Health and Social Care Committee

Good afternoon, everyone. My name is Jake Smith and I am the policy officer at Carers Wales.

Good afternoon. I am Catrin Edwards, head of external affairs with Carers Trust Wales.

Good afternoon, all. My name is Kate Griffiths and I am the director for Wales for the British Red Cross.

Thank you ever so much for being with us and for your evidence paper ahead of today's session as well. Can I first of all ask an extremely wide question? Tell us what the main issues and problems are with regard to hospital discharge in Wales, from your perspectives. Who would like to go first on that?

I'm happy to kick off, Chair, if that's okay. We are told, from carers and from our network partners across Wales who are providing care and support to carers as part of their hospital discharge services, that hospital discharge continues to be experienced as happening rapidly for carers. Carers aren't always feeling as if they're fully involved in that process, that communication isn't great around that, and that the cared-for person is often discharged without an appropriate care package in place to meet their needs. So, that means that carers are having to step up. But, of course, that places significant pressure on them, and often over a prolonged period, which is not sustainable in itself. We're hearing about people who need a package of care waiting upwards of three months at this point for support, and when perhaps a person is discharged from hospital, there might be a person who is becoming a carer for the very first time, then. That places a significant pressure on them to deliver around-the-clock care in some instances. So, those are the concerns that we're hearing in particular, as a general overview around hospital discharge.

Thank you, Catrin Edwards. Jake or Kate, do you want to come in? Jake. Jake Smith.

Thank you. I would, of course, agree with everything that Catrin has just said in terms of hospital discharge often being a very unexpected and daunting prospect for so many unpaid carers, that can find, with very short notice and with very little consultation, that suddenly they may be being asked to provide huge additional caring duties that they weren't originally expecting to.

We actually held, just last week, a carers summit, and we had a session on hospital discharge, so we've been able to talk to some carers about this very recently. One of the interesting points that was raised was about the sense of moral obligation that many unpaid carers feel that they're being placed under to provide that care and to agree to a discharge that may be sooner than it should be and may potentially be unsafe. And, of course, we all know and appreciate the huge challenges that health is under, that social care is under, but it is very much unpaid carers that are being caught up in this, feeling pressured by hospitals to agree to discharge before it is safe to do so, feeling pressured to take on caring duties that they would otherwise not wish to. And, considering the Social Services and Well-being (Wales) Act 2014 has a very strong focus on carers only caring if they are able and willing to do so, that important principle is being undermined by all of the pressures around hospital discharge that are forcing unpaid carers to do more than they would wish to and as they have that right to under the Act.

Thanks, Jake. Kate, did you want to come in at all?

Please. Thank you, Chair. I think we all recognise that the pressure on health and care services at this time is at an all-time high, with waiting times for hospital treatment reaching record levels, et cetera, and hospitals still dealing with COVID-19 patients, and patients also being unable to enter or leave hospital because of workforce pressures. So, we do recognise that there are significant pressures within the system at this time, but we have some upcoming research, 'Listening to What Matters', and there was broad cross-sector agreement within that research that patient outcomes tend to be better when people are able to recover at home, as long as there is capacity to provide a follow-up assessment and support at home after discharge. And our experience as a service provider, working in partnership with the NHS, and our research show that whilst there's evidence of best practice, the hospital discharge process currently is not meeting the needs of all patients and carers, and we see that there are three main reasons for this.

The first is around a lack of communication, and that could be communication between teams in hospitals and community-based staff, but also a lack of communication between health and social care professionals and patients and carers during the discharge process. Pre- and post-discharge arrangements are not always carried out when patients felt they had support needs. And there's a lack of resources within the community, so that includes the availability of social care services in the community, and those services not having the capacity to run seven-day services, which we all, I'm sure, are in agreement are very much necessary. And there are also barriers to the voluntary and community sector being able to provide support in the community.

So, I think those are our three key areas that our research has drawn out, and we do strongly believe that the voluntary and community sector can help relieve the pressure on the health and social care sectors to improve patient flow and achieve better outcomes for people, and the VCS can also help to tackle some of that fatigue that exists within the health and social care sectors at the moment and deploy flexibly along the discharge process. So, we do have some recommendations as a result of this upcoming research that we would like to share.

Thank you, Kate, for that. And I won't ask you to share all your recommendations, because they'll no doubt be drawn out through questions from different Members this afternoon. But I'm interested in just one aspect: you detailed the issues around poor communications and the consequences of poor communication. But what do your recommendations state in that regard? What needs to change? What needs to happen to change the issues that you've outlined in terms of poor communications?

