Health and Social Care Committee
HSC(4)-18-12 paper 1
Inquiry into Residential Care for Older People – Written Evidence from the Deputy Minister for Children and Social Services
Context
1. Social services are at the heart of Welsh public life supporting 150,000 citizens every year to achieve their potential and to help make them safe. Many of these services are provided in partnerships between social services, housing, health and education. The story of social services in Wales has been a positive one over the past ten years, with the range and nature of service provision having adapted to the changing needs of the people they support. However, our society continues to change and social services must also change in response. There has been and will continue to be shifts in the public’s expectations of social services and a desire for people to be able to live independently in the community as far as is possible, however, there will of course always be a need for residential care for some individuals. Local authorities and the NHS, are responsible for commissioning good quality, appropriate residential care to meet that need. Our role as the Welsh Government is to provide the strategic direction and framework within which residential care can flourish and rise to that challenge.
The Sector
2. As at March 2012 there were 694 care homes in Wales registered with the Care and Social Services Inspectorate Wales (CSSIW) to provide accommodation and care to those aged 65 years and over. In total these homes provided 23,234 places with 11,577 places registered to provide personal care only (ie assistance with daily living such as washing, dressing and toileting) and 11,657 places registered to provide nursing care.
3. The sector is made up of around 86% private and independent providers and around 14% local authority providers. This high ratio of private and independent provision is one that has built up over time since the community care reforms of the 1990s. Homes range in size from small scale settings through, more frequently, to larger multi-purpose settings including some accommodating over 100 residents in small units.
Demography
4. In 2010 the number of people in Wales aged 65 years and over stood at 558,000 but this is projected to increase by around 306,000 (55 per cent) by 2035. This significant increase is driven by increasing life expectancies as a result of improved healthcare and increased longevity. Both factors will continue to contribute towards a growing number of people in Wales in the 85 years plus age group which is projected to more than double again by 2033 to reach 5 per cent of the total population i.e. 160,000 in Wales. National Statistics projections suggest a twelve fold increase in centenarians over the next 30 years
5. While many of these older people will live long, healthy, independent lives, many will develop a social care need in later life. The trend in residential care provision over recent years is for individual to enter care at a later stage in their life and with more complex care needs. As such, where older people’s needs increase, and become more unpredictable and complex, residential care (often with nursing care) can provide a more suitable and safe option. The provision, therefore, of good quality residential care that meets increasing care needs will remain an integral part of our social service provision. Residential care remains key in ensuring that the long term care needs of the most frail and vulnerable people in our society are met in a safe and responsive manner.
6. In terms of the needs of older people generally, phase 1 of our Strategy for Older People took the United Nations Principles of independence, participation, care, self-fulfilment and dignity and raised the profile of their issues and concerns. It promotes healthy ageing, moving away from a negative image often associated with ageing. At the time it was the only strategy of its kind in the UK. Phase 2 is building on the achievements of the first phase and focuses on economic status, general well-being and independence. The Programme for Government makes a commitment to undertake a review of the Strategy and to put in place proposals for a phase 3. A copy can be found at:
Tackling the Challenge of Residential Care
7. In response to our changing expectations as a society and the challenges of meeting these, the overall provision of residential care will need to diversify and evolve. Future residential care provision will need to reflect our expectations in terms of physical design and facilities, together with a focus on new and more novel models of care and support. We will also need to promote a more multi-disciplinary, multi-professional approach to the development and delivery of care within a range of residential settings that can respond to future demand.
8. We are already responding to emerging trends by taking a multi-pronged approach to shaping the future provision of residential care for older people in Wales. This is being achieved through prevention (to maintain independent living in the community as long as possible), better commissioning (to provide greater stability for the sector), diversification of provision (to reduce the risks inherit with public services being provided by non-public bodies) and improved regulation (to ensure good quality, safe services). Our White Paper, Sustainable Social Services: A Framework for Action, sets out our overall vision and practical approach to the transformation of social services in Wales, supported by our planned Social Services (Wales) Bill. The White Paper can be found at:
http://wales.gov.uk/topics/health/publications/socialcare/guidance1/services/?lang=en
Consequently our current and planned activity to shape this agenda is through:
Prevention
9. We have already invested in dedicated development of reablement and other preventative services across Wales through funding provided in connection with continuing NHS healthcare. In total £37.5 million is being provided to support a range of local projects partly aimed as reducing the reliance on residential care and promoting older people’s ability to live independently in the community. This is coupled with the Telecare Capital Grant where we have invested over £9 million in improving telecare services across Wales with nearly 20,000 people now living more independently in their own homes as a result. We have also invested £12.5 million to improve the infrastructure of community equipment services. There are now 11 formal partnerships with pooled budgets between health and social services operating in Wales. This investment is in addition to that which local authorities and the NHS are making at a local level.
