Item 6 this afternoon is the debate on the Health and Social Care Committee’s report, ‘Hospital discharge and its impact on patient flow through hospitals’. I call on the Chair of the committee to move the motion. Russell George.

Motion NDM8089 Russell George

To propose that the Senedd:

Notes the Health and Social Care Committee report ‘Hospital discharge and its impact on patient flow through hospitals’, laid on 15 June 2022.

Motion moved.

Diolch, Deputy Presiding Officer. I’m pleased to open this second committee report debate this afternoon, this debate on the Health and Social Care Committee’s report on ‘Hospital discharge and its impact on patient flow through hospitals’. I’m happy to move the motion tabled in my name.

Our report made 25 recommendations and I was very pleased that the Welsh Government accepted 20 in full. Of the five that were accepted in principle, it is disappointing that a number of those recommendations were aimed at improving dementia care. Our recommendation 19 called on the Government to mandate further dementia training for NHS staff who may come into contact with people living with dementia. We made this recommendation because witnesses told us that there was a lack of understanding of the needs of people with dementia in hospitals and how best to support them in their situation in a less frightening way for themselves.

So, our recommendation 20 asked the Welsh Government to work with health boards to set up pilot schemes to trial set discharge slots for people with dementia. This would ensure that vulnerable people are not being discharged from hospital late at night when there is limited access to transport, and when they may be going home, perhaps, to a cold house, or at a time, of course, that causes distress by disrupting family routines.

It is clear from the evidence that we received that issues raised around delayed transfers of care were, of course, no doubt exacerbated by the pandemic—that's, of course, accepted—but also recognising that there are long-standing problems that existed well before COVID-19. It is, however, totally unacceptable that there are more than 1,000 people in hospital beds when they could have been discharged.

And let's just remember as well that delayed transfers of care are not just statistics. Behind every delayed transfer, there is a person who has not received the care and support they need to be able to return home or to move into appropriate accommodation. It also affects family members and unpaid carers, who find themselves in the impossible position of leaving their loved ones in hospital longer than is necessary or taking on further caring responsibilities that they may not be able to cope with, often at a cost to their own health or well-being. And the financial implications, of course, with that as well also can be significant, especially in the context of rising costs of living.

We’ve all seen pictures of ambulances queuing outside A&E departments unable to hand over patients. This inevitably affects the number of ambulances available to respond to emergency calls, leading to the unacceptable long waits for people who are ill or injured and in pain, and in some cases, sadly, with life-threatening consequences. But at the heart of this issue is the severe lack of capacity in our social care system. Patients who may be ready to leave hospital are unable to do so because there isn’t enough capacity in the care services to put in place homecare packages that would enable safe discharge. This lack of capacity, coupled with the social care workforce crisis that we have, continues to be one of the main causes of delayed hospital discharge and restricted patient flow through hospitals.

Now, unlike the NHS, which I'm sure everyone will have accessed at some point in their lives, the social care sector is largely invisible except to those who need its support; to them it's invaluable. Unless radical steps are taken to reform the way in which social care is provided, rewarded and paid for, we are unlikely to see any real change. Social care providers told us that these are unprecedented times in terms of staffing shortages. People are leaving the sector because they can earn similar amounts elsewhere for doing less pressured jobs. Until there is true parity in pay and terms and conditions for social care staff with their NHS counterparts, I think the sector will continue to struggle to recruit and retain staff.

So, it was disappointing that the Welsh Government’s response to our request for information on how it will increase recruitment to the social care sector was less than robust. While it repeated what has been done to date, it provided no real clarity or assurance on plans for the future, so I do hope perhaps the Minister could provide that detail this afternoon. It would also be helpful if the Minister could provide an update on the work of the social care fair work forum in developing a pay and progression framework for social care workers, and assurances that this work is being taken forward with the urgency it needs.

A very strong theme that we received was concern about the pressure being placed on family and unpaid carers to fill the gaps in care provision. I was pleased that the Welsh Government accepted our recommendation to undertake a rapid review of whether carers’ rights under the Social Services and Well-being (Wales) Act 2014 are being breached as a result of having to take on more caring responsibilities than they may be willing or able to, due to the lack of available services. And I welcome also the priority being given to unpaid carers by the chief social care officer for Wales in his forward work plan.

The involvement of patients and carers is central to the discharge process, and we heard from families and unpaid carers that, in many cases, this is sadly lacking. I'd like to point out or mention Angela Davies, an unpaid carer whose father had dementia, who told us about the difficulties she experienced. We also heard from other stakeholders, like Care Inspectorate Wales, about the quality of patients' needs assessments in hospitals. We heard about assessments being filled out by ward staff or social care staff with no involvement of the patient or people who know them best.