I think a primary recommendation is around the consistent involvement of families, including those with lasting power of attorney or nominated family members for patients living with dementia, and carers in decisions made during that discharge process. We know that that's challenging, particularly in an environment where visits have been restricted, for example. That has been particularly difficult to achieve, but that communication and that involvement and the consistency of involving all of those—from a carer's and family's perspective, as well as the patient's—is essential, and we really do feel that hospital teams should be working in addition with relevant organisations to help identify all of those who are relied on to provide care—informal carers included—and ensure they're linked to sources of support for carers.

What you've outlined as a solution just seems pretty basic to me, that the hospitals need to have better communications with the family in terms of discharging them. So, why on earth is that not happening now, do you think? And I can see Catrin nodding away as well. So, happy to bring Catrin in, perhaps to add to points that Kate Griffiths outlined as well, because you mentioned poor communication in your opening comments as well.

Yes, absolutely. Thank you, Chair. So, pre pandemic, of course, there would have been a discharge office whereby your discharge nurses, your social workers, perhaps your OT, and many of the third sector would have been there physically in the hospital—very present. I know many of our network partners had hospital discharge services where they were either in that office or they were out there on the ward, and, of course, since COVID, that just hasn't happened. Those services, quite rightly at the outset of the pandemic, weren't seen to be essential; they were the non-essential services and people started working from home. Now, without that physical presence there, of course it was inevitable, really, that that communication and that link that the third sector was providing between healthcare professionals, the patient and the carer wasn't going to be as strong when the physical presence on the ward wasn't there.

And in many ways, Chair, I would draw out that point around—. Building on Kate's point, of course, around communication, one of the important things around that is to recognise, of course, that whilst the third sector—that carer support service—was seen to be non-essential at the outset of the pandemic, in fact, it's a preventative service, and preventative services really are essential. It might be non-acute in the medical sense, but it really is essential and we need to be thinking about this as a strategic approach, about how we can bring back those preventative aspects of the service to better facilitate that link between healthcare professionals, patients, carers and the wider family and the wider health and care system, so that we're—

How's that done? How should that be done?

It would be great if we could have—. Well, I think we're moving now, hopefully, from a position where we're in the pandemic, where it's an acute situation, to a longer term situation. And I think, naturally, of course, our focus is on reducing the backlog, as you as a committee have heard, but we also need to be thinking about the longer term funding of preventative approaches. Some of the things that I'm hearing from my colleagues on the ground who are running hospital discharge services for carers are around—. Well, they recognise that, right now, they can't be physically present in the hospital, but they're thinking about—. So, colleagues in the Carers Outreach Service, working across Conwy, Gwynedd and Môn, are thinking about whether they can put together a third sector hub, where carers services, Care & Repair, Age Cymru and the relevant agencies join together, and at least there they're able to tap in, in a co-ordinated way, to the hospital service so that it's one person feeding in, rather than many.

I think we also need to get to a stage where we can take advantage of some of the virtual approaches that are making communication better. I've heard of some colleagues running hospital discharge services for carers where they've got a virtual ward and they're present on the virtual ward, involving carers in that space and in multidisciplinary team meetings that can happen in a virtual way. There are some ways that we can think about doing it, but we need to be taking that step back to appreciate the value of third sector and preventative services that really are essential if we're going to have a sustainable approach.

I was just thinking, you probably don't need to convince the committee of the need for better comms—we all agree on that. We're just trying to understand how that can be done. You've outlined some positions there. I think, Jake Smith, you wanted to come in. I'm particularly keen not to rehearse what's been said. We want some further examples of how the comms could be improved in terms of the discharge process. But just before you come in on that, Jake, can I just ask you as well—? In your evidence, you talked about there being a legal obligation under the Social Services and Well-being (Wales) Act to ensure that carers are willing and able to provide care and to fulfil this there must be a meaningful consultation with carers throughout the process. I think that was in your evidence paper. I'm just trying to understand as well whether you think that all involved in this process understand that. Is that why you're highlighting it? So, perhaps you could address the comms bit and that bit as well.

Thank you. So, I think, first of all, in terms of the communication, a very large piece of this issue is the unfortunate situation that unpaid carers are not being routinely identified in healthcare settings, especially through the hospital discharge process. And if carers aren't being identified through the process, then it's highly unlikely that they will be communicated with and meaningfully consulted with. Just some examples: we've had many carers say to us that the paperwork that they're asked to fill in in hospitals doesn't actually specifically refer to unpaid carers; it might talk about next of kin, it might potentially talk about paid care workers, but unpaid carers themselves are, in some cases, not actually being recorded in the process.

