in the north of Wales, and I think that created some risk averseness in local authorities about making direct provision. I think they were worried. But at the same time, of course, there were changes pre-devolution in the regulation system that actually made it more difficult for the third sector and public sector to provide and was actively a policy decision to encourage the private sector to come more into care, adult care and children's care.

I don't think I can answer the question as to why, since devolution, it's taken us as long to get to this. What I can say is that our young people asked very clearly for this after a big consultation with other care-experienced young people before the last Senedd election, and from their point of view, this is a promise being kept. But that's not to say that they don't have some concerns, and some of the concerns you've already heard, around individual young people's placements, around particularly the point about needing to have advocacy to ensure they get what they want out of any move. But it's a question of political history, Mr Davies.

Yes. Well, it was a political question.

I'll buy you a cup of tea one day and we'll go through it. [Laughter.]

Thank you, Helen Mary. Briefly, Sharon, and then we'll move on to another question. Sharon, over to you.

Thank you, Chair. I think it's about how we value children, how we value children and young people's voices, and I wonder if we hear the voices of adults more loudly and therefore, for children and young people, it takes more work to change legislation and policy. I think we've got a really strong history in Wales. I'm really proud that Wales is the first country, the first nation in the world to have an active offer for children and young people who go into the care system, so it's a fundamental right, an entitlement. But I think there's so much more still to be done. I think the UNCRC could be into domestic law here in Wales; I think there could be a children and young people's Minister who is there exclusively for the voice of children and young people. So, I think that's a very short answer, but I think we have to really put children and young people at front and centre of our valuing and for them to be part of decision-making processes here in Wales.

Thank you very much. I know we may come on to some more of this in a few moments, but I'll bring Mabon in first and we'll go from there. Mabon.

I wouldn't like to talk about extending the time frame on the Bill. I think, as we said, to an extent, it means that there isn't a deadline and something to work towards. Our concern, and hearing from the young people who spoke to you previously, is that the focus needs to be on the quality of placements for young people, as opposed to the deadline being on the current placements. So, that's our concern, that the focus is the wrong way around and there need to be clear timescales and objectives in terms of meeting what is required to ensure that young people have the quality placements to move into, in order to move away from the current model.

In relation to the question about how we got here, something that we're concerned about is in terms of the resource within children's services. We've got to a point of being like a reactive service and obviously it is at the high end and meeting the child protection needs, and that needs to be there, but we would like to see there being a focus on and investment in being more of a proactive service, and there being more services available.

In the Bill, there's financial support for local authorities to look at their provision, but there's no financial support for the third sector, which could be really utilised in this situation, for example, looking at supporting young people to safely return home as opposed to looking for new local authority placements. TGP Cymru have provided 250 family group meetings to families over the last year, which is just the tip of the iceberg, but they're really successful in terms of looking at the resources within families and supporting young people to safely stay within families. So, yes, we'd like there to be a focus on that proactive nature of looking outside the box and looking at what resources are available, not just within local authorities, but within the third sector and families themselves.

Thanks, Rhiannon. I'll bring Rachel and Sharon in and Helen Mary after that. Rachel first.

Thank you. I suppose the thing that I want to be most clear about is that we're not actually advocating for a delay or an extension of the timetable, so I wouldn't want that to be the impression that comes from our office. I think, with every piece of legislation, the closer it gets, it always feels like, 'Oh, gosh, there's so much to do here and we're never going to get this done.' I remember when the Social Services and Well-being (Wales) Act 2014 was coming in, this was exactly the conversation that was being had. Even when it had been passed, it was talking about whether it shouldn't be extended. So, it's not about a cliff-edge point in any of this work. We're not saying, 'From this point, everyone will move on 1 January, or whatever date, and that will be that'; this is about the managed transition and plan for this. I think that if you push the date back for it to even start, then the investment and the work won’t follow, so you need to have the firm date in place to make the actions happen that need to happen.

We started calling for this in 2017, when young people had been bringing this issue to our office. We were saying then about the need to involve young people in the design and delivery of these services, and it’s those things that need to happen in this intervening period, to provide the stability and all the things that we’ve been talking about as a panel this morning. The transitional period from 2027 onwards in terms of how individual care plans and cases will be managed, it’s that detail that needs to be there more and for young people to be involved in that. But, certainly, we wouldn’t be advocating for a delay in this happening. We want it to be managed carefully and sensibly, but not delayed.

Thanks. Sharon.

Yes. I think it’s the implementation after 2027 is where I would like us to focus on the detail. There needs to be a clear communication plan for our social care sector and for children and young people leading up to that. But, as Rachel talked about, it’s not then having a cliff edge at 2027 and everything is in place; there needs to be full regard for, I think, a number of years of enabling a transition to take place.

My understanding is that, with exceptions from ministerial agreement, there can be circumstances whereby children and young people remain in some certain placements. I think we’ve got to be really clear what the criteria is, therefore, for those children and young people. Because, from an advocacy provider’s perspective, I want to ensure that my workforce of advocates know the rights and entitlements for children and young people, so that when we have advocacy casework relating to this issue, we’re able to give the correct information and advice and representation to and with children and young people. So, I think that implementation phase is critical. I am cautious about it being a ministerial decision for those exceptional circumstances for children and young people to remain in placements. I know, on a Friday afternoon, when you have safeguarding issues and urgent phone calls, and heads of children’s services have to make critical decisions about a placement move, to have a ministerial decision or an official to make that call may be challenging. So, I would suggest that that is actually taken into account.

Thank you, Sharon. Helen Mary.

Thank you. Diolch yn fawr. Mabon, one more question from you before I move on to other committee members. Is that okay?

Shall I come in first on that?

Go on then, Rachel.

Not to step away from the provisions of this Bill—we think what's in this Bill is important—but it does feel like a missed opportunity for some other things that children and young people bring to us that affect their daily lives. As someone who is in an office that has to tell young people what the Government's priorities are and what they're going to do about them, when there's a health and social care Bill on the table and it doesn't include some of the key things that young people have brought to us, that's really hard for us to explain.

For example, there's the extension of support for personal advisers to work with all young people up to the age of 25. We're not talking about a massive cohort of people here. It's something that the Government have agreed to from a recommendation from our office from 2017, and they have directed local authorities to put that provision in place, but, as with everything, unless you have an entitlement and a statutory provision to back that up, then often that doesn't follow. And so the young people aged 22 to 25 who may have fallen out of the system, who may not be in formal education or training, who are the ones that need the most support to get back in and have their opportunities to progress—career opportunities, or even navigate the housing market and what have you, the things where they need the most support—are the ones that are missing out. We've been waiting since 2017 for a legislative opportunity for this to be implemented as an entitlement for all those children and young people, and to say that that's not happening now feels like a real missed opportunity. We're told there's legal advice in Government that this can be done through secondary legislation, and will be done, but we'd always been told previously that we were waiting for an Act to come forward. It begs the question if we weren't waiting for an Act to come forward, why hasn't it happened sooner.

Something else that's really important in this space is the extension of 'When I am Ready' for those leaving residential care at 18. At the moment, some young people in foster care can stay with their foster carers beyond the age of 18, subject to both sides wanting that to be the case, but that option isn't available for young people when they leave residential care. We've spoken to young people who literally are moving on their eighteenth birthday in the middle of exams periods and what have you. Again, the Government agreed in 2016, I think, to look at extending the principles of young people being able to stay connected to their residential care home. It comes back to some of the questions we were talking about earlier about that support network when you leave residential care, and perhaps being closer to home so you can maintain those links. It might not mean living in the residential home full time, but perhaps retaining access to a key worker, or being able to go there for advice and to access advocacy, and things like that. But, again, there's been no progress on that, and it feels like a fundamental inequality for those children. They don't choose whether they go into foster care or residential care, but they then don't have the same entitlements when they come out the other side.