The Minister herself told us that there was room for improvement in communication with carers and families in hospital, so I welcome the acceptance of recommendation 24 and the commitment to commission a review of the quality and effectiveness of carers’ needs assessments in this financial year. I do wonder: is the Minister able to confirm whether the quality and effectiveness of patients' needs assessments in hospitals will also be reviewed?

Finally, I do want to move on to talk about the lack of consistent communication and joined-up working between health, social care and third sector bodies, which is all the more concerning because it’s an issue that has been consistently raised by other Senedd committees. Indeed, our recent report on the impact of the waiting times backlog on people in Wales found that progress needs to be made on digital records and information sharing, so that patients can receive seamless services from all parts of the health and social care system, and on the compatibility between ICT systems used in different parts of the health and social care services. Witnesses told us that clear and consistent communication between hospital-based medical professionals and primary care is invaluable, and unhelpful distinctions between clinical and non-clinical staff need to be removed if patients are to benefit from an integrated health and social care workforce.

The general data protection regulation is often cited as an obstacle to data sharing, however we were told that it is possible to have memorandums of understanding amongst statutory organisations and information governance protocols that would allow a truly shared electronic record.

I do look forward to Members' contributions this afternoon. Finally, I would have to say, Minister, that we were astonished to hear that, in 2022, not only are fax machines still being used by the NHS, new ones are actually being bought. I look forward to contributions this afternoon.

Thank you very much, Dirprwy Lywydd. Thank you to my fellow members of the committee, and thank you to the researchers and the clerking team. This is a very important report. We're getting to the heart of issues that are holding our health service back at the moment.

We're talking about patient flow through the health service. If there isn't that easy flow through the system, you have a problem. We'll start at the back door of the hospital, when a patient is ready to leave the general hospital after receiving treatment. I've sat in huddles in Ysbyty Gwynedd twice—the morning meetings where staff come together to assess where they are at the beginning of another busy day—one of the statistics discussed is how many patients are ready to leave on a medical basis, medically fit for discharge. It's striking to find that 80 or more beds in the hospital are being used by patients who don't need to be there. The same is true in general hospitals across Wales. That means a problem at the front door: cancelling treatments because there aren't beds available, perhaps, and longer waiting lists then; it means that patients arriving through the emergency department can't move from the emergency department to the ward if needed, because the ward is full. The emergency department is full, which means that an ambulance can't unload a patient; they're queuing outside the hospital; they can't respond to calls. It's a vicious cycle, isn't it, and through our work as a committee, of course, we tried to understand why this block is happening at the back door, this delay in discharging patients—why that is happening.

Now, the focus in recent years has turned to care services. There are robust recommendations in this report to this end: how to ensure that the NHS and social services departments in local authorities work better together to integrate health and care; how to ensure that integration funding is spent effectively; and how to support care staff, to pay them properly, and to support them so that we can recruit. I won't go into the details of that; they are comprehensive recommendations in the report. The Welsh Government, as we've heard from the Chair, agrees to the vast majority of the recommendations. It's a matter for us to hold the Government to account and to scrutinise progress.

There are five of the recommendations that are only being accepted in principle, and I want to turn to one of those, namely recommendation 8:

'The Welsh Government should set out how it will work with health boards and other partners to increase the availability of more appropriate step-up/step-down facilities across Wales'.

The lack of that step-down provision is a huge problem. The capacity isn't there. It has become increasingly clear to me that we can't depend on the care sector to provide that capacity and that, indeed, it's not fair for us to ask them to provide that capacity. And I'm afraid that what we're seeing here is the result of decades of poor policy. I've seen figures that suggest we had around 20,000 hospital beds in Wales at the end of the 1980s. There are very specific statistics by 1997, where there were just under 16,000. Just over 10,000 beds, that's how many we have now. What we've seen is a purposeful deliberate programme of closing community hospitals, closing beds, decreasing capacity. And now, are we genuinely meant to be surprised that there is a capacity problem, that there's a poor flow of patients through the system? The Government is turning to the care services, and says that that sector needs to be accepting patients more quickly. I'm afraid, as I've said, that we are asking them to do something that is impossible to do. Does that take away from the recommendations of the committee? No, it doesn't, not at all. We need to strengthen the care sector, we do need to fund it properly and we need to support care workers.

But by closing all of those beds, Labour and Conservative Governments, here and in Westminster, were helping to create the problem that we have today. People are living longer. More people need treatment. And no matter how much we would wish, entirely correctly by the way, for people to receive care at home, to go home as soon as possible after receiving treatment and so on, it's common sense that there are still more people who will need just that little bit of additional care after having hospital treatment—exactly the kind of treatment that can be provided in a community hospitals. So, I'd like to hear from the Minister a commitment to a new programme of creating that capacity. She'll say that there's no funding available, I'm sure, but we're talking here about beds that are so much cheaper than beds in general hospitals. We're talking about taking the pressure away from that expensive end of the NHS. Let's create a programme that will generate that capacity, rather than just asking for care services to do what I think is impossible.