10. Sustainable Social Services places reablement at the heart of our approach and we will introduce a requirement for reablement services to be provided across Wales, planned and commissioned on a regional basis. These will be led jointly by social services and the NHS. The Social Services Improvement Agency will identify good practice examples of integrated assisted living services and ensure that these are shared across Wales via their learning and improvement networks.
11. Through the Social Services (Wales) Bill we also plan to provide Ministers with the powers to make regulations or issue guidance requiring local authorities to demonstrate how they are discharging their wellbeing duties for people in need through implementation of prevention and early intervention strategies; and will couple this with powers to strengthen partnership working. This will include the use of pooled budgets and other flexibilities that will require partnerships between, and across, local authorities and the NHS.
12. We are conscious of the need for a more coordinated and improved response to the needs of those with dementia. Our National Dementia Vision for Wales (2011) outlines the commitments required to continue the development of high quality services with attention focused on joint working across the sectors and collaboration between all key agencies. This includes earlier diagnosis and more timely interventions; information, support and advocacy for people with the condition, and their carers, together with better training and research. To help promote training, support and awareness-raising the Dementia Services Development Centre Wales has been funded to improve the skills and knowledge of staff in care homes as well as those working in the community, hospitals and primary care settings.
Commissioning
13. To improve the commissioning of residential care we have issued comprehensive guidance to local authorities entitled Commissioning Framework Guidance and Good Practice on the commissioning of social services, including procurement and contracting procedures. This is set out in two parts. Part 1 is statutory guidance issued under section 7 of the Local Authority Social Services Act 1970 and sets out 13 commissioning standards which local authorities are expected to achieve. These standards centre on the development of evidence based commissioning plans and their delivery through effective procurement, setting the benchmark against which commissioning will be measured. It also sets out the responsibilities of social care commissioning teams for producing joint commissioning plans which shape services over a three to five year period. The quality and effectiveness of such plans will rely heavily on the extent to which they draw together the views and support of stakeholders including the private and independent sector. As such it stresses that commissioners need to engage with these sectors to ensure a range of service provision. Part 2 provides good practice in commissioning and procurement. The guidance can be found at:
http://wales.gov.uk/topics/health/publications/socialcare/circular/commissioningguidance/?lang=en
14. The guidance is supplemented by a Procurement Route Planner developed by Value Wales and includes a full set of on-line, step by step guidance specifically for the contracting of social care and housing related services. It is further supported by the ‘Daffodil’ database, a care needs projection system designed to assist the modelling of future service demand by analysing the prevalence of a range of health and social conditions and projecting them across population changes over a number of years within each local authority and local health board area.
15. We have taken action to bring together the signatories of the Memorandum of Understanding (MoU) established by local government with the independent and private sector so that it can be refreshed. Some providers have sought to resolve differences they have with their commissioners through the courts rather than these being resolved in partnership with local government and the NHS. Given the pressures on public services this is a situation that we simply cannot afford to continue. The MoU was development to establish constructive and effective joint working arrangements between local government and the care sector, particularly in the provision of residential care, and through the National Partnership Forum for Social Services, we will press for progress on this.
16. We have also issued statutory guidance on procedures when discharging patients from hospital to remind health and social care professionals that a move directly into residential care should not be the default position, but where this is appropriate patients should have a choice of the home they are placed in. This supports and strengthens our statutory directions and guidance on Choice of Accommodation, which ensures individuals are able to make informed, positive choices as part of the process where they are placed in residential care. The guidance is aimed at ensuring local authorities and the NHS manage choice actively and in a way which is fair and minimises unnecessary delays in hospital discharge. The guidance can be found at:
http://wales.gov.uk/topics/health/publications/health/letters/2011/letter/?lang=en
Diversification
17. We have also sought to promote and encourage other forms of accommodation and care to meet the needs of older people without the need for them to go into a residential setting. For example, extra care housing allows older people to maintain maximum independence but with the assurance of support close at hand if needed. The Welsh Government’s Housing White Paper for Wales sets out our key aims for the housing requirements of older people, taking into consideration individual’s varying requirements.