And lastly, to strengthen the provisions around corporate parenting. It's really welcome that there is a corporate parenting charter that encourages organisations across the public sector to sign up and make their pledges to care-experienced young people about how they will support them. Our organisation, the children's commissioner, has signed up, of course, as you'd expect, straight away, and we've published a promise to children and young people of how we will meet those pledges. But it is a voluntary commitment at the moment, and even as we sit here today, not all local authorities are even signed up to those, and they are the statutory corporate parents in this space. But then you're talking about health boards, housing associations, other people that come into contact with really important aspects of these young people's lives—their education, their healthcare and their housing. For them to not have statutory responsibilities to support care-experienced young people at all, and certainly beyond the ages of 18—. I think these are important points. It just feels like, when you're having a big piece of social care legislation, the removal of profit and the changes that are to come with the transformation of children's social care are important, but so are these other things too.

Thanks, Rachel. We've got Helen Mary, then Sharon.

Diolch yn fawr, Helen Mary. Sharon, and then Rhiannon. 

Diolch yn fawr iawn, Mabon, for the question. I would totally agree with my colleagues Rachel and Helen Mary. One of the things that NYAS Cymru have been asking for is to have more engagement and consultation with care-experienced children and young people on protected characteristics as a right and entitlement. It was one of the recommendations that came out of the radical reform inquiry last year in the Children, Young People and Education Committee. We know that there are some local authorities across Wales that have adapted the right for young people to have that status within their local authority, Newport being one of them. NYAS Cymru have pledged to be a corporate parent and we're very proud to do so, but we also believe that it should be statutory for other public bodies to be part of a corporate parenting charter for children and young people. We think the voluntary arrangement is a stepping stone. This Bill was a missed opportunity to be able to incorporate that within legislation. 

As an organisation, we'd also suggest there's a missed opportunity with regard to the Bill in terms of amendments to the Regulation and Inspection of Social Care (Wales) Act 2016. TGP Cymru have long been calling for it to be a requirement of regulation and inspection for private residential homes to have a visiting advocacy service—again, coming from things like the Waterhouse inquiry and the importance of advocacy. In terms of the figures, we suggest that the proportion of looked-after young people who are currently in private placements is about 30 per cent, whereas as an advocacy provider, our proportion is about 5 per cent. So, 5 per cent of the young people that are referred to advocacy are living in private accommodation, which is a really small proportion. It means we're not seeing those young people. They're not being referred by their social workers, they're not being referred by their residential workers. Obviously, that's as a half-provider. So, even across the board, if NYAS were seeing the same, that would be 10 per cent. So, it's a really low proportion of young people that are being seen, and it's a missed opportunity. We've been calling again and again, in our own report, ‘Out of Sight—Out of Rights?’, and in the Children, Young People and Education Committee in terms of radical reform, for that to be a requirement of registration. And it's an opportunity now in terms of the transitions in registration for that to be a requirement.

Thank you for that, Rhiannon. Mabon, are you able to move on from there?

Thank you, Mabon. Joyce, can I bring you in on some of those points?

I want to talk about the unintended consequences, and of course, you've talked about some of them already. But NYAS, you did say that you don't agree with section 10, which amends local authority duties so they have to take all reasonable steps to secure the accommodation for looked-after children within or near that authority area. Why have you put such an emphasis on that? 

I think it's ambiguous, the language within that section of the Bill. Where it says ‘near to’, we feel there needs to be much more clarity about what that means and what that looks like for children and young people. For some children and young people, they don't always want to return to their home authority. We do have to be mindful of that as well. To have a position where we think that's the case for every single child and young person—. I think we need to do more of an inquiry into that. Because for some children and young people, absolutely, they will want to go back to their home local authority, but for some who have maybe been out of county, out of country, for many years, where this Bill will affect them, it's not a blanket approach to have that agreement for every single child and young person. So, in all its entirety, we wouldn't support the whole of that statement, but in part.

We've heard mention about the deadline and the extension, and we've heard concerns around the fact that some profit-making organisations might need to reregister to be able to take on new young people into their care after that transition period. But the Bill actually says that can't happen, and that they can keep—. Because stability has been often talked about here for the young person, of course. The Bill does recognise that if the young person is in a stable environment that suits them, but it's profit making, they can stay there for the duration of that care. But that care provider can't then take on new young people after that. And yet it seemed to me from some of the evidence I had that you didn't seem to be quite aware of that. Am I reading it wrongly? 

If I can clarify my comments, I can't speak for my colleagues, but my concern was that if you as a committee were to recommend further flexibility other than what the Bill currently allows, that flexibility should not extend to allowing new children to be taken in. Obviously, the Bill as it stands says 'no'. I think we have to question the practicality of that, because if you've got a setting that's normally a provider of provision for four young people and you're a profit-making company, and you're down to the point where you've got one young person and perhaps that young person is 15 and they want to stay there until they're 18, is that profit-making company really going to allow for that stability? I think we have some scepticism about that.

My concern was that if you as a committee were to go back, based on some of the evidence that you've heard about the need for flexibility, and recommend to the Government that they allow for more flexibility after the legislation is introduced, there would then be a risk that we could inadvertently create loopholes. And if I may say so, Chair, that's partly based on the experience in Scotland when they attempted to remove private provision from foster care. In their attempts to allow sufficient flexibility, the Scottish Government created a situation where, essentially, private companies could register not-for-profit arms in Scotland and then take, as management fees, exactly the same amount of money as they were taking previously as profit. And when that went to the UK-based parent company, that became profit. 

One of our concerns has been that anything that you should recommend in that very worthwhile interest of that individual child and trying to make sure that they, as Sharon has said, are not negatively affected does not inadvertently make the same mistakes that the children's community and the Scottish Government made together, which has essentially left them in a situation where nothing very much has changed, except the legal status of the providers, and no more money—. Because part of the point of that legislation was to take more money from profit and put it directly into the care of children. And that's just all being taken out now as management fees. So, it's just about wanting to suggest to you as a committee to be flexible, but no so flexible that the legislation risks becoming almost meaningless.

Finally from me, we listened to the young people this morning, and, as you've mentioned, they didn't seem to have universal confidence in local authorities providing the care, providing the training that was needed for the care providers. And also—and crucially for them—they said they were listening to them but not hearing them. They drew that distinction. So, what recommendations would you want to see implemented within that sphere?

I think that's a really important point to hear from the young people, isn't it, in terms of working on how to address this. I don't think we can avoid the responsibility sitting with local government, and the very committed workers in those services who are looking to make decisions in these young people's best interests. I think one model, for example, that seems to be quite successful is where the third sector works with local government to provide these placements. The placement might be owned by the local authority, but the staffing and the provision might be through the third sector, or they might do, in some way, some sort of joint enterprise between them. We understand there's been funding made available to local authorities—the £68 million for the transition so far. But we understand that that might not be available for third sector providers to come in on that work, if you like. I think there's a real strength to working with someone who isn't seen as a social worker and the corporate face of local government, for those young people, and people who have the training and skills in offering this kind of provision already. So, what we would like to see is either greater clarity or more detail, really, on how the third sector can work with local government in increasing the placements in this space, so that you've still got the responsibilities and everything coming back into the public sector, but, at the same time, you've got people who are really experienced and knowledgeable in doing this work, as an active part of that.