I thank the Chair for chairing the committee in a collegiate manner and for the report that has come out of that. We can't, of course, look at every aspect in this short time of what is creating the problems, but one of the problems in discharging patients at the appropriate time, quite clearly, is staffing. It isn't of any value at all, whatsoever—quite the opposite, really—for patients to be staying in a hospital unnecessarily. So, it isn't conducive to the patient's physical or mental well-being, and neither is it fair on the hospital staff who, despite their very best efforts, won't be able to give the necessary attention that is required in an overly busy ward to somebody, for example, who might be suffering from a condition like dementia. The report does highlight staffing in the social care sector. It's been mentioned already. It does need urgent addressing. And I do know and understand that the Welsh Government is in that space and that they are trying to come to terms with what they're able to do, like the living wage, like extra training, but nonetheless, we cannot move away from the fact that there is a huge shortage of staff within social care, but also within hospitals as well.

And I did mention, just last week, that we need to address why it is that people—and it's mostly women—are moving out of the profession at a certain age, and it's around the age of 40. What is underneath that? Why are they leaving and leaving us with these shortages? Is it because they themselves have become carers, or is it because they've been in a system for 20 years and they completely want out? We don't know the answers, and the Minister said she would seek that, because that will help us, if we know the answers to those questions, in looking at and forward thinking about managing that turnover of staff, and also what we will need to do in terms of the numbers being trained to fill that gap, if we know that that's the age where most people might consider leaving, or alternatively offering them different contracts, more flexible working, part-time working. We talk often here about agency staff, but very often, if you ask somebody why they've gone to an agency, they will tell you it's a lifestyle choice because they can work the hours they want to work, in the places they want to work. So, we need to examine that, because all of this actually plays a part in what we're talking about here. If you haven't got the staff, wherever those staff are missing from, you cannot and will never solve the problems.

I do want to briefly talk about unpaid carers and the need for respite. We know, and there was evidence again about this, that lots of the facilities they relied on are no longer available to them, either, again, due to staffing shortages, lack of funding from the austerity that we've all endured, or whether other facilities are available but not immediately accessible to them. We've heard an awful lot about step-down community beds, and whilst I support the need for those, ultimately people want to go home. If people don't go home, they deteriorate really quickly, and whether they're in a hospital bed or a community bed, that person is still in a bed. They become very confused very quickly. They become dependent very quickly, even though they go in from an independent state of living. So, it is essential that people go home.

I'm watching the clock; I know I'm going to be out of time. But I do think that it is a massive, massive challenge, and I know that this won't be the only report of its kind. What I do hope is that the next one will show some of the progress that we all want to see.

It's a pleasure to take part in this debate this afternoon, and of course as a member of the Health and Social Care Committee, I've seen first-hand evidence from witnesses who are placed in the best position to commentate on the current state of hospital discharges across Wales.

After hearing cases by multiple people across Wales, it's clear that this is an issue that the Government must take immediate action on. However, because the Government has suspended the collection of figures since February 2020, there is no real indication of how big a problem it actually is, and if the cases that we see on a daily basis are our evidence, I expect it could be a lot worse than thought. The last figures showed that many people were prevented from leaving hospital because of delayed transfers of care, which left an additional burden on the availability of beds. This issue leads to greater implications for the NHS, as daily available beds are shockingly low and showing little sign of improving.

Since Labour took responsibility for the running of the Welsh NHS in 1999, we have seen a 29 per cent drop in daily available beds. Although these statistics are appalling, the suffering many face due to this issue is all too real. It's emerged that a patient was forced to wait for 41 hours before ambulance crews transferred care over to A&E, and considering the target time is 15 minutes, this shows that calling it a failure is too soft a verdict on this problem. And in social care, what we need to be aspiring to achieve is a system that is fit for purpose, so that safe discharges can be conducted. Currently, low staffing levels and resources are the main contributors to discharges not occurring, which in turn leads to the whole system blocking, resulting in overcrowded A&E departments and long waits for ambulances, which we see all too often.

Part of the reason for that is that social care staff levels are low and the pay and conditions the staff receive are low. Where the Welsh Government bathe in their minimum-real-living-wage glory at £9.50 an hour, it simply isn't enough. So, what I'm calling for is the alignment of social care staff pay with NHS pay scales, which it is estimated would cost the Government within the region of £9 million. I think this is achievable and I'd be very grateful if the Minister could cover this in responding to the debate this afternoon. Because let's not forget that social care don't just work nine to five, Monday to Friday; they work 24 hours, seven days a week, and work weekends, nights, unsociable hours and sleep-ins. So, I think it's high time that they were rewarded for their commitment to helping our most vulnerable and that we make a career in social care more attractive.

