Agenda item

To present the report of External Audit.

The report of Audit Wales setting out the findings from the Auditor General’s review of care home commissioning arrangements across North Wales was presented for the Committee’s consideration.

Mr Jeremy Evans, Audit Wales reported that the review looked at how the members of the North Wales Regional Partnership Board work together to commission care home placements for older people (the term care homes being used to reflect all types of residential and nursing care homes in a generic sense). The Social Services and Well-being (Wales) Act which came into force on 6 April, 2016 requires councils and health boards to work together to assess the care and support needs of the population in their area. The Act established Regional Partnership Boards (RPB) to prioritise the integration of services including for older people with complex needs and long-term conditions including dementia. In North wales the RPB includes the statutory partners – the six local authorities and the Betsi Cadwaladr University Health Board.

In early 2020 Audit Wales identified strategic commissioning of care home placements for older people was a risk to both councils and the Health Board for the reasons set out in paragraph 5 of the report. Fieldwork was undertaken in February and March of 2021 and as the messages were drawn together it was found that the legislative and policy frameworks were leading to a way of working that is impacting on health and social care professionals and users of the services. Although a review of the Partnership Boards in Wales has not been carried out, it is anticipated that many of the finding and challenges highlighted in the review for North Wales will to a greater or lesser extent be replicated nationally.

The key messages and overall conclusions from the review are as follows –

·         Partners are working together to provide care for vulnerable service users but are carrying significant risks associated with market stability, workforce and pre-placement agreements along with a reliance on spot purchasing.

·         The RPB’s 2018 Market Shaping Statement set out some aspirations for care home commissioning which were added to by the RPB’s response to “A Healthier Wales” in 2019, however, neither of these have driven the development of a clear regional strategy for commissioning care home placements for older people in North Wales or a delivery plan to take forward the aspirations that have been identified.

·         Whilst the RPB network brings partners together to “think regionally”, its structures, largely set out by the Welsh Government, are extensive and complex, and lines of accountability need to be strengthened.

·         Nationally set fee structures are complex and result in a significant focus on cost which causes division amongst partners and has the potential to impact adversely on service users and their families.

·         Partners need to do more to demonstrate they are meeting their statutory responsibilities around the Welsh language, and the Well-being of Future Generations Act, when commissioning care homes provision and making individual placements.

Audit Wales has reported separately to Welsh Government and has recommended actions it should take to improve the framework within which regional partners operate and has challenged it to look at some of the key legislative requirements as it reviews social care and health in the Rebalancing Social Care White Paper. Welsh Government needs to assure itself that the changes it proposes go far enough to resolve some of the longstanding challenges that have been identified and reported upon - specifically the complexity of the funding models and the need for greater clarity around the operation of pooled funds; better scrutiny and accountability with regard to RPB activities and decisions and the establishment of a framework against which to evaluate the progress of the RPB in meeting well-being goals.

Whilst some of the responsibility for improvement lies with Welsh Government, it is important that partners including the Isle of Anglesey County Council, consider their own role in the process. In light of the considerable amount of resources spent on care by councils and the BCUHB, the Council needs to be assured that this money is being spent wisely and that it is contributing towards building a more sustainable care sector that provides for the different types of care for today’s citizens and for citizens of the future. To this end the report makes 5 recommendations for the councils and Health Board which are set out at the end of the report.

The Chair thanked Mr Jeremy Evans for presenting the report and findings and acknowledged the considerable work that had gone into producing it. In the subsequent discussion the following points were made –

·         Reference was made to independent living schemes and to the Council’s own Extra Care Housing provision for older people with the question being whether the development of these and similar models of care should be encouraged as being more cost-effective and sustainable options capable of addressing some of the issues identified.

Mr Jeremy Evans confirmed that the North Wales response to “A Healthier Wales” reflects a move towards encouraging people to remain within their communities for longer through domiciliary care provision and/or extra care establishments. The flipside of this is that when people do go into care homes their needs are therefore greater and require more specialised provision which few councils are able to afford close to home hence the importance of having a strategy for care home commissioning across North Wales that will support care planning. Councils need to determine what they want, to establish the balance of the types of care that they need in their care homes and to develop a roadmap that will take them from where they are currently which might mean having a greater level of general residential care than is required for the future, to where they want to be at the more specialised end of care provision.