Thanks, Rachel. Sharon and then Helen Mary.

Thank you, Chair, and thank you for the question; I think it's a really important one. And not only should we listen to children and young people—we do have to hear—but also we have to act. I think we need to have more engagement and consultation directly with children and young people. As I say, one of the concerns NYAS Cymru has is that children and young people currently who are going to be affected by this don't know this is going to happen—not all children and young people; I would say the majority don't know. So, I think there needs to be a real regard for engaging more with children and young people, to enquire how they can have the trust in local authorities. I think it's been really difficult for local authorities and social care staff. We've had a pandemic and we've had the outcomes from that pandemic. That's been incredibly challenging to our social care sector and social services, and I know they work incredibly hard to try and have suitable placements for children and young people, and I think it's really important we acknowledge that.

We know there's a real concern at the moment of people coming into the social care sector, and we also know there's a concern from foster carers coming in and working with local authorities, because they believe they have more support, sometimes, from private providers. So, I think we need to unpick that to really understand what it is from the private sector that foster carers get that they don't feel they receive from local authorities, and what we can do to support social workers, on the ground, to have that 'listen, hear and act'. And I totally agree with Rachel's point about involving the third sector in those partnerships and conversations, and I would recommend, as Rhiannon has said, that we give children and young people who are going to be affected by this an active offer of advocacy again, because this is a major transition in their care plan.

Thank you, Sharon.

I'll be very brief—

It's okay.

—because you've heard from the young people directly already. I think what it is is that, through the radical reform process that we've been working on with the Welsh Government, with care-experienced young people all over Wales, it's become clear that there are some huge differences in practice between different local authorities. There is some really, really good practice out there, where young people really are listened to and their concerns are acted on, and then there are other local authorities where it doesn't seem to be as much of a priority, and what our young people are concerned about—. You know, we'll have some young people who say, 'Well, I can get this in my local authority. I get real help with this'. Why is the young person who might live two streets away, in a different local authority, not able to access that same level of support? And likewise, young people saying, 'Well, I know my friend can get this in one local authority'—I was going to name them, Chair, and I won't do that—'and I can't'. So, for young people, it's about that consistency. In the context of this legislation, I think what they're asking for you, as a committee, to ask of the Welsh Government is to ensure that, in implementing this legislation, there is consistency and that the Welsh Government then puts resources into monitoring the provision and to making sure that it is that good quality and it builds on what other colleagues have said.

It's absolutely clear that there are lots of people on the front line in local authorities who are absolutely doing the very, very best they can for their children, but the decision makers in those local authorities often give these issues very different priorities, and what our young people would say is that that isn't fair and that that isn't acceptable. So, it's not about the people at the front line, but it's about what the people at the front line can do. You know, if you're a social worker with 30 families on your case load, how can you possibly do that preventative work that Rhiannon was talking about before? You can't; you're lucky if you can see them all once a month. So, it is, for our young people, about asking you to ask the Welsh Government to ensure, when this legislation is implemented, that some of the inconsistencies they've seen in other things are not allowed to creep into this.

Thank you very much, and thank you, Joyce. Mark, could I perhaps bring you in? I'm not sure if you've got any particular questions around the unintended consequences, or just anything else you thought might be useful to ask.

Thank you, Chair. I just wanted to make sure, first of all, I've understood what the panel are saying to us. The Bill sets out a time frame for transition from the current system to the future system. It has a series of flexibilities inside it to allow local authorities to manage that transition. I think I'm hearing from you that you don't want the transition period to be extended. I thought it was very good to have the commission’s view so clearly on the record in that way. And you're not asking from more flexibility. What you're asking for is more detail as to how that is to happen and how it's to take into account the different principles that you've been articulating about the voice of the child, consistency across Wales, and so on. Have I understood that correctly?

Certainly from my perspective, yes. I think uncertainty is the enemy of a lot of good progress, isn't it, and people are so afraid to do the wrong thing and, having gone down the wrong path, I think it's the certainty that's needed here for everyone to be able to make those decisions, particularly those who will sit within that transition period and sit, perhaps, outside the expected planning of not-for-profit placements,—how that will be managed, and how the young people will be actively involved in those decisions.

Helen Mary.

I'd pick up Sharon's point about clarity around the criteria with which ministerial decisions will be made and how that will actually be done. Is somebody going to have to get the Minister on the phone at 3 o’clock on a Friday afternoon, because I think that might be a bit of a challenge? So, it's that clarity around those criteria, because otherwise that's the risk of drift then.

Okay. Sharon.

Thank you. I think it's not just about Ministers. I think, even if it were officials, that would be quite challenging as well, at times. So, I think definitely more clarity on the criteria of exceptional circumstances, of when children and young people can remain in placements, and what kind of placements and for how long, is needed, and I think we need to bring the sector with us. We need to bring children and young people with us, we need to bring social care staff with us, we need the third sector with us, and I don't think we are there yet. So, whilst I'm not saying there needs to be an extension of the time of the Bill to come into force, I do think there needs to be consideration for the full implementation of it to be a phased approach, whilst we take into account all the many different factors of taking people with us.

And perhaps, before we move on, do you have anything you want to add, Rhiannon, to those points?

I would agree. I think it's really important to have a clear timescale, a clear focus on all those things that we've discussed, making sure there's a clear communication plan. Our priority is making sure that young people are at the centre of this and that the Bill does what is intended. We'd happily support, with a communication plan, in terms of young people and making sure they're getting the right message and that there are resources available to support that outside of the local authority, with regard to the third sector, and that there is oversight in terms of how those finances are being used. We've seen previously with things like the active offer, where the Welsh Government specifically funds an agenda like the active offer, that that doesn't actually transfer to providers. So, we'd like there to be oversight of that and it being key that there is support around young people who need to be at the heart of this.

Thank, Rhiannon. Mark, do you want to pick up anything?

I want to go on to the issue of ministerial decision making here, because this is not a new thing in our system. If a child is placed in secure accommodation under certain circumstances, it can only happen with a Minister’s agreement, and the Minister has written to the committee to make it clear that that can be retrospective—that it's not going to be a matter of, at 10 o’clock on a Friday night, having to chase down the Minister or an official. People will be able to make the decision on the spot, but they will then have to get ministerial approval of it. And, as well as the detail, I just wanted to make sure whether you agree with the reason why the Bill suggests this, because I think it goes to the heart of some the points Helen Mary was making earlier. If local authorities, simply on their own say-so, were able to continue to place children in private provision, it's a bit of a barn door, isn't it? What this is is a check and a balance in the system. Local authorities will be able to place children with private providers. It's unlikely, I think, to be in an emergency situation. These are for children whose needs are so unusual that you’ve got to look for very specialist providers. And this will be something the local authority will be working on and considering, and they’ll come to the Minister with that case. But if you didn’t have the Minister as a gatekeeper in this process, then isn’t the risk that that flexibility—which needs to be there, so that the private providers can be used—instead of it being an exceptional use of that, could very easily become something some local authorities would default to as the normal way in which they navigate their way through some challenging circumstances?