So, you're suggestion is that that document asking those questions should include unpaid carers. That's what you're—

Absolutely. Just as a first instance, it would be so useful if all of the paperwork that health boards were asking families to fill out, and such, specifically made reference to unpaid carers, not just, say, through being next of kin. The social services and well-being Act has a legal obligation to be identifying carers and to be offering them information, but we hear from carers that that, very often, isn't taking place in hospital discharge, and I think that that says something about the training and the awareness of the staff in the process. So, actually, if health boards could be doing more to make sure that discharge co-ordinators and the staff involved in the process were trained in carer awareness, were aware of carers and probably were fully up to date and fully aware of their legal obligations to be identifying and consulting with carers, that would go a long way towards it.

And in terms of the point that you raised about willing and able, it is only through meaningful consultation with carers that health staff will ever be able to arrive at an accurate and honest appraisal of what the carer is able to provide after discharge. Because where there isn't that meaningful consultation and that good communication, then they're discharging patients into a home where they don't actually have a full picture of what the family can provide, what services might need to be provided. So, to fulfil that willing and able principle, you absolutely need to be meaningfully consulting with carers and giving them that choice that they have in law that, very often, isn't coming out through hospital discharge.

Okay. Thanks ever so much, Jake. Thank you for that clear answer. Jack Sargeant.

Diolch yn fawr, Cadeirydd. Can I stick with Jake and Carers Wales, please, Chair? Just to come back to your written paper, your evidence suggests and highlights that, from summer to winter 2021, six of the seven health boards in Wales—that's all of them apart from Powys—and their associated local authorities announced that they would no longer be able to honour all previously agreed care packages and would be asking families and carers to step in and provide more care. That seems pretty significant to me, but perhaps you could just help the committee out and give the actual scale of the situation, with an idea of the proportion of the care packages affected and the impact that that's having on carers, and, additionally to that, whether or not there have been any additional measures put in place to support carers as a result of those health boards announcing that.

Thank you. Over August and September 2021, we conducted a 'State of Caring' survey that measured, amongst other things, the level of disruption that there was to services. And we found, for example, that only 8 per cent of carers said that day centres and sitting services for their loved ones were fully operational.FootnoteLink Only 20 per cent of carers said that NHS-funded care was fully operational and fully reopened at that point, and only 40 per cent of carers said that support from paid care workers was still fully operational.

This data was, of course, gathered in August and September 2021—many, many months after the end of the previous lockdown. So, it's very concerning that we were still picking up then widespread service disruption. And actually, in that survey, two thirds of carers—66 per cent—said that they expected service disruption to continue into 2022. So, unfortunately, there is also widespread pessimism that services will be restored, because, so many months on from lockdowns, it just hasn't really happened. When the health boards were putting out those statements, as well as our initial concern that they were asking already exhausted unpaid carers to provide more care—. Because, for example, research released for Carers Week in June 2021 found that 72 per cent of unpaid carers in Wales hadn't been able to take any breaks whatsoever since the start of the pandemic over a year previously. So, we were very concerned that health boards were asking even more of unpaid carers, but particularly concerned that these statements didn't give any form of timescales or reassurance of when care packages would be reinstated. So, the health boards talked about this as an extraordinary and temporary situation but gave no indication of when packages would be restored. And we haven't had any indication that they have been better at communicating with carers on a one-to-one basis, and that means that carers are already having to provide more care with less support—it feels like an open-ended situation. And, no, we're not really aware of health boards introducing new measures to try and mitigate the additional pressures they've put on unpaid carers.

Thank you for that. That's very useful, actually. The start of your answer leads me on to my next set of questioning. You said there that the data you collected for us was from August and September, about the availability of support services, and perhaps, on the back of that, there is an expectation from some that disrupted services would continue into 2022. Do you have any evidence to suggest that is the case? And, if that is the case, then what needs to be done? What can health boards do and what can Welsh Government do to address the problem? And perhaps I can open that up—. I'll start with you, Jake, but perhaps I can open that up to other witnesses as well.

And just because we're a little short of time, just perhaps concentrate on the what-needs-to-change aspect, because I'm just conscious of time as well.

Sure. Of course, Chair. So, what needs to change is the Welsh Government needs to work with health boards and local authorities as a matter of urgency to be restoring these disrupted services as quickly as possible. So many other aspects of society have been opened up in recent times, but we just haven't seen that with unpaid carers. So, I think there's a strong role for the Welsh Government in providing that impetus, but also the funding for local authorities to do so. They've been given a quite generous funding settlement recently, but we need to see that monitoring and that direction from the Welsh Government to make sure it translates to the restoration of carer services on the ground.

Thanks, Chair. Just to open the question up—I'm conscious of the Chair and the time—is there a measure that could be implemented really quickly to help take the burden off that, or is that too much of a question to ask? Perhaps, Kate, or, Catrin, you would like to come in there.