Turning to winter, if I may, and, as I mentioned in health committee last Thursday, I get very anxious at this time of year as the temperatures fall and the nights draw in, and it's simply due to the fact that, year in, year out, we see the horror stories on a daily basis, as pressures are exacerbated during the colder months. It's all well and good talking about winter plans when we're in the full throes of it, but what we'd be best doing is planning for the winter when the sun shines and making sure we have the correct resources in place in a proactive way, so that we can best protect our people from the health conditions that the elements of winter can cause.

I'd just like to conclude my speech today by thanking the Chair of the committee, Russell George, and the hard-working Health and Social Care Committee staff, and, of course, all the witnesses who have contributed to this report this afternoon. Thank you.

As a new member of the Health and Social Care Committee, I want to start by thanking my colleagues and the clerks and everybody who contributed to this report, and I am glad that the Welsh Government has accepted, or accepted in principle, all 25 recommendations.

As a Member with a hospital in my constituency, the Princess of Wales, hospital discharge continues to be one of the key issues, whether that's from healthcare workers on the front line or patients, or their families. I am pleased that the Welsh Government has accepted, as a matter of urgency, to act on step-down care provisions, as set out in recommendation 11. My own health board, Cwm Taf Morgannwg, have told me that hospitals have become a little too much like care homes at this point. Over 25 per cent of patients in hospitals need a step-down bed; there are simply none available. So, they are waiting on wards, some for really long periods of time, where it is not the best place for them, as we've heard from my colleague Joyce Watson. We know that evidence shows that patients start to decline if they are not discharged when they need to be, and I've also been told that the cost-of-living crisis is resulting in some of the care homes in my constituency considering having to close, which would then, of course, reduce bed capacity even further. In Cwm Taf Morgannwg, Prince Charles has access to 100 step-down beds, the Royal Glamorgan Hospital has access to 100 step-down beds, and the Princess of Wales Hospital in Bridgend has access to just six step-down beds, so I am told that step-down beds are critical for my community. So I know, and I do acknowledge, that the Welsh Government has accepted these escalating pressures, laid out in their response to recommendation 1, and have prioritised a system reset to improve the transition of patients to the most appropriate place for their care, but I would ask that when this money and these discussions are going on with the health boards, that it does make sure that it goes to all of the hospitals across that whole health board.

I'd also like to highlight recommendation 5 on the discharge to recover then assess, and the need to reduce the risk of readmission. Again, in Bridgend, we have some amazing community organisations, such as Age Connects Morgannwg, Care and Repair Cymru, who have been helping with patients post discharge, and I know, from speaking with many community nurses, how much they rely on Care and Repair to assist with recovery time at home and to ensure that patients are safe during and after leaving hospital. Bridgend has also relied on the Age Connects service for discharge for over 20 years. Not only do they provide transportation for patients from hospital, but they also get them settled back into their home, as opposed to just dropping them off at their front door, and they also follow up then over six weeks and offer signposting to other organisations. That helps with aids, adaptations, housing, meal planning and maybe introducing them to a hobby. However, due to financial constraints, these services have now been cut by the health board, so that's no longer happening. I heard from an employee of Age Connects that they were in the hospital the other week, because they were just passing out information about their services, and one of the nurses came up to them and said, 'Would you mind taking this patient home?' They said, 'Well, we don't provide that service anymore.' So, then, the patient had to wait for an ambulance to be able to take them home. So, like I said, I do understand the financial constraints, but it does demonstrate that when these services are disinvested, it impacts patients, but also puts pressure on the ambulance service.

Finally, I'd just like to end by drawing attention to recommendations 12 and 14 regarding the reform of pay and the recruitment drive for social care workers. I've been working closely with deputy leader and cabinet member for social services, Jane Gebbie, and Bridgend County Borough Council, as I've been pushing for a recruitment drive to fill those gaps. I am pleased the Welsh Government has implemented the real living wage for care workers and have stated, in their response, that this is a starting point and not an end point for long-term improvements for workers.

Bridgend council have been lobbying the UK Government as well for a 45p mileage allowance review, after 12 years since the last review, as they are finding it a barrier to recruitment. The fuel crisis impacts on social care workers who rely on using their cars to attend patients in their homes. It's disappointing that the UK Government will not review this allowance, given the fact that we're in desperate need of social care workers. These vital workers are typically low waged and are being impacted by the energy crisis in their jobs. I therefore ask the Welsh Government to work alongside Bridgend council in asking for that review by the UK Government to assist with this recruitment drive in Bridgend and across Wales. Diolch.