·         With regard to the Regional Partnership Board structure (Appendix 1 of the report) which the Committee thought might prove perplexing to a service user, there was some concern at the overheads of running such a structure and concern also that such a complicated set up might be making life more difficult as regards meeting the care needs of service users.

Mr Jeremy Evans advised that the RPB structure is largely set out by Welsh Government and because it includes the seven principal partners and is supported by a range of other groups and organisations it is complex, and can be confusing. One of the report’s main findings is that although the RPB network brings partners together the scale of its structure and operation makes it unwieldy and presents challenges for the way it operates. It is an area which Audit Wales has highlighted should be looked at by Welsh Government with a view to simplification thereby improving effectiveness.

·       In noting that there is a push towards regional partnership working in several areas, the Committee wanted to know what the main lessons to be taken from the review were in terms of applying a regional working model to other service areas.

Mr Jeremy Evans advised that as regards the report, Audit Wales has highlighted the need for Welsh Government to be clear about its expectations for partnerships (the RPB in the case of the report) so as to be able to objectively evaluate their progress towards the goals set and to have in place a set of measures against which progress in delivering the Welsh Government’s aims and ambitions for a specific partnership working arrangement can be demonstrated. Regional working can be productive and effective as attested to by the North Wales Economic Ambition Board (NWEAB) a review of which by Audit Wales found evidence of strong governance, good progress in developing the programme of the Portfolio Office and flexibility in adapting to the context in which the Board operates. The RPB needs to be placed on a similar footing with good governance, accountability and links back to the home partner organisations and these are aspects the Council can help develop as one of the key partners.

The Head of Adults’ Services confirmed that the service’s experience in Anglesey supports the review’s findings with regard to placements in as much as people are entering residential care with more complex needs and they tend to remain in care for shorter periods. As an Authority, whilst Anglesey would like to develop more extra care housing provision or similar to enable individuals to remain in a homely environment for as long as possible, it recognises that there comes a point when that is no longer possible when individuals require more specialist provision in a residential care setting. The recommendations have been the subject of much thought and reflection and there is consensus regarding the general direction of travel.

Councillor Llinos Medi commenting as Portfolio Member for Social Services and as the Council’s representative on both the RPB and the NWEAB highlighted the differences between the two boards and emphasised that the NWEAB had been developed organically from the bottom up within the region in response to an identified and agreed need to develop the region’s economy whilst the RPB is the product of the Social Services and Well-being (Wales) Act. She raised questions about the ability of the RPB in its present format to be able to make the difference which the report advocates and referred to challenges and risks associated with the pooled budget approach towards care home commissioning and to the implications of additional administrative requirements and whether value for money can be obtained. Councillor Llinos Medi said that the needs of the service user has to be paramount and is at risk of being lost within the RPB’s structure. She thought that collaboration works best when it is on the basis of an agreed approach by the partners themselves rather than when it is imposed.

Mr Jeremy Evans acknowledged that the NWEAB and RPB have had different starting points and because it is prescribed by legislation the latter is more difficult to shape to meet needs locally which point is reflected in the report and recommendations to Welsh Government; (which he urged the Committee’s members to seek out for information). These challenge Welsh Government on the effectiveness and delivery capability of the RPB and likewise on the expectations for and workability of pooled budgets. Care funding models and the systems supporting them are complex because of the range of care placement types and they sit within a complicated structure that is the RPB. The report and recommendations seek to encourage councils to streamline as much of these processes as possible and for Welsh Government to ensure that its policy reform goes far enough to resolve the challenges identified so as to make the process easier and smoother for service users who are elderly and vulnerable individuals.

It was resolved to note the finding and recommendations of the report by Audit Wales with regard to commissioning care home placements, and to thank Mr Jeremy Evans for the presentation and clarifications provided.