18. Over the past ten years 24 extra care schemes have been completed providing over 1,124 homes where older people can maintain their independence but with some support. A further 12 schemes are under construction or at an advanced stage of planning giving a total programme of over 1,600 homes across Wales. These schemes have been funded by the Social Housing Grant, which includes a specific allocation of funding for extra care schemes. In 2011-12, a £10 million budget was top-sliced for extra care, in 2012-13 this budget will rise to £12 million. In the longer term extra care schemes will be prioritised as part of the Social Housing Grant allocation.
19. We are also committed to exploring the role that other models of care can provide, such as social enterprises, mutuals and co-operatives. We are conducting an internal review on how social enterprises could be used to deliver social services and to consider whether this is a viable business model for Wales. The review will consider opportunities and barriers and will focus upon best practice across the UK, Europe and other countries. As part of the awareness raising and engagement on social enterprises we have met with Directors of Social Services to gain views on the role of social enterprises and social care in Wales. Engagement has highlighted substantial potential for social enterprises in regard to service transformation and impacts on individuals and service delivery. We are in the process of developing our social enterprise action plan which will form part of our further engagement proposals later this year.
Regulation
20. You will have heard from CSSIW of the plans to modernise the way in which it regulates social care. As part of our consultation on the Social Services (Wales) Bill we have set out our intention to better focus on the regulation of care settings and to use legislation to provide the vehicle to introduce new regulation which revises the regulation model so as to place greater focus on organisational governance and quality assurance mechanisms. This is so as to ensure providers themselves work within an overall framework of continuous improvement and that information is transparent and available to the public. This will help increase people’s control over the services they receive ranging from very practical issues in terms of providers being explicit about what they provide, to more formal arrangements such as those proposed in the Social Services (Wales) Bill on the Public Register.
21. We know that care workers themselves also play a vital role in the provision of any service and so we will provide for the regulation of training of social care workers in much the same way as training for social workers is already regulated. This will help to provide a more consistent standard of training that is more clearly relevant to the needs of service users and employers alike. High standards of training will support the development of professionalisation amongst the social care workforce.
22. Recognising the key role that managers of services play, we have already introduced a statutory requirement for all managers of care homes providing services for adults to be suitably qualified and registered with the Care Council for Wales to undertake that role. We have also, through the Social Care Workforce Development Programme (SCWDP), increased the proportion of staff across the whole social care sector with the qualifications, skills and knowledge they need for the work they do. This work is led by local authorities and informed by the commissioners of services within local authorities. Planned expenditure on the SCWDP for 2012-13 will total £12 million with the Welsh Government element (which provides 70% of the programme) costing £8.4 million, matched by a 30% contribution from local authorities and is intended as a supplement to employers’ own training resources.
23. In addition we are aware that the events surrounding Southern Cross Healthcare have raised concerns over the suitability of private providers of public services. In parallel with our proposals on future regulation we will also take forward other changes to the regulatory system through existing powers, to strengthen our approach to the assessment of financial viability of care home providers. This is to ensure we have the confident that providers entering the sector, or involved in the sector, are financially robust to do so. We are currently considering the options for this.
Conclusion
24. The nature of residential care for older people today has altered over the last ten and will be very different in the next decade. The needs and expectations of older people who require residential care are increasing and will increase further in the years to come. The challenge facing local authorities, the NHS, and providers is to respond to this by being flexible in their approach, by making the best use of our resources and in tackling this agenda in a partnership approach. As a Government we are seeking to facilitate this by providing the strategic and legal framework for services to grow that enable more older people to live independently in the community, either at home or in alternatives to residential care; in providing direction over the commissioning of services local government and the NHS undertake; to provide good quality services and stability to care home providers; by encouraging a diverse sector that can respond to change and; by making sure that the regulator has the tools required to ensure the provision of good quality care delivered by a good quality workforce.
Deputy Minister for Children and Social Services
June 2012