I recall about 10 years ago the then chief executive of the Cardiff and Vale health board telling me that in the Heath hospital—our tertiary hospital—the average age of patients was 84 years old, and I very much doubt that that age profile has changed. So, I don't think we should be blaming hospitals for the situation we're in. Everything tips up in the hospital because the other services aren't there. We are never going to arrive unless we are redirecting resources from those hospitals where we have these emergency responses. We have to therefore strengthen community nursing.

Nobody wants to spend more time in a hospital than is medically necessary for them to be there, unless, of course, they haven't got a home to go to that is suitably equipped to meet their needs for convalescence or ongoing needs. I recall one of my constituents, who was a former headteacher, who, aged 93, went into hospital because he had a urinary infection. He played absolute merry hell with me, the MP, the police commissioner, to get him out of there, as well as his family, because he just did not want to be there any longer. Obviously, being a former headteacher, he was somebody who was used to being obeyed, even though he was in his nineties. But you can imagine how somebody else, who didn't have that skill set, would just be left there to die. We cannot go on like this. Nobody wants to die in hospital at all. I certainly don't. 

District nursing is not a new idea. It was pioneered in Liverpool in the 1860s and it was an important forerunner of the NHS. It used to consist of a nurse with a bag of kit strapped to the back of a bicycle. But modern district nursing needs to use electronic case load scheduling to optimise safety and cost-effectiveness. I recall visiting the Cwm Taf neighbourhood nursing team in 2020 just before lockdown and heard how the e-scheduling system saved the senior management absolute hours of scheduling to take account of people either going into hospital or people coming out of hospital who needed to be added to the number of people they needed to deal with.

I know that this is something that the Minister is working on, and I'm very glad to hear the progress that is being made, because it really is one of the keys to changing the dial on this system. Because what it does is enable us to understand the demand for district nursing services where there is capacity or need to support the system to prevent admissions and to facilitate discharges. The team leader has got to be able to understand what demand the neighbourhood requires and what skill and volume of staff they're going to need to meet it. This has also enabled teams to safely incorporate the skills of healthcare support workers into their teams and release more highly qualified registered nurses to deliver more complex care. Understanding capacity and demand on an hour-by-hour basis can enable district nursing services to flex the workforce to meet the demand and to respond to any short-term financing issues. So, I'm really pleased to understand—[Interruption.] Altaf, did you want to make an intervention?

Thanks, Jenny. I have worked in the hospital, and apart from nursing care and apart from social services, it is the discharge summary that is never prepared on time. And that discharge summary comes from the most junior doctor in the department when it should be coming from the consultant when he is taking the ward round and discharging the patient. That should be done as early as possible. 

Thank you for pointing that out, because that was something that was picked up by Audit Wales as well, in their report. They said that less than half were recording whether the discharge was complex or simple, and less than a third of hospitals were recording when the patient was actually fit for discharge, as opposed to when they actually got out.

I'm glad to say that, today, at the Queen's Nursing Institute annual conference, the Betsi Cadwaladr nurses are presenting the work that they're doing up in Betsi Cadwaladr on how the visibility of their community services data is transforming care delivery. So, well done to the Betsi Cadwaladr team. And tomorrow, Paul Labourne, who I pay a lot of attention to because he's our integration and innovation nursing officer for primary and community care in the Welsh Government, is speaking. It's really important that we understand that the way in which we're rolling out these electronic case load systems is also being used to test whether we can capture the levels of care for every single patient visited on this system. This apparently has never been undertaken before, and so this could seriously improve our genuine understanding of what people need in the community. So, well done, Minister. 

What is also good news is that up to three local authorities that have now started using the same system with their domiciliary care services are reducing duplication, enabling better joined-up visits with neighbourhood district nursing—hooray—

Jenny, you need to conclude now, please. 

—as well as giving those services the workforce, the productivity and efficiency savings that such systems can and should deliver. This will make for a much more interesting and less stressful job and therefore will impact positively on our retention systems. So, I look forward to hearing exactly when we're going to have it out across the whole of Wales. 

Can I thank the committee for the report and for the debate today? I have to say that there are a lot of good recommendations and analysis within this, focusing particularly on the issues of discharge and how we deal with this. I think it's also recognition that this is exceptionally challenging, extremely complex and that there isn't a simple switch to solve this. There is a range of things that we need to do.

Minister, I just want to reflect in my opening remarks on the fact that the NHS, the staff within the NHS, from the clinicians and the nurses to the people who clean the operating theatres and prepare them and the porters, are performing miracles every day, and I get told that by my constituents as well. So, whilst there is immense pressure, probably unprecedented pressure, on the system and it isn't, as you were saying, simply in winter any more, it's every single day through every single year, the demands are rising on what we expect of the NHS as well as the challenges that it's facing post pandemic and the cost pressures on it, it is performing miracles, and I know that. Both my parents passed away in the last few years, and the treatment they had and the care they had over the years, in acute settings and actually when they finally went into hospital and didn't come back out, was simply incredible, and I challenge anywhere in the world to give them the care that they had and the compassion and the treatment that they had. 