I'd like to come back with a really urgent and rapid solution to that, but I think it is a systemic problem, isn't it, around the social care pressures. I absolutely welcome the bonus that we've heard being delivered for paid care workers and the introduction of the living wage. Unpaid carers tell us that the most important aspects that they'd like to see changed—. So, in a recent Carers Trust survey, we found that the three big issues that would affect carers would be: better finances, reducing their financial hardship; and then, secondly, more breaks, more respite; and thirdly, better care for the person they support. And that absolutely demonstrates the relationship between unpaid caring and paid care work. So, I'd completely agree with the points that Jake made around that funding going from local authorities to the paid care workforce, to help relieve pressure on unpaid carers, to make it a sustainable approach for them and to reintroduce those respite breaks. So, just to come back, Jack, on perhaps an urgent or rapid change that we could make, we could be thinking more about the respite options that are available to us, even within some COVID restrictions. Certain day centres can operate safely, and we could see an introduction of more respitality options.

Okay, thank you. And just briefly, Kate, and then I'll finish there, Chair.

Certainly. Some very quick points: I suppose the first, really, is around updating the current guidance on hospital discharge so that hospital discharge teams check what support family and carers can provide and build that into the discharge process. I think that's something that could happen rapidly. I think the other element is that—certainly our recent research has found this—communication on discharge or even pre admission is not always there. So, the COVID-19 hospital discharge requirements in Wales emphasise the need to provide information leaflets, but, from our research, we've seen that that doesn't always happen. And where it does happen, those leaflets don't always include a point of contact, locally. So, actually, those are some quite quick wins, I suppose, in terms of solutions that could be made relatively quickly and improve the discharge process for people.

There is also a wider issue around knowledge of the discharge to recover then asses solution. That was implemented at pace during the pandemic, understandably so, and the right thing to do, but it has meant that knowledge and interpretation of that guidance is variable. So, I think there needs to be guidance and tools for hospital teams and discharge teams to better determine the appropriate pathways for patients.

Thank you, Kate. That was very useful. Chair, I'll leave it there now.

Thank you, Kate. Thank you, Jack. That's a helpful answer. Rhun ap Iorwerth.

Thank you very much, Chair. And, Kate Griffiths, if I can stay with you for a moment, you refered to the discharge to recover then assess model. What needs to be strengthened around the guidance on discharge to assess?

Thank you. I think there are a number of elements. The first, as I've just mentioned, is around the communication around the guidance and the tools. I think we would suggest that national policy should be amended or complemented with guidance that includes advice for hospital staff around how to determine appropriate discharge pathways for patients, building on recent complementary guidance, such as the 'Home First' discharge to recover then assess model, which was published just in January. So, I think that there are some elements there. But it's also important to note that, when we looked at our survey, we did actually find that there is quite a significant proportion of discharges that actually don't fall into the criteria required for that specific D2RA pathway, and therefore we're seeing quite a lot of discharge needs not necessarily being picked up because they're not following that specific pathway. So, I think it does come back to guidance and tools specifically, but also ensuring that patients who are placed on the D2RA pathway have appropriate access to assessment following discharge. So, that might need to involve updating the pathways policy so that it's clear where an assessment is required following discharge, and then, again, complementary guidance around that to ensure that there is capacity within the community to carry out assessments post discharge.

And you're happy that it's a lack of understanding of those pathways and the requirements of those pathways, and nothing more dangerous than that at play here—the interaction of financial responsibilities between different people and so on. It's just a lack of clarity that's allowing this to happen.

It's a lack of clarity, it's a variation in implementation across health boards and across hospitals, and it has to be said that there are workforce pressures, as we're all very familiar with, that actually, I think, are meaning that, potentially, those pathways aren't always implemented in the ways that they are intended to because we are working within systemic pressures around workforce that are limiting the effectiveness of those pathways.

So, I think they're the right pathways. I think it is about embedding them and understanding them, and having teams that are familiar with them and have the appropriate guidance to support them. But it's also about making sure that we have the capacity to deliver. I really do think that the assessment post discharge is an important element, and ultimately one of our recommendations within our report is that we do want to promote the five-point independence check. It's a holistic check of a person's practical, social, psychosocial, physical and financial needs prior to discharge, so that it can all be incorporated within that pre-discharge assessment process.

And from your point of view, Jake Smith, that the carer too is assessed is something that you've referred to already.

Absolutely. Carers, of course, have a right to have their needs assessed under the social services Act, but we hear from many carers that they're not being offered that assessment before hospital discharge takes place. Especially in a situation where health boards are asking carers to take on more duties because of insufficient services, it's even more important that those assessments take place.