I mean, for me, that would particularly be a risk in terms of there will still sometimes be out-of-country placements for very unusual needs. I think we wouldn’t be wanting to do away with the ministerial oversight in that way, but it’s that point about clear criteria, so that people can understand the basis on which that decision is being made, and particularly that the child themselves can understand the basis on which that decision is being made.

Thank you. Rachel. 

I suppose the question it raises to me, when you talk about retrospective approvals, is in what way that acts as a safeguard, because if the approval isn’t granted, then does that mean that the young person has to move placement again because they’re not allowed to stay where they’ve been? So, I’m not sure, if you have a retrospective approval, that it does act as a check and balance in the system. And there will be other mechanisms that are in the Bill to require local authorities to report on the current state of their provision and the sufficiency of the offer that they’ve got, and also the placements that they’ve been making. So, the query for us was whether an additional level of scrutiny was necessary, beyond that reporting that’s also in the Bill, if it could have the potential for placements that are the right placements for children and young people to be lost because of a delay in reaching the decision. So, I’m not sure if a retrospective approval could cause more problems than it’s trying to solve.  

Thanks, Rachel. Anybody else want to add anythig to that at all before we move on? No. Mark, do you want to come back or ask a further question?

I have one, very tiny question, but, just to say, I've exercised retrospective approval powers as a Minister in the Welsh Government, and I have exercised them by saying to a local authority, ‘I don’t agree that that young child should be kept in secure accommodation. You put them there and we’ll give you a number of days now in which you can find something more suitable for that child'. It did mean that the child would be moved, but they were being moved to somewhere, I believe, which was more in line with that child’s needs. So, that’s the check. That’s why you need some grit in the system, isn’t it, so that local authorities can’t just make decisions that aren’t challengeable, and that’s what this provision in the Bill seeks to do, I think.

Finally, just to go to a very small point about the provision in the Bill about allowing local authorities to place a child not just within their own local authority area, but in a neighbouring local authority, because, Sharon, I thought the reason for this being in the Bill was to answer exactly the points that you were making. At the moment, the local authority is under a pretty clear obligation to find another place for that child within their own boundaries. Think of Ceredigion, for example. A child from Cardigan could be placed 10 minutes away in the north of Pembrokeshire, but, instead, the local authority is under pressure to find somewhere inside their own boundary, which could be two and half hours north of where they are. So, this is in the Bill, I believe, simply to allow local authorities to have some sensible flexibility to be able to meet the needs of that child, including children who live close to boundaries, and they don’t have that flexibility at the moment.  

Did you want to respond, Sharon, from your side, either to that point or the previous point?

Yes. I think, for me, it’s about coming back to the voice of the child and young person, and for the Bill to be flexible enough so that we take into account the views, wishes and feelings of each individual child and young person. I can really appreciate the intention of the Bill, and, as I said at the beginning, NYAS Cymru agree in principle to the Bill. It’s about the detail, Mark, as you said, that we’re asking for, and in particular the criteria. The example you gave about 'secure', that’s quite a small group of children and young people in Wales. I think there are some children and young people, in much larger numbers, who are vulnerable and are in certain placements at present that are private fostering arrangements and children’s homes.

I mentioned young women and girls earlier, where we’ve worked with 500 young girls and women over four years, who are pregnant or who have children, and we have been able to keep families together through the early intervention and prevention fund from the Welsh Government. I wouldn’t want other programmes of Government to be at risk because of the workforce not understanding the detail and criteria for where those children and young people can stay currently within those arrangements of private care.

Thank you. We’re going to have to move on. Time is really pressing. I’ll come to John for perhaps one or two questions, and then I’ll ask Gareth to wrap up with a final question. If we can try and do that within five minutes. Let’s do our best.

Diolch yn fawr, Cadeirydd. Sharon, when we talk about the need for children currently with private providers to have advocacy so they understand about the Bill and what might happen, is there anything you’d point us to specifically in terms of what needs to be done to ensure that those advocacy services are taken up by those young people?

Thank you for the question. It’s a really good one. We know that advocacy played a really important part in the radical reform inquiry last year held by the Children, Young People and Education Committee. As I said earlier, I’m incredibly proud that, together with local authorities, the Welsh Government and TGP and NYAS Cymru, we now have an active offer for advocacy, so all children and young people coming into the care system now in Wales are entitled to a statutory right to advocacy. So, they know of their entitlements to have independent representation to make sure their views, wishes and feelings are heard within decision-making processes.

I think we should reintroduce that active offer—as I’ve said, and as Rhiannon has said—when there is this implementation of this Bill—that we give that active offer again to children and young people. The active offer of advocacy is one that needs to be continually reviewed and monitored, because we know in some local authorities it’s working well, but in others not so well. We need to learn why that is the case—what is happening in some local authorities where children and young people are receiving that active offer and in others where they aren’t.

Advocacy is at the heart of safeguarding. We know it’s to make sure that children and young people have independence, that they have a right to see somebody in confidence about anything that they’re concerned about, to get it stopped, started or changed. So, I think that advocacy should be at the heart of offering that provision to children and young people through this Bill.

Thank you, Sharon. Does anybody else want to add anything to that?

Just to say I think that might be particularly important in the context of private sector provision closing. The staff who are working with those children will obviously themselves be affected by that. Hopefully, some of those will be coming over to the third sector or public sector through the Transfer of Undertakings (Protection of Employment) Regulations 1981 and so on, but if they’re not, those young people may particularly need that independent advocate, because the people who were working with them on a day-to-day basis may not be able to give them—. And that’s not to be critical of them, but if I was about to be made redundant, I don’t think I’d find it easy to make the child I was working with feel calmer and better and safer. But an independent advocate would be able to do that.

On the funding and the £68 million made available for preparatory work for what the Bill will bring, you’ve mentioned some issues around funding already, but what do you think about the use of that £68 million? Is it being best used to do what it’s intended for?

We’ve seen some really good practice models where local authorities have worked with their existing private sector providers—very often, actually, the smaller companies that run one or two settings—either to transition them into not-for-profit providers themselves or to take over that setting in a completely non-disruptive way. We were talking to a young woman a few days ago who had gone from living in a very expensive private care setting to living in a local authority-provided setting, and she was in exactly the same bedroom with exactly the same staff and exactly the same young people were there, and she only knew the difference because there were certain things that were changing in terms of additional pocket money. That was the one thing that she mentioned. So, she was feeling the benefit of the profit being lost.

We're seeing some really good things. There are some innovative things that can be done working with registered social landlords, because, of course, they can borrow in a way that local authorities can’t. But I think I’d echo what Rachel has said about perhaps more needing to be done to explore what could be done to support the third sector in that space. I know the Welsh Government has done some work around that and they were doing some work around that in the early stages of this process, but that seems to have gone off the boil a bit. I think if we want a range of provision, because we know we're dealing with young people with a range of different needs, we don't want a monolithic system. I think having some third sector provision in there with local authority provision could be really useful, and I think it might be useful for you to ask the Welsh Government some questions about how that's being focused and whether that's being done sufficiently.

Thanks. Rachel, briefly, and then Sharon.

It comes back to the point I started with, really, that this sits in the broader transformation of social care. We know that local authorities haven't just been using this to open children's homes; they're looking at the preventative space and the edge of care support and all that side of things as well. There probably is more scrutiny needed to see whether there's enough going into that space and make sure that the support is there so that that aspect can also be worked on, because it's part of this wider system transformation, and all levels of that system are important to be supported to make this a success, and then to, ultimately, bring down the numbers of children that are coming into care.