What this report focuses on is something that I reflected on after I recently visited the hospital that Sarah and I share, the Princess of Wales Hospital. I met and spoke in detail and at great length with the emergency services staff in A&E and wider. I reflected with them that I've always known that that A&E unit has been from time to time commended for the best-practice approach that it has in the way that it deals with patients, identifies the problem coming off the ambulance and gets them into the hospital, and so on. It's been an innovator over many years. And they're still doing what they believe to be best practice, but the simple fact is—. Their analysis was interesting, because they feel that they are now caught in a situation where they cannot provide the standard of care that they need to, and it's not to do with what you see at the front end of the hospital, it's what you see at the back end; it is discharge.

They saw as symptoms the fact that you have ambulances queueing; they saw as symptoms the fact that you have people stuck too long in emergency services, sitting in chairs when they should be in beds, lying in beds when they should be in a ward, and so on, and when they get to that ward, being stuck in that ward too long and not being able to actually leave the hospital because of problems with discharge. They're seeing people, as has been remarked in this debate already, who are turning up—these are not people who are turning up for futile, silly reasons within emergency services; they are typically much older, they're typically much iller by the time they present. So, it's not people you can turn away.

Luke was there with me at this visit; we heard this face-to-face from front-line staff there. They're unable to get them onto the wards, unable to move them out of emergency services, unable, then, to move them from the hospital into good wraparound care in their homes—despite, by the way, what Jenny was referring to as really good practice within Cwm Taf and within the Bridgend area about that wraparound care and nursing service that we provide; despite a brilliant—I'd say the best in Wales—Care and Repair service who have got a backlog as long as your arm. So, every part of the thing we rely on for discharge back to home is creaking.

Meanwhile, as Sarah was rightly saying, we are significantly under capacity in the Bridgend area in terms of step-down care. So, I would say to you, Minister, around the issue I raised on the floor yesterday about the old Maesteg Community Hospital—much loved, much valued—here's an opportunity here, curiously, that could be one of the roles that Maesteg hospital actually provides going forward. But we need to find even more capacity within the Bridgend area.

There are definitely issues we need to tackle on breaking down the funding things that still remain after all these years between local authorities and health boards. We've sat with them—I've sat with them—and said to them, 'We know what the problem is here with lack of capacity in being able to move patients out. Put your heads together, put your funding together and decide how you're going to do it, and move on.' I know they are trying to do it, Minister, but I guess that challenge is replicated across the whole of Wales.

The point on social care levels of pay is a point that's really well made, and we've recognised this for a long time. It's good that we've moved to the real living wage in the health service and so on and so forth, and we've tried to professionalise the social care system and so on, but I would simply say that the solution to this is not to see what more we can actually say to that Minister sitting there—take away from the health service in some area to give to social care workers here or whatever. I want Welsh Ministers to do whatever they can, but this needs to be a UK-wide uplift. This needs to be right across the UK, because we know that what the UK Government gives in terms of social care settlements, in terms of that uplift, we can replicate here.

I've gone over time. There are significant issues, with staff trying to do their absolute utmost to deliver best practice and compassionate care, but what I would say is that they said to us, 'We're at the point now where we worry when we come in, because we're trying to do our jobs and we can't do it.' The problem is not at the front door, it's at the back door. How do we resolve that, Minister? How fast can we get to resolving that?

I call on the Minister for Health and Social Services, Eluned Morgan.

Diolch yn fawr. I welcome the report, and I'd like to commend the committee on its really thorough approach to the review. The report explores a wide spectrum of areas that can impact patient flow through our hospitals, and ultimately on to discharge and recovery. What we've heard today is how complex the situation is. It has got to be a whole-system approach, because unless we do it as a whole system, some part will bung up the other part. The recommendations that you've made will be valuable in helping to provide further steer and focus as we tackle improvements in this area. We've provided our formal response to the report. I welcome the comments provided today by Members, and I wanted to use this opportunity to highlight a number of key measures that we're taking forward in support of addressing patient flow and safe and timely discharge.

Now, in order to make improvements to our systems, we must look not only at patient flow and discharge, but also at community responses and admission avoidance services. So, it's not just at the end of the system, as you suggested there, it's actually, 'How do we stop them from coming in in the first place?' as well. It's the preventative, so, again, that's an extra complication, but we're putting a huge amount of resource and work into those prevention measures as well. We have work under way focused on anticipating care and to support people closer to home, wherever that may be, and we seek the best clinical response for them.