Another point I might quickly make in terms of assessments is that, in many cases, of course, the patient in hospital might themselves be an unpaid carer. Public Health Wales released some research in November talking about how unpaid carers, even controlling for other socioeconomic factors, face poor health. If an unpaid carer is stuck in hospital because of the problems around discharge, it raises the issue of who is caring for the person who relies on that unpaid carer. Unfortunately, we have quite a lot of evidence that shows that emergency and contingency planning, which should feature in carers' needs assessments, very often doesn't, so you have the situation where carers themselves might be in hospital for an extended period, and because their carer's needs assessment didn’t cover contingency or emergency planning, there could be a quite dangerous situation with the person who relies on them, at home or in the community. So, it's so important to get assessments right and to make sure that all carers are receiving them.

If I could come to you, Catrin Edwards, the written evidence that we've had from you—and thanks for that—says that the policy of discharge to assess is causing anxiety for some carers, and financial concerns and eligibility around NHS continuing healthcare is part of that. Could you explain more about those concerns and some of the things that could be done to mitigate them?

I'll just take a step back, if I may, and mention the fact that the discharge to assess policy is an assessment of the needs of the patient, but then the assessment that's made of the carer is an assessment that comes under the social services and well-being Act 2014, which is different. As Jake mentioned earlier, what's important about that is identifying that there is a carer in the picture and in that system in the first place. It's important that we do continue to ensure that we do identify those carers in the first place.

I'll also say that our carers services have told us that they are having fewer referrals for carers at present, but that those carers who come to them have more complex needs. So, something's happening there in terms of the system—that we aren't identifying enough carers, but when we do identify them, their needs are more profound.

In terms of the discharge to assess policy, and how that works in terms of residential care settings such as care homes, we've heard from carers that—again, this comes down to communication—communication doesn't happen during the process of discharge, they're not aware of what's happening to them, and because COVID has meant that we're trying to discharge very rapidly, that conversation or choice isn't emerging in terms of where to place that person when they are well enough to be discharged from hospital. So, they go to the first place where there is a space for them, of course. We understand that that's important in terms of pressure, but there are broader concerns, aren't there, in terms of the carer.

We've heard several examples where the patient has been discharged into a care home that is a long way away from the carer, or the carer isn't aware of the implications in terms of their finances in terms of that care home. So, the main point that we return to is that communication. The communication that's happening in terms of the discharge to assess policy doesn't include, necessarily, the carer in that conversation. So, decisions are made without them being part of that conversation, and then there are implications down the road, which can be financial implications but can be practical implications in terms of reaching the person they're caring for in that setting.

That message is coming through very clearly this afternoon. A brief word to close, Kate Griffiths, with you in terms of the reference in your evidence to what's happening in the NHS in England at present in terms of looking at the needs of carers and the recommendation that there is a need to have this five-part independence check. How would that be beneficial in Wales? How would it look if that system was introduced in Wales?

Thank you. Ultimately, that five-part check, as I mentioned earlier, is a checklist to be used by an MDT team—a hospital discharge team—to support the conversation that focuses on what matters to the patient. It includes things like talking about and assessing a person's practical needs, their social needs, psychosocial, physical and financial needs. Our research has shown that professionals have reported inconsistencies and confusion around assessments, with examples of the same assessment being carried out in the hospital and then repeated in the community. And 15 per cent of the survey respondents felt they needed an assessment after leaving hospital but didn't necessarily receive one.

In terms of introducing that five-part independence check, that will start to bring into the conversation at a much earlier opportunity those practical and emotional support needs that feature outside of the hospital and, in particular, will start to improve that conversation and that communication that we've talked about being quite difficult to build. If you're starting the process early and having those conversations that are opening up discharge beyond being a clinically-led discussion—. Obviously, it needs to maintain clinical input, but having those other broader, social elements included creates an environment with that broader communication, and you're starting to think about the implications for carers, the implications for community support availability, access to that support on a seven-day basis. It starts to open up that conversation and broadens it. It's something that I'd very much like to see us welcome here in Wales as well.

Thank you very much. Thank you, Chair.

Joyce Watson.

I'm going to ask, very quickly because we are running out of time and we want to get the critical points in, about specific issues around discharge that you've mentioned, so I can bring them out to the fore. One of them was rushing things so that, instead of it becoming a rushed discharge it becomes an unsafe discharge, and the difference between those, particularly people being discharged at night and delays to prescriptions and medication being prepared. So, if I could have some key feedback on that so that we can put it in our report, it would be really good. Thank you.

Thank you. Can I come in again and just say that I think, again, that this is a communication issue? Under the new process, of course, the discharge planning process begins as a person is admitted to hospital. You start thinking about those checks right at the outset to make sure that the discharge happens appropriately. So, at that point, it is about identifying whether there's a carer involved, making that holistic needs assessment. A rushed discharge is not necessarily a bad thing; an unsafe discharge would mean that you hadn't consulted the carer, that medication wouldn't be available, that no-one is available at the house when somebody is returned home, et cetera. Again, I think, for me, this comes down to communication.