I think £68 million for the first year for 22 local authorities—. I'm interested to know what local authorities think about that. When you divide that up, it doesn't feel a huge amount. But I guess my main concern is what happens after 2025, and whether there is continuation of funds for the local authorities. There does need to be regard for the third sector within that, as Rachel has said. There may be third sector organisations out there that would wish to be considered a provider, so it's how do we enable and empower them to have a partnership approach with local authorities to achieve the Bill. 

I was just going to ask a brief question about numbers. We know that too many children go into care, and it's very variable between local authorities. Obviously, if fewer children are going into care in the future, there'll be fewer placements required. Do you see that happening to any significant extent?

As I said previously, it's not just young people going into care; I think we can look now at the young people that are currently in care, and not just transitioning into non-profit providers, but safely to return home. As I said, we've done a lot of work around family group meetings, which is a recognised successful model to support families to recognise their strengths and have a plan in place for young people to safely transition home. We'd really like to see that preventative work done to prevent young people coming into care when unnecessary, but also to really use this as an opportunity to support young people to return home safely where possible.

I think it's likely that there will be a reduction in numbers but an increase in complexity, because if we are successful in enabling families to stay together when there are issues around poverty and neglect and things like that, the likelihood is we will have fewer children coming into the care system, but those children will have much higher needs.

The other point I very briefly wanted to mention, Chair, is with regard to cross-border placements. We have relatively few children placed from Wales into England, though we do have too many, but our colleagues in our sister organisation in England think that there are about 800 English children who are currently in Welsh private sector care homes, mostly in rural Wales. I think it would be really helpful for the committee to ask the Welsh Government what they're doing with their colleagues in England to work out what's going to happen to those young people.

Many of those placements are really inappropriate—they're very isolated, with no access to advocacy, as colleagues have already said. Children are being taken out of big English cities and placed into small rural Welsh-speaking communities. Nobody's advocating that that should continue, but there has to be a proper transition plan for those children. Obviously, that's not our Government's responsibility, but I think we would all feel that, while these children are in Wales, they are our responsibility, to a certain extent. I think it would be useful for you to be assured that there's a proper plan with the UK Government to ensure that those children are also safe.

Thank you for the question. I think that's a big question, 'Will this Bill reduce the number of children and young people going into care?' We know that the reasons why children and young people come into care are complex and they're interconnected with other issues. We know child poverty is a huge issue in Wales, and we know that a large reason why children and young people come into care is because of poverty-related issues. So, I think it is complex, and we can't assume that this Bill on its own is going to reduce that.

But I would say that there are programmes of Government that are really instrumental in aiming to reduce the population of care-experienced young people in Wales. We had the roll-out of parent advocacy, for example, in all 22 local authorities, and we have investment in Project Unity, as I say, supporting young women to prevent their children from going into care. Those projects are grant funded. We know, through research that NYAS has conducted with CASCADE and Cardiff University, that this is having a major impact currently on the numbers of children going into care now. We need to continue to invest in those early intervention and prevention programmes for families to stay together whenever it's safe to do so.

Thank you very much. Gareth, I'm really sorry, but we'll have to draw things to a close. I tried for five minutes but we hit 10. We're going to have to close this part of our meeting here now. Thank you very much for joining us today and providing the evidence that you have. We may have a couple of questions that we haven't got to and we may write to you for a response. If you're able to do that, that'd be very helpful to us. So, thank you again. We'll take a short break, Members, as we prepare for our next group of witnesses. Thank you very much.

Welcome back, everybody, to our Health and Social Care Committee here in the Senedd. We are now moving on to agenda item 5 of our meeting, and it's continuing our work on the Health and Social Care (Wales) Bill, and this particular session is an evidence session with representatives of local health boards, with a particular focus on the direct payments provisions that are within the Bill. So, as I say, a welcome to Jennifer Winslade, executive director of nursing at Aneurin Bevan University Health Board, and also to Gaynor Williams, who's national director of complex care with NHS Wales. Really grateful to you for joining us here today.

I'm going to kick off with a question, and then I'll ask other Members to join in with some questions as we go along. So, the first question from me is really in relation to your views on the direct payment provisions in the Bill—fairly broad—and how you feel about health boards taking on the administration of direct payments, and any concerns that you might have with this plan. Who would like to come in first? Gaynor.

Good morning, everyone, and thank you for the opportunity to be here today to talk about this very important issue. My background is in nursing, so I always try and think about this from the person’s perspective. One of the main reasons why individuals decline to accept a continuing healthcare assessment is they are very concerned about the fact that their care may change if they move into CHC, they'll lose all their voice and control, they'll lose their direct payments package of care, which may have been in place for many years, and so they decline an assessment. That puts them in a very difficult position. They’re in limbo somewhere around, ‘Who is to provide for my needs?’ It puts local authority partners in a difficult position as well, because they could possibly be acting outside of their area of responsibility. So, I think this is a really, really welcome step, and it will be very welcome for many people who are currently in receipt of direct payments at this time.

Thank you, Gaynor. Jennifer, anything more to add to that? Yes.

Just to add to what Gaynor has said, I come from the English system and this has been in place for many years within England, I think with some success. In terms of health board preparation, it is the right thing to do, to enable that to be managed by and administered through health boards. But, of course, it will be a learning curve and we will need additional support in terms of training, establishing a system and process. We can look across the border to our English colleagues to help with the understanding of some of that, but it’s a task that will take quite a bit of time to make sure that we get it right. So, I think some ability for health boards to have that time to reflect on what is needed will be important.

Thank you, Jennifer. In particular, we’ve heard from health boards who’ve raised concerns about the need for increased governance arrangements to ensure safe delegation of care, in particular to personal assistants. I wonder whether you could talk us through some of those issues, so we can understand those a little further. Would you consider there being a risk that the quality of care for continuing healthcare recipients could suffer without the regulation and governance of the NHS being as it should be? Who’d like to respond to that first?

If I talk about this as I see it, as it applies to people, and Jenny can talk about the board level governance and assurance that will need to be in place. If you’re happy, we’ll do it that way.

This will be really welcome, and it’ll be a huge opportunity for some people. It won’t be for everyone. I think there are some elements of healthcare that are very technical, highly technical and highly complex, and there would be a lot of risk and a risk-management approach to have to deliver that within a direct payment.

If I give you an example of something that happens across Wales—and there are several individuals like this—somebody comes off their motorbike, traumatic brain injury, very profound needs after that, is cared for at home on a ventilator with a package of care of nurses and expert carers, 24/7. I would have some concerns about that level of technical care being provided through PAs. Having said that, it doesn’t mean that some of that care couldn’t be provided through PAs, you know?

So, we need to make sure that we give individuals the amount of control that we can, but there will always be some individuals—and I think the Minister referred to this when she made a statement in May about some delegated health tasks. There is recognition that some healthcare is complex and may require additional training or additional support or additional supervision to ensure competency, before we could make sure that we had confidence that that package of care could proceed. Jenny.

Yes. I think, from a health board perspective, it's really important—. As Gaynor said, this is really welcomed, and it's been welcomed—I've been looking at some of the research from the English implementation—it's definitely welcomed by individuals and their families. I think what's really, really important is that we focus on 'what matters to me' conversations and outcomes, rather than looking at process. So, it's really, really important that we understand the experience of the individuals and that we really focus on the outcomes for those people.