Part of that prevention strategy is within our six goals for urgent and emergency care, and that's a strategic primary care programme, so it brings in primary, secondary and ambulance and all of those. This is all being developed by clinicians and they've told us, 'This is what will work'. So, we've got six goals. A lot of it is about prevention, a lot of it is about, 'How quickly can you get people out? Where is the flow coming from?' I expect all services to use that home-first principle and to adhere to the discharge to recover then assess pathway. So, we know that it's better to make an assessment in someone's home, rather than in a hospital bed. That's something I'm really pushing on, so the reablement, for me, has got to be done in the home, so getting those occupational therapists back out into the community is really important.

It's important also that we provide same-day emergency care and support people to return home without admission into hospital. Estimated dates of discharge should be set early and communicated so that all the teams, both within the hospital and community know what's being planned, and then allocating the correct discharge to release is really important, and to ensure that we have fewer days when someone is in hospital.

Gareth, you mentioned that we should be planning for winter. I can assure you that we've been planning for winter since April. We have been preparing for this. It is now built into our annual structure. That £25 million we put in right at the beginning of the process, because we know that if you start recruiting in September, it's too late, you've got to train people up. So, we've had this huge campaign over the summer to recruit people into the care service, into reablement, because, actually, we needed them ready for the autumn. So, all of this is being prepared, the money—usually, what we do is we give a lump of money now, but it's too late, and everybody's asked us. So, we're doing that already.

As well as introducing revised pathway processes—

Will the Minister take an intervention from Altaf Hussain?

Of course.

Thanks, health Minister. Does it include an observation ward of 30 or 50 beds attached to each A&E department and district general hospital? It will be that ward that you could be using for these extra patients who are fit for discharge, but not going home.

Altaf, you'll understand that the real challenge is not actually infrastructure, it's staffing. So, that's the issue, and we know that the staffing issue is something that is challenging everywhere, but particularly social care. So, we want people to go home, we want that support in the community, and we're having difficulty with recruitment. Part of that difficulty in recruitment, I think we all accept, is that carers need to be paid more.

Gareth, I'm going to say this gently today, but I'm going to warn you that this noise is going to increase in volume every time you tell us to spend some money, because, actually, we would love to pay more to carers. But, actually, your Government has just made this a hell of a lot more difficult—a hell of a lot more difficult. That is going to be really problematic for us, and that's on top—

Will the Minister take an intervention?

I'll take an intervention.

Thank you for that. It's not just carers I was talking about, it's social care staff pay, which are completely different things. And I do understand the complexities in social care compared to healthcare, because 99.9 per cent of healthcare services fall within the NHS, whereas in social care, it's fragmented and it's public sector, local authority and private sector. And I do understand those challenges, but I think if we can really work to achieve some parity of esteem between health and social care staff pay, I think we can really be a shining example to the rest of Europe and, indeed, the world. 

Gareth, I would absolutely love to do that, that is absolutely our ambition as a Government, it's in our manifesto, that's what we want to see, it's just that your Government has just made that a hell of a lot more difficult. We've just had a £207 million bill for energy that we weren't expecting, and we've got a bit of a rebate from the UK Government—maybe £100 million—but that leaves me with £100 million gap that I've got to find from somewhere. So, that is a problem, and that's going to be a problem next year. We decide as a Government where that money's going to go. And we actually spend about 33 per cent more on social care in Wales than they do in England already, so I'd hate to imagine what state the care system is in England if they're spending 33 per cent less than us. Huw, you were mentioning that we've got to put this funding together—we have. We are putting £144 million where we expect local authorities and health boards to determine together how they're going to spend that money, and it's all in this space, it's all in this space, which is about how we address this delayed transfer of care bill. There are a couple of other issues in there as well—mental health and whatever—but a huge amount of it is about this delayed transfer of care. 

The community care capacity initiative that we have embarked on now is aiming to deliver additional system capacity from October this year until April 2023. This is something, again, that we've been working on over the whole summer, and the objective is to create extra step-down-to-recover beds and community equivalent provision, alongside taking additional measures to boost the community care workforce. And the focused effort for this winter is consistent with and complimentary to that urgent and emergency care programme of work, and I look forward to giving you a bit more detail on that, because we have been working really, really hard to prepare for building that additional community capacity over the winter. So, capacity within social care is an area that we absolutely are focused on. We are aware that the lack of sufficient numbers of social care staff is having an impact on patient discharge, and we've got a number of actions to deal with this. Additionally, each region has developed a plan to increase its community social care capacity and is co-ordinating recruitment drives at local and regional levels.

Now, a couple of people talked about the need for systems—digital systems—to work together, and what we have now is the Wales community care information system. We've already spent £30 million on this, and we intend to spend £12 million additional in the next three years. And what this is going to do is to integrate social services and community health data, so that they can have shared electronic records for health and care, so we get the systems talking to each other. We've got to get modern here; this is going to help us to get modern, and this is going to do some of issues that many of you were talking about, and getting data—why are people stuck and what is stopping them? I think that's really important. We've done a huge amount of work with local government to identify exactly why people are not moving in the system. Is it because their medicines haven't arrived? Is it because they haven't got transport home? Is it because there's nobody to look after them when they get home? So, all of those things, we've broken it all down and we're coding it and we're making sure that we know why people are stuck there.