Can I just ask: do you think that discharging patients at night is okay in some cases, or should it be stopped altogether?

I don't think we would have a clear view on that point. I think it would be down to individual and personal circumstances as to whether the person is safe and able to be discharged at that point, and whether they are being discharged to a setting that is ready for them, is expecting them and has everything set up for them, including aids and adaptations that need to be there regardless of what time that would be.

Who else wants to come in on that? Jake Smith.

Just to add very briefly to Catrin's point, on the significant issue around unexpected discharge and people not being given much notice, and often people being delivered home with the carer not having had any notice in advance that this was going to happen, this whole situation assumes that unpaid carers can put their lives on hold to then just receive the cared-for person at the drop of a hat. But, of course, unpaid carers have jobs, they have children, they have hobbies, they have lives to maintain, and they can't be expected to, essentially, sit by the phone 24/7 and pick up their loved one at a moment's notice. So, we would say that, as well as all of the very important points about whether or not it's a safe discharge, the lack of communication and unexpected discharge also has significant impacts on the carers' lives outside of caring.

Joyce, any further questions from you? No. Thank you. Gareth Davies.

Diolch yn fawr iawn, Gadeirydd, and good afternoon to all the witnesses this afternoon. I just want to use my section of questions on the role of the third sector. I'll throw the first question for everyone, really, to try and establish a view on what role the third sector should play in the discharge process and any improvements you'd like to see in the current arrangement. And just to consider as well at the bottom of that, what would be the challenges to those being achieved in the environment that we're currently in at the moment. So, I'll throw that open to any takers, really.

Who'd like to come in?

I think the third sector is in a really unique position there, isn't it, to support broadly the health and care system in a sustainable way. In terms of hospital discharge, what we need is to address the needs of the individual that's being discharged, but to do that, we need to look at the family, at the carer situation. So, we need to approach discharge not only about that patient, about that individual, but in the wider, the more holistic sense. For me, that's about prioritising the strategic approach that we can take across health and care to look at prevention, to commission for prevention, to see prevention as an essential service within our health and care system. Hospital discharge is, in many senses, the microcosm of that broader concern. But, the third sector offers that really valuable opportunity to make connections. We're nimble, we're dynamic, we're flexible, and we are able to refer. We have a good knowledge of community bases and assets, and we connect from one place to the other in a way that perhaps our healthcare settings at this point don't have the capacity to do, but they need to be making those referrals to us, speaking to us, communicating with us, so that we can do that work that we're best placed to do.

Any other views? Thanks for that, Catrin. Anything from Jake or Kate?

Jake wanted to come in, I think. Jake.

Thank you. So, the third sector, of course, can play a really useful role in terms of helping unpaid carers manage with the discharge of a loved one through providing information and advice, be that condition-specific charities with advice about caring for them after discharge, especially if they're receiving less help than they might have otherwise from a health board, or an organisation like Carers Wales or Carers Trust Wales, who can advise on general issues for carers and their entitlements and such. The third sector can also be really useful in terms of—. An issue that springs to mind is home adaptations and the great work that an organisation like Care & Repair Cymru do.

What are the challenges and the impediments to that? Well, first of all, much of the third sector exists on short-term funding settlements, and they might only be one, two or three years' long. That means, of course, there is high turnover of services, but it also makes it harder for people in healthcare settings to signpost people to third sector services, because the service that existed a year ago might not even exist any more. Another issue as well is that it's so important, therefore, to make sure that staff involved in hospital discharge are adequately informed and knowledgeable about local services and the third sector support that might be on offer. So, there is also a piece around making sure that staff in the process can adequately inform carers about the third sector support that may be available.

Thank you. Kate, did you want to come in, or—?

I would second, actually, those comments that Jake just made—absolutely. It can be awareness of the resources and services provided by the voluntary and community sector, but, yes, absolutely. There is this ebb and flow of those services because of the nature of the funding attached to them. So, longer term, more sustainable funding really allows the sector to be far more responsive, but it also means that the partners that we work with are more familiar with those services and develop relationships and have more of a history and an understanding of the services on offer, but also the impact they make. Ultimately, we do want to shift the direction and the prioritisation towards, ultimately, prevention. And as a sector I think we're well placed to do that and to be able to respond to needs so that they don't escalate into demand on health and social care. Again, that comes back to funding of the sector and its ability to be able to progress in that direction on a much stronger footing in future.

Thanks for that, Kate. My final question is probably best directed to yourself, as the British Red Cross says that the majority of patients will be discharged without any further formal support, and we've found out that people aren't always managing with informal support networks, or informal support networks aren't always there, so do you have any more information about that, or views on the solution to these problems?