I think one of the interesting things in my research that I've been finding is that you do need a framework for governance and, in particular, clinical governance around this. So, how do you ensure that those providers are fit for purpose and remain fit for purpose, so that individuals aren't placed at risk of harm? So, I think there are many positives to this, but there is a need for some baseline of governance around outcome monitoring, and, in particular, that fitness for purpose.

I think the other thing I would say is around delegation of care. We already have this in a number of areas about what is safe to delegate, and I think there's further work to be done across the health boards about what that means in practice. I'll give you an example. There are variations, for example, across the health boards in terms of the practice of suctioning, around the provision of enteral feeding, and I think we could do some work nationally around ensuring that we're really clear about what's safe to be delegated to a personal assistant.

Okay, thank you, and just before I bring a colleague in, I'm just interested in terms of that governance to make sure that that is right. I'm wondering what sort of arrangements you'd want to see put in place to mitigate any of the risks that you've highlighted just there. What sort of arrangements would you expect to be put in place to enable those risks to be mitigated appropriately?

I think you need to ensure that there are regular reviews of care, that those test out the outcomes and experience of the individual, and that the basics that we would expect a personal assistant to have in place in terms of training, appropriate employment checking, for example, the Disclosure and Barring Service, are all in place and maintained. So, I think there are some basics. Again, England have a quality assurance framework that I think we could build on in terms of what we want in Wales for our citizens. But I think it is certainly really important that we focus on the outcomes and the experience. I don't know if Gaynor wants to add anything.   

No, I'd agree completely with that, yes, thank you. 

Okay, diolch yn fawr iawn. Thank you very much. Mabon ap Gwynfor, can I bring you in? 

Who'd like to respond to that? Gaynor. 

Shall I come in first? Every health board has a head of long-term care that is a registered nurse. We meet regularly, bimonthly, we go through many issues. We work with Welsh Government policy colleagues as part of that group. They've led us through this process, and we've been involved and engaged a lot. So, they've had a lot of warning and a lot of awareness of this. I'm not saying wider in the health board that that may be the case, but, certainly, for the people who will be involved on a day-to-day basis, they have had that awareness, and they are involved. 

In terms of being ready, I go back to what Jenny said in response to the first question, I think. This is new territory for us in NHS Wales. It's been running for 10 years or more in England. It's very, very new to us, and I think we will need some support and guidance, and we'll need some training and development work as well, to make sure that our staff fully understand this. We're not sure yet what the delivery model will be. We don't know what the numbers will be initially. So, a lot of these issues are not knowns at the moment, and over the next year we're going to have to grapple with that and look at it very closely.

We've done some work looking at the numbers in England, and that would indicate that we're talking about possibly 2,000, at a maximum, direct payment requests in Wales, but we just don't know. It could be very different. So, this next year is going to be about us really getting up to speed, understanding what the task is, and making sure that we do that properly, so that people are ready and we are ready to put that in place, because there are many people out there who are desperately waiting for this to be available.

Okay. Jenny, do you want to add to that? 

Just to add to what Gaynor has said, I think the knowledge and skills gap can't be underestimated. This took a long time to implement in England safely and effectively, and I think we need to pick up the learning from there. I think there's also the local authorities we can look to in terms of their experience, and certainly they've indicated a willingness to share that with us. 

I think the other thing is that we have to consider that we will need to be able to provide that training to the personal assistants as well. So, it's how we consider the training and competency in the provision of the package of care as well. So, I think this needs to be a comprehensive wraparound for us as an organisation, or set of organisations, but drawing on that expertise that already exists in other parts of the UK and also within the country.

Thanks, Jennifer. Mabon.

Okay, thank you. CHC is a demand-led service; we respond to the demand that comes in to us. So, it's always really difficult to allocate the budget as such to that, and budgets have to flex, depending on the level of need of the individual who is identified as in need. You're right, the resource position is really, really challenging at the moment, and the experience from England, during initial implementation, was that it cost 20 per cent extra for every package of care that was delivered through direct payments. It's really good to hear from colleagues in England that that reduced over a three-year period to parity with an NHS-provided package of care, for example, so I think that early stage support would be very, very welcomed by health boards.

We're also doing work under the value and sustainability board on CHC, and looking at how we can work more efficiently and effectively, and I'm sure the principles that are picked up there will also, over the next few years, roll out and be relevant to this as well. And as Jenny mentioned, we've had significant support from local authorities. I know Jason Bennett has spoken to you at a previous meeting, and local authorities have been very, very willing and open to saying, 'We will share our processes, our systems, our knowledge, our skills.' So, hopefully that will help us to really hit the ground running, but I still think those few years of support will be very welcome.

Okay. Mabon.

Costs of care vary now, they fluctuate depending on need. So, an individual may need more support at one point and a reduced amount of support at another point, so they do fluctuate anyway. The evidence that we've had from England is that, in time, there is parity with a normal, usual package of care delivered by the NHS, so I do not see that as a particular issue. Jenny, as an executive, would you see that any differently?

No, I wouldn't see it any differently, and I think we have to look to—. Whilst this is a demand-led process and service, actually, I think, as we look to some of the work we're doing already in terms of understanding need, prevention, supporting people within the community and that community capacity, all of that will impact, and I think there are opportunities to think about how we in the healthcare part of the system start to reduce dependency. So, if you look at the impact of deconditioning by delayed discharges, et cetera, the days lost and the muscle wastage that comes with that, if we can impact earlier in the discharge pathway and encourage people to be as independent as possible, rather than as dependent as possible, I think that will also have an impact. So, I think, as Gaynor said, there are multiple opportunities here. We know it levelled off in England, but also I think the way in which we provide care to people who are frail, older and who have additional needs is really important in terms of getting that pathway right.

Thank you, Jennifer. Mabon, are you comfortable there?

Diolch yn fawr iawn. John Griffiths, could I bring you in?

Diolch yn fawr, Cadeirydd. Yes, I'd like to ask some questions relating to continuing healthcare. I guess we're all fairly familiar with the disputes that sometimes arise as to whether continuing healthcare applies or not, and we've heard from the Welsh Local Government Association and the Association of Directors of Social Services Cymru on these issues, and they believe that the legislative change that we're considering should be underpinned by a significant change in practice and implementation.

In their view, local authorities are increasingly having to fund more complex care packages, as people are being wrongly denied continuing healthcare, and they say the eligibility bar has increased over time. So, in their evidence, to quote,

'the interpretation of health needs and gatekeeping practice needs to change'

and they think that change needs to happen urgently. So, we’d be interested in your response to those views and how, perhaps, those sorts of disputes might be avoided as we move forward.

Anybody like to respond to that initially? Gaynor.

I’ll start. Yes, thank you. CHC, no doubt, can be a very contentious issue, okay. You give anything a label, and it creates borders, so, once we’ve got borders, we’ve got boundaries and interfaces, and, with CHC, that happens at many levels. There’s the health board/local authority positions—there’s an interface there—there’s an interface between health and social care policy; there's an interface between the free-at-the-point-of-delivery and potentially chargeable services; and there’s an interface with the voice and control for each individual user as well. So, there are all those things, which can be difficult. What I would respond, in terms of the threshold being set too high, is there’s no evidence at all that I’ve seen that that is happening. The decision on whether a person is eligible for continuing healthcare or not is made by a multidisciplinary, multi-agency team. They undertake a comprehensive assessment and, based on that, they come to a decision around whether there’s a primary health need or not. That decision is then made as a recommendation to the health board, and only in exceptional circumstances can the health board decline that recommendation. I can honestly say, in the past five years, I’ve heard of one case where the health board went and declined that recommendation. So, I'm not sure what—. I’m sure that, as we all meet the financial challenges and the challenges of increased demand and things, that it can feel like that, but I’m more than happy to openly work with local authorities and share information, data, and to get a joint, shared view on this to make sure that we’re responding to concerns.