Minister, you need to conclude now.

Thank you. Rhun, you asked about hospital beds. Well, we've got considerably more hospital beds in Wales, according to the Nuffield Trust, than they do in England. There are 270 beds per 100,000 in Wales; 170 beds per 100,000 in England. But what we're keen to do is to make sure that we get into that reablement space that you talked about. It's not just about hospital beds, it's about actually how do we get them out of hospital beds into the community.

Now, we have a report from the expert group on care, and that's going to be published soon. I think it's probably worth saying that whatever the ambitions were, we could be restricted in terms of our financial restrictions in future. So, we've just got to understand that, whatever the situation was before the summer, it has changed significantly. Julie Morgan, my colleague, has been working very hard on this as well. I think that that is enough from me, Chair. 

I have been very generous, Minister.

Thank you very much.

I call on Russell George, Chair of the committee, to reply to the debate.

Thank you, Deputy Presiding Officer. Can I thank all Members for taking part in this debate this afternoon, and I particularly thank—I think Gareth Davies made a point in his contribution of thanking the clerking team and the wider research team that support our committee’s work, so I’d like to put that on the record from myself as well.

I think that it was Rhun and Sarah who talked about the need for step-down beds, and the need to allocate funds for step-down beds fairly across health boards was a point that I think Sarah made. The Minister, in her contribution, referred to that, and I welcome some of the contribution that the Minister made in terms of building more community capacity. Also, I think that Rhun, in his opening remarks, talked about the importance of considering patient flow. I think that we do need to look in the round, and examine where the barriers lie, and of course remove and address some of those barriers.

Joyce mentioned, in her contribution perhaps why the committee has focused on hospital discharge. We had quite a discussion about this in committee: long-standing issues, social care capacity, health and social care integration, the workforce crisis that we are in. And Joyce highlighted, of course, the plight of unpaid carers as well, and some of the challenges that they have now. Joyce also put the question as well that we need to know more about why people are leaving the social care profession. I think that we know that to a certain extent, but I think that there is more that we can do to understand why that is.

Many Members mentioned those beds that—. I mentioned in my opening comments the ambulances queuing outside hospitals. I think that it was Huw who mentioned—and it was a good phrase—the queuing of ambulances as a symptom of patient flow. So, while I mentioned that, and we are all aware of those ambulances waiting outside hospitals, so patients and people who need those beds can’t get in there, there is the other side to this as well, which Joyce and Jenny referred to, about people’s health deteriorating when they are in hospital beds, and when they themselves need to go home for their own health as well, but in terms of the frustrations of people in those beds who can’t get home. Jenny gave an example of one of her constituents, but perhaps not all of those have got the skills to advocate for themselves to get home, which I think was the point that Jenny was making.

Many made the point as well about the need for people to get home as quickly as possible, but again, of course, we know that this then links to some of the issues that we have within care staffing levels. Gareth, importantly, mentioned the issues around data. This is part of the report, and some of the issues that we made some recommendations around. But he was also mentioning around the pay and working conditions as well. But, importantly, we need to make the profession more attractive, don’t we? And pointing out as well the exacerbated pressures that we will have this winter.

I thank Sarah for, quite rightly, pointing out the praise for organisations such as the Red Cross and Age Concern. I think that both the Minister in her response and Huw talked about the complex issues, and also rising demands and rising expectations as well, and that a whole-system approach is needed, which Huw and the Minister both referred to. 

In terms of the Minister’s response, the Minister talked about the need for people to get home quickly as well, but of course, people can’t get home if those services aren’t available to support them. I very much welcome, particularly as a rural constituency Member, some of the discussion from the Minister around having services as close to home as possible. I very much welcome that from a very rural perspective.

There is a huge need there for recruitment, and the drive for recruitment, and the Minister mentioned that in her closing remarks, and the huge campaign that is behind that. But what I would have liked to have known a little bit more about is how successful that campaign has been, and has that campaign been effective. I think it would have been good to know a little bit more about that. But I’m pleased with the Minister in terms of some of those integration problems I mentioned at the beginning, with GDPR and other systems working together. In my opening comments, I talked about fax machines still being not only used but bought in the NHS. It’s good to see the improvements in terms of the integration of systems are making good progress, and obviously as a committee we’ll keep a particularly close eye on that. Diolch yn fawr.

The proposal is to note the committee’s report. Does any Member object? I don’t see any objections. Therefore, the motion is agreed in accordance with Standing Order 12.36.

Motion agreed in accordance with Standing Order 12.36.