I think we're going back to the main crux of what we talked about several times already, which is communication. It's about that discharge documentation, that discussion that happens between a multidisciplinary team within the hospital and involving other agencies as well as the patient and their family or carer as well. So, I think that that's the root and the solution; getting that right means that ultimately those issues that we see later on down the line aren't necessarily coming to the fore.

In terms of, yes, those—. The discharge to recover then assess pathway, it doesn't apply to all patients who leave hospital, so we are going to see a number of those patients who are leaving without having that very comprehensive assessment, so we would be recommending that anyone leaving hospital undergo that five-point independence check, so that there can be that broader assessment of need. So, yes, as I say, communication is key to all of this.

Yes. I just wanted to come back on communication in particular, because I suppose if the third sector don't feel valued as part of the MDT, the multidisciplinary team, that's going to jeopardise effective communication, isn't it? So, I'm just wondering: do the third sector feel valued in the MDT, because my experience is that they sometimes don't, and what would go some way to improving that?

I think there's a lot of variation, in all honesty. In some areas, there are quite well-established relationships between partners in the sector with health and social care teams. Catrin mentioned earlier the approach around using a hub, so having partners across the third sector within a hub model, so, actually, as a statutory provider, if you're working as part of a hospital discharge team, who do you go to to connect with, and how do you make sure you reach across the sector in one go, and that hub approach is a really useful tool to be able to do that.

There are some really strong examples of very well-engaged teams. I'm certainly aware of the Pembrokeshire intermediate voluntary organisations team service, which is down in Pembrokeshire, which has a really good integration between the voluntary community sector and health and social care, and it's a really shining example of where it works very well; I think there's a lot that could be learned from there. But I think, in other areas, the interaction isn't as routine and familiar, and, on that basis, it's difficult. When, let's face it, health and social care staff are very busy, how do you find the time to build those connections and make those relationships, so it becomes a natural part of the conversation around discharge?

Diolch. Thank you, Chair.

Jack, you wanted to come in. Jack Sargeant.

Just very briefly. We hear in pretty much every evidence session we have, in certainly this inquiry, and perhaps most inquiries, that communication is pretty poor. There are obviously some examples of good pockets of communication, and best practice isn't shared as well. I'm just trying to gauge, really: have the communication levels always been this bad, or has something happened that's changed it? Has the pandemic changed it? Has something else changed it? What is the case here, or is that too much of an open question to ask?

Can I come in on that point? And just picking up on the idea of the MDT, so, whilst the question was around the third sector involvement in the MDT, in preparing to gather this evidence, I spoke to several carer support agencies who were telling me about carers who were involved in that MDT, and that was physically on the ward pre pandemic, and in that case, of course, it is the pandemic that has made that a difficulty. And the third sector were then the low-level advocacy that that carer needed to be able to speak their own concerns and to put forward their own needs and what they were willing and able to do, as we know around assessment.

So, the pandemic is the issue that stopped that, where the MDT is physically present on the ward, but, of course, we know from community colleagues that, actually, MDTs work really well when they're done virtually, if you have somebody that's able to facilitate that. So, there's no reason that—. Perhaps it might be impractical to think that every MDT on a hospital ward around discharge would be done virtually, but I'm sure there can be circumstances where we could involve carers, the third sector and all those professionals who aren't able to be physically present on the ward in that MDT, which would be—. It's one of the things about the pandemic that's been positive, that we've become used to that virtual approach, and, in my view, we should be extending that where we can to involve the third sector and carers who need to be part of that conversation around discharge.

So, is it a case of sharing perhaps best practice better, then, rather than starting from scratch?

It absolutely could be. It's happening in some places, so I'm not aware of reasons why it couldn't happen in others. Yes, it's about roll-out.

Okay. Thank you, Chair. Thanks, Catrin.

Thank you, Jack. And Mike Hedges.

Diolch, Cadeirydd. Two quick points from me. I heard what Jake Smith said earlier about funding and annual funding. Has the move to three-year budgets been of any benefit to you?

I'm not aware of what impact it's had on the ground in terms of services health boards can refer to. Longer term funding, be it of three years or longer, will always be of benefit, but there's still that lever of churn and turnover in those services. But we don't have any specific data on that point.

What I meant was specifically about third sector organisations. As people working in the third sector know, just before Christmas, three months' notice is given fairly regularly to staff because there's no continuity of budget certainty, and then when they get the money then the redundancy notices are taken back. I'm just wondering whether having three-year budgets to the third sector will actually help them. I've got a 'yes' from Kate.