Thanks, Gaynor. John.

Okay. Continuing with continuing healthcare, then, one health board raised the issue of fluctuating health needs, that eligibility isn’t for life and there are instances where continuing healthcare might be withdrawn following a review, if those health needs have changed, and this was also raised by Carers Wales. So, again, I’d be interested in your views on those issues and how that transition between continuing healthcare and social care might be best managed.

Thanks, John.

Thank you. There are a number of issues here, I think. It goes back to what Jenny said about making sure that people are at the optimum point for assessment and we don’t assess people too soon and we don’t assess people too late either; you’ve got to get the timing right to make sure that we make sure that people are as independent as possible. In terms of your question, I think the framework, the policy framework, does state very clearly that people can move in and out of eligibility. Moving in is much more common than moving out. There are few people that will move out of eligibility, but some people do get better, and that’s good news—they’ve improved—but it does mean that we then need to look at which area and which service and which sector is appropriate to meet their needs, and that is clunky, if I’m honest. It can be difficult, that bit. It is about, ‘This individual now needs to return to a different package of care’, and that can cause problems and be clunky, is the word I’d use. I’m sorry, I know that’s not very technical, but it is a difficult area. Few people do move out of eligibility, I have to be honest, very few, but it does happen.

Thanks, Gaynor. Jenny, anything you want to add to that?

Just to say that Gaynor’s right that needs do change and adapt, and we need to respond to those needs as a collective system. I’m very clear that this is about a multidisciplinary, multi-agency approach, and we need to work together. Retreating to our silos is not the answer here for individuals. And it is a good thing if people do move out of CHC eligibility. I think, as Gaynor said, and I’ve said earlier, the timing of the assessment is critical, and, often, doing that within a healthcare setting isn’t the most appropriate environment, and we do need to ensure that people are as independent as possible, because that achieves better outcomes for them. So, I think, as Gaynor has said, this is about how we work together. I’ve seen very few people move out, but it has happened. We’ve had a case recently of a patient who has moved out. So, I think there are opportunities to provide that outcome-focused care together in a multi-agency context.

Okay. Thank you. Can I bring you back in in a moment, Gaynor? Is that okay? John, perhaps ask one more brief question, and then we'll come straight back to you.

Yes, sure. Finally from me on continuing healthcare, around direct payments, what needs to be put in place in terms of information, advice and support so that people can make informed decisions as to whether they want to use direct payments for continuing healthcare?

Thank you, John. Gaynor.

That's one of the things that we have to look at over the next year. We won't be starting from scratch. We have information already from local authorities, who, as I've said, are more than happy to share that with us. We've got information and information booklets from England.

I put my hand up earlier just now to say we're talking about adults here now, and I'm very conscious I haven't mentioned that direct payments will apply to children and young people's continuing care as well. Children and young people move in and out of eligibility a lot, so there's a lot to learn from that type of service as well, and they have information as well that we will be able to use and adapt. So, there's a lot of learning for us in the next year, but we have a lot of information that is there to support us as well.

Great, thank you. Okay, Mark, can I bring you in?

How well is the NHS coping with the current level of continuing healthcare demand that it faces? Would you describe it as being a steady state? How long do people have to wait to have their assessments completed and the service provided?

Diolch yn fawr, Mark. Anybody able to respond to that initially?

Yes, thank you very much for that question. At any one time, we tend to fund between 5,000 and 6,000 people across Wales as continuing healthcare—that's the sort of total number. There will be a similar amount of people for funded nursing care, so we're funding about 12,000 people outside of the NHS at one time. Interestingly, we have now, as of the last StatsWales count, 10,400 NHS in-patient beds, so we are now funding more people and funding more care outside of the NHS than we provide in our beds, which is an interesting statistic, isn't it, that I think we don't focus on enough sometimes, because there are governance issues there as well.

In terms of assessment for individuals, that is always done best when it's done on a multi-agency basis. It's always done best when we get the timing right. If we assess somebody too soon after an acute episode, then, particularly frail older people need longer to recover from that, and that is what discharge to assess is all about. If we leave it too long, as Jenny’s mentioned earlier, then we get individuals who are deconditioned, are unable to return to their normal level and need more support. So, that assessment is about getting the context and getting the intelligence and getting the expertise there, as well as getting the timing right. There can be delays, when people are on holidays; getting everyone together, collating assessments can take some time, but the national framework, the policy framework, requires us to do that within a specific timeframe, so that is measurable.

And in terms of the services, that depends very much on what that individual needs. If the care needs are assessed as to be met within a care home environment, and that's what the individual wants, then it's about availability, and there are usually care home beds available, but they may not be the home of choice for an individual, so we have to manage that process very sensitively, because it's where somebody’s going to live for the rest of their lives, isn't it?

If it's about a package of care in the community, then that can depend on the availability of domiciliary care agencies and what they've got in terms of workers. We find that increasingly difficult. There are more delays and more waits for dom care. It's a very difficult area, isn't it? It's not paid hugely. We are competing with retail and with hospitality for the same pool of individuals who may be interested in this work, and it’s something that we all have grapple with, around how we actually make care services much more attractive as a career. But that does impact. So, the location of care and what the actual package of care is will depend on how quickly we can put a service in place.

Thanks, Gaynor. Jenny.

Just to add to what Gaynor said, I think, again, this comes back to how health boards and local authorities work together, because we’re all pulling from the pool for domiciliary care workers, healthcare support workers, and I think there's a real opportunity, from an education perspective, to think about how we create careers in health and social care, and how we do that collaboratively, in a way that enables people to enter either domiciliary care, a care home or a healthcare setting, but to have a career in health and social care that we can facilitate, so we're not in competition for each other, we're working together to create the workforce of the future, based around the future needs of the population. And there is work under way to understand the future needs, but some of this is demand led, some of this will always be difficult to predict, but I think we are in a position where we understand better the future needs of the population, we understand how we can work collaboratively, building on the learning from the local authorities and from children's complex care. But it's how we work together to ensure we do have the workforce of the future. And I suspect that that greater integration of the health and social care workforce in the unqualified workforce will enable us to perhaps think differently about how this can be provided for the future.

Thanks, Jenny. Mark, do you want to ask anything further? No. Thank you very much. Diolch yn fawr iawn. Joyce, over to you. 

You started talking about some of the barriers, and, therefore, solutions, to the implementation of this Bill and getting the direct payments. Are there any other observations that you have you want to bring to our attention in that space?

Shall I start, Jenny? Yes. I think we’ve mentioned already that direct payments will reduce one of the main barriers to people actually receiving continuing healthcare, because it’s the main reason why people decline to accept that a CHC assessment is undertaken in the first place. So, that addresses one of those barriers, really, in the current policy approach.

Sometimes, resources are limited and we focus on today. And we constantly focus on today, and it’s really hard to make space and time in the day to think about, ‘Right, what’s happening here? What are the trends? What are the predictions? What are the patterns, and what is the service model?’ so that we can use that information to think more strategically. And I think that is sometimes a barrier to us working out how we can do things more effectively. I’m sure that the value and sustainability CHC workstream will look at issues like that and will help us with that as we move forward.

