Looking ahead to the next five years, in your view what will be the three biggest challenges for health and social care in Wales?

1) Funding

The biggest challenge facing the health and social care sectors in Wales is undoubtedly the level and distribution of funding. Whilst funding for the NHS has in many ways been protected from some of the harshest cuts, Local Authorities in Wales have been cut by £1.6billion in the last five years.

It is vital to understand the impact this has on domiciliary care and other social care services, which have faced the brunt of these cuts. The Association for Directors of Adult Social Services (ADASS) budget survey found that 35% of local authority budgets in England were being spent on adult social care. Therefore it is of no surprise that cuts to budgets have fallen heavily on social care, with the budget survey for 2015 finding adult social care savings for the financial year made up 30% of total council savings.

In England around 70% of all homecare is purchased by the local authority. In Wales we believe this figure to be much higher, due to the current system of paying for care, which has resulted in a very small private purchase market.

With significant further cuts anticipated, and at a time when extensive funding will be required to implement the Social Services and Wellbeing Act 2014, it is essential that budgets to adult social care are adequately protected. Without protection we foresee the domiciliary care sector becoming unsustainable. These risks are quite substantial and are likely to have a significant knock on effect to many other areas of Welsh society, including:

· Increased pressure and costs on the NHS, as more people fall into a state of requiring acute care, in addition to having fewer avenues to leaving the hospital setting once they are ready to leave;

· More constrained eligibility criteria, as available money is stretched. Recent figures from Welsh Government show in the last year alone 8% fewer people are receiving state funded homecare. http://gov.wales/docs/statistics/2015/150902-assessments-social-services-adults-2014-15-en.pdf ;

· Reduced working conditions or size of workforce, resulting in more people in search of work and potentially reliant on benefits to live;

· More people being forced to leave the environment of their choice, the home, due to a lack of available support to help them live independently;

· Increased pressure on family carers, in turn leading to additional health conditions for this group and a higher percentage leaving work to provide care.

In April 2016, the National Living Wage will be introduced, at a rate of £7.20. Whilst an increase in workers’ terms and conditions is certainly welcome, for this measure to work the level of funding available must be reflected to cover this increase. UKHCA have calculated that a minimum indicative price for homecare to cover the NLW should be £16.70 (http://www.ukhca.co.uk/downloads.aspx?ID=434 ), to include wages, on-costs, money to run the business and travel time. Yet from Freedom of Information requests to Welsh councils, the average rate paid to providers is £14.28 (http://www.ukhca.co.uk/pdfs/average_homecare_fees_201409_wales.gif ). This figure is particularly low if we consider the rural nature of many parts of the country, meaning travel time for many domiciliary care workers can be substantial.

2) Commissioning

Commissioning is another significant challenge to social care in Wales. This is an issue which is multi-faceted , as it is not only the quality of commissioning that is vital to how social care progresses in the next five years, but the consistency of such practice and the knowledge/skills held by those who carry it out.

As outlined above, cash strapped local authorities have been given an almost impossible task due to budget cuts. In 2013/14 77% of domiciliary care in Wales was carried out by the independent sector, whereas in 2008/09 only 55.6% was delivered by the independent sector. In turn, local authorities are increasingly seeking to shift some pressure onto providers, with draconian contracts and unsustainable rates.

Commissioners must be allowed to see the wider picture of health and care, and if we are to move to an outcomes based model of care and support as part of an integrated system, commissioning across health and social care will need to be rethought and redesigned in the next five years.

Time and task driven commissioning, as remains the norm across Wales, directly opposes the notion of outcomes based support, in addition to the key principles underpinning the Social Services and Wellbeing Act 2014.

Increasingly we hear from UKHCA members in Wales who are concerned by the commissioning practices of their local authority. Reverse e-auctions for care packages, block contracts, ending sleep-in arrangements, dividing boroughs into regions without any consideration for local factors (such as distance between calls) all provide genuine cause for concern.

Over the last twelve months Powys has received a high level of media scrutiny over a series of failures relating to the delivery of domiciliary care. An independent report (http://www.powys.gov.uk/en/democracy/council-committees-and-meetings/?membs2%5Bformname%5D=documents_form&membs2%5Baction%5D=view_doc&membs2%5Bfilename%5D=rep_2015-01-06c1_5b_en.pdf) into the failings, in addition to a CSSIW inspection of the local authority, identified significant problems with the standard of commissioning in the local authority. It was reported that the necessary skills and expertise, and understanding of the locality, were missing.

As argued in the first point of this document, commissioners are on average paying £14.28 for an hour of homecare, when we believe at least £16.70 an hour will be required by April 2016 (£15.74) for services to be sustainable. UKHCA would wish to see greater openness and transparency around commissioning practices, and clearer dialogue between commissioners and providers, linked together with a joint ambition to provide outcomes based care for people in Wales.

We would strongly welcome, and actively support, the Committee in any review of domiciliary/social care commissioning in Wales. UKHCA is Chair of the National Provider Forum (Wales) and have developed a good relationship with the National Commissioning Board. Whilst this represents good progress, we would wish to see a number of considerations around commissioning in Wales as soon as possible, including:

· Improved training and support for commissioners, including the development of a professional qualification, particularly around commissioning for outcomes and implementing integration;

· Increased transparency around the setting of rates for domiciliary care;

· Better understanding of the unique nature of domiciliary care provision, particularly at a time when it is rising up the political agenda, in addition to the specific requirements of local areas and populations;

· A clearer inspection regime around commissioning. The Regulation and Inspection Bill currently suggests that CSSIW will ‘review’ local authority practices, however UKHCA firmly believe this should go further, and evolve into an inspection, as is the importance of commissioning to the whole process of providing care;

· Wider dialogue between local authority commissioning teams and local providers;

· Greater support to help local authorities understand the wider care market in their area, particularly with changing rules around charging in the Social Services and Wellbeing Act.

3) Workforce – Recruitment/Retention & Training

Increasingly, UKHCA members inform us of the challenges they face in developing the workforce required for a developing sector. At a time when the population is ageing and domiciliary care is increasingly on the political agenda to help people remain where they wish to be, at home, wider factors are reducing the number of potential candidates applying for positions in the sector.

A lack of funding and therefore low rates means too many providers are forced to offer minimum wage roles. In addition, domiciliary care providers are progressively asked to take on more complex tasks, tasks that until recently would have been carried out by district nurses with years of training. Despite the additional pressure and required expertise this requires, domiciliary care work remains low pay and low status. Media scrutiny is also often negative and unhelpful.

Many people do not view the sector as offering long term career prospects, or the potential to progress. UKHCA believes this may be a particular issue in Wales, where there is a big gap in terms of training and skills provision. In England, the Government-backed organisation Skills for Care has significant resource to develop and fund training programmes, and set national standards for skills and qualifications. Not only can this help to develop care workers to be more competent and confident, but it can be a significant factor in drawing new workers, who are keen to develop, into the sector.

Currently, recruitment costs are very high for providers, due to the extraordinarily high turnover in the sector (care worker turnover is believed to be around at least 30%). This is valuable resource that could be better used elsewhere. High turnover can also interrupt continuity of care, as it becomes increasingly difficult to provide the same carers to the same clients.

UKHCA believe the Committee would benefit from considering the following workforce points around recruitment, retention and training:

· Introduction of a national sector skills council;

· Review of funding designated for training in Wales;

· Better recognition of the training needs of the wider workforce (care co-ordinators etc);

· Training opportunities across the health and social care sectors;

· Supporting providers with recruitment drives;

· Promoting a more positive image of the sector and the work that is carried out.