Can I come in there? Thank you, Chair. We are actually starting to have those conversations now with statutory commissioners, which is really positive. So, it's trickling through, but I think it's about understanding how that funding arrives and how it's managed, and, from a statutory perspective, getting to grips with that change in funding approach. It will be of immense value, and it's a really positive move, definitely, in the right direction from a sustainability perspective, but also in terms of the sector being able to strengthen those existing services. So, it's very much welcome. And, yes, certainly from my perspective, we are starting those conversations with some of our commissioners already, which is good. We hope for more.

Can I come in at that point as well? Just to say that, absolutely, longer term funding is really helpful in terms of being able to plan and deliver services. We've recently heard, of course, that the regional integration fund is moving the ICF from that shorter term to a five-year funding arrangement. There'll be many hospital discharge services that will be funded through that position, and that's to be welcomed, of course, but I'd also say, above and beyond the idea of sustainable funding or longer term funding approaches, of course the third sector needs to be involved at that strategic level in the planning. So, it's early conversations, pre-commissioning conversations, to ensure that commissioners understand what the need is and what's available and how we can be part of that solution together as part of the health and care system.

And finally from me, I'm very keen on reablement. Too many people come out of hospital, they get sent to a care home, they were okay before they went into hospital, they've lost capacity and muscle strength when they were in hospital, they're sent to a care home or they're sent home and they get carers, and nothing is done to reable them to get back to the state they were in before they had their knee mended. What I'm asking is: is there more you as a third sector can do in order to engage with the statutory sector to increase reablement?

Can I come in there? The short answer is 'yes'. There absolutely is more that we could do. As a sector, we provide regulated services as well, which does mean supporting people with personal care so they can return home from hospital, rather than to a formal care environment. So, yes, there is capacity to do that. We are in the same challenge across the sector, from a health and social care perspective, in that the workforce availability is quite a critical issue. But, yes, there is more that could be done; there is more that I think the sector is keen to do to be involved in, in that respect. But, yes, there are some challenges around it that we will have to navigate.

Thank you. Thank you, Kate. Can I just ask the witnesses, finally, just to give us, in bullet-point form—so, no more than bullet-point form—your key messages in terms of recommendations that you think that we should be presenting to the Welsh Government? Who would like to go first? Catrin, you look like you might want to go first.

Diolch. Improving communication between healthcare professionals, the statutory sector and carers and the cared-for person. Longer term funding and sustainability, involving the third sector in planning so that we're funding prevention as well as acute need. And, to be bold, to trust us, to involve the third sector in delivery. We're key elements in involving the family and the carer in hospital discharge and wider across the system; involve the third sector and draw on our expertise.

There we are. To be bold and to trust you. Yes, absolutely. Jake Smith.

Training for staff in health boards to make sure that they have the knowledge and are able to routinely identify unpaid carers, so that unpaid carers are seen and are meaningfully consulted with throughout the process. Health boards should also be looking at reviewing the information that they provide to unpaid carers to make sure that it is effectively conveying their rights to support and to assessment, so carers at least go through that process with high-quality information that will, then, enable them to care, should they choose to.

At a time when health boards are reducing the amount of support that they provide to unpaid carers and sometimes discharging people with very little or no support, then there needs to be more flexible use, for example, of direct payments, which enable unpaid carers to source alternative forms of support.

If unpaid carers are going to be taking on more care because of the discharge, then there needs to be proper training for those unpaid carers on things like medicine management and manual handling to actually help them to manage. Because if unpaid carers can't manage and their health and well-being continues to deteriorate, not only will their loved one be back in hospital before too long, but the unpaid care worker will probably be as well. So, that failure to adequately support unpaid carers is only storing up problems for the future.

Thank you, Jake. And, Kate Griffiths.

My five points would be, firstly providing all patients with a leaflet and information about discharge when entering and leaving hospital, and that is within the current discharge guidance, but it needs to be implemented by the hospital discharge teams. Secondly, improved communication. We've talked a lot about that today, so I'm not going to expand on that any longer. Thirdly, provide hospitals with the guidance and tools that are needed to better determine the most appropriate discharge pathway for patients. Fourthly, it would be to update the current discharge guidance so that holistic checks—those five-point independence checks that I referenced earlier—are used to support conversations with patients, families and their carers, and to ensure that they have the support that they need at home. And then, finally, the fifth point would be around increasing investment in community-based support to address some of those gaps that we are seeing in provision, including seven-day services, so making sure that we have weekend coverage.

Thank you, Kate, and thanks for summarising those key messages at the end—that was really helpful. And thank you also, all, for your evidence papers, particularly the examples, which I thought were helpful, that you presented in your evidence from carers and others. That was helpful to see as well, to help us understand the issues. So, diolch yn fawr iawn. Thank you very much. Thank you for your time, all. We'll have a 10-minute break and be back at about 14:13.