Integrated working as well, as Jenny said, is a key issue. If we work together, then the sum—. There’s a saying, isn’t there, that the sum of the parts is greater than the individual parts, or whatever. But the focus has to be on that person in the middle and how we work together to deliver that. They are the main barriers that I would identify.

Okay, thank you, Gaynor. Joyce, do you want to ask anything further again?

No. [Inaudible.]—answer. 

No. Okay. Diolch yn fawr iawn, thank you very much. In terms of any unintended consequences, obviously there are barriers, and there are—. Would anything further come off the back of what may be implemented here, do you think, that would have a knock-on effect for existing services?

Not particularly focused on direct payments, but, for CHC generally, I think there are a few things that are an impact of unintended consequences, really. As we’ve said already, undertaking assessments at the wrong time is a huge issue for individuals and can impact on their quality of life from that point on. The move away from assessment in acute settings is a really good idea, but we have to make sure that that individual is in the setting for that appropriate assessment at the right time. And we all know about the issues around delayed pathways of care, and the fact that people can’t get into those settings, and then that goes back along the hospital pathway as well. So, there are issues around that.

It seems to me that there’s an opportunity to look at how we incentivise care in a different way as well. Individuals whose care needs tend to worsen over time will require additional support, and that is provided and funded. We’re talking about something very different, really, in terms of what Jenny said at the start, about maintaining independence, keeping that very fragile independence going for as long as we can, and how we incentivise that in the system as well, because we tend to pay more for the more care an individual needs, rather than the focus being that we can incentivise care to perhaps drive independence and reablement. And I’m sure there are opportunities around discharge to assess to look at that more.

And the only other thing that occurred to me was that PAs are like gold dust at the moment, aren’t they? They are a very valued service, even if that value doesn’t seem to turn into a financial value for them. I’m not sure that the PAs are there. I know that individuals in receipt of direct payments would say, ‘We already have our PAs and we take them with us’, but the PAs coming through for children and young people, perhaps, who are now reaching transition and coming into adult services and will need a form of support—. We need to make sure that that access to that group of people is there, and we need to work very closely with our partners in the local authorities and the third sector on that, I think, as to how we grow our own PA workforce in Wales.

Okay, thank you. 

Could I just add something? I think the most important thing for me, really, is around getting the assessment correct, because the assessment is what drives the care plan and the outcomes, and we need to make sure that we are using the discharge to assess pathways to do that.  I walk through my hospital wards and there are patients who I look at and I think, 'Actually, you could be better cared for at home and we could complete your assessment at home.' We've been doing a pilot in Aneurin Bevan around early supported discharge, and it's had some really interesting outcomes in terms of dependency and need. And I think that focus on discharge to assess and the opportunities that the Further Faster and frailty programmes are going to give us are what will benefit this programme of work, because we need to be moving to a place where we encourage and incentivise that independence, as Gaynor has said, and use those opportunities with this discharge to assess, to assess people in their own home where their needs can be more accurately defined, and we can work with them and their family to understand the outcomes they want to achieve. It's very difficult when you're in a hospital bed being cared for, because your care environment is very different in that circumstance. So, I think there are huge opportunities with discharge to assess.

Thank you very much. Okay, Gareth, could I bring you in just to perhaps wrap up the questioning?

Thank you, Chair. Just briefly, because we're pushed for time, in terms of all the topics we've spoken about in this session this afternoon, what would be your takeaway message to us as a committee to best effectively scrutinise the content of this Bill, given your professional outlook on this, and the skills that you could pass on to us as Members, and things to look out for in this Bill that particularly affect health boards and care provision across Wales?

Thanks, Gareth. Gaynor and then Jenny.

We do not have, currently, a performance framework for CHC in Wales, so there is no formal way of knowing how we're doing across Wales at the moment. There used to be one. It's being revised, but there isn't one at the moment to go with the 2022 national framework. Developing metrics that go with this direct payments issue is going to be essential, I think, so that we can capture and measure progress and success. So, one of the big things, I think, is metrics. The other issue that I would flag, and I'm not sure what the detail on this is, is the social care service has issued an implementation plan, and in phase 1 of that plan they talk about removing CHC as a policy altogether. So, I'm not quite sure what that does to the Bill and direct payments and CHC and the relationship between that and what the intention is instead, because those individuals will still be there. We will still need to provide that level of care for people, and I'm not sure how we do that. There just seems to be a bit of tension between those two statements, really: 'We're introducing direct payments for continuing healthcare at the same time as we are saying that continuing healthcare as a policy construct will disappear,' and the national framework will be removed, essentially, so I think there's something there to flag. The only other thing I would say, and it's really going back to basics, is that the main expert in the room for the assessment is that individual themselves. They know what their needs are, they know how they can best be met, and we need to listen.

Okay. Thanks, Gaynor. Jenny.

Thank you. So, I'll echo a little bit, briefly, what Gaynor has said. The performance framework and the model are critical. It is absolutely critical that we really understand what we're trying to achieve and how we're going to achieve that. So, the performance framework and the model of delivery is absolutely important, and, I think, the needs assessment, so understanding the need of the population and how we're going to address that in the future, but really focusing, as Gaynor said, on the outcomes—so, those measurables that really focus on what are the outcomes we're trying to achieve for the individuals, but also that person-centred approach. I can't emphasise enough the need to focus on outcomes and person-centredness.

I think the knowledge and skills gap is significant from a perspective of how we prepare the future workforce, but also how we prepare the organisations, and I think we do need to look back at the evidence base. What is the evidence base from the English implementation? How can we learn from that? What is the evidence base about the impact on individuals of that programme being put into place in England? I think the final thing I'd say is about the interdependencies. This programme of work has a huge number of interdependencies across a number of policy areas, and I've mentioned a few of those already. The work that is happening in the population health management space I think is critical here, and some of the work that's happening in the frailty space around the Further Faster funding and the opportunity that gives us to focus on how we might implement this differently and effectively, and, I think, some of the work, as I've said already, around how we really utilise discharge to assess—how we do things differently in terms of looking at the discharge and assessment process and how we work in a way that focuses on how we keep people independent in their own home for as long as possible, because that is the best outcome for almost everybody. If I look at the harm that occurs once someone walks into a hospital, the opportunity to care for people at home in a way that meets their needs and is person centred, I think, is immeasurable.

Great. Thank you, Jenny, for that and thank you, Gaynor, for your time with us here this afternoon. I'm sorry that I have to draw this to a close, but I appreciate the information that you've shared with us today. Thank you very much.

Thank you.

Thank you.

Okay, we're going to move on now with our agenda in front of us. We're going to move on to item 6, which is papers to note. There are five papers there. I would suggest that we note those papers en bloc and pick up any actions as necessary. Okay, are we all in favour of that? That's fine. Thank you very much.

Item 7 is a motion under Standing Orders 17.42(vi) and (ix) to resolve to exclude the public from the remainder of this meeting, and from items 1-3 at the next meeting, on 17 July 2024, where we will be considering the committee's forward work programme, the latest draft NHS waiting times monitoring report, and the draft report on the general scrutiny session with the Welsh Ambulance Services University NHS Trust. Are we happy to move that motion? Yes. Okay. Thank you very much. We'll move into a final private session.