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Rebalancing Care and Support Programme

A nurse speaking to her older male patient

Rebalancing Care and Support Programme

Consultation questions


Consultation Questions – Chapter 1 – Part 8 – Code of Practice – National Framework for Commissioned Care and Support

Question 1.1: Do you think the principles and standards set out in the Code will help to ensure Wales-wide consistency in commissioning processes and practice and reduce duplication and complexity?

It is essential that commissioning reduces complexity and rebalances care and support to focus on quality and outcomes, with what matters to older people at its heart, if we are to ensure the provision of the social care we need now and in the future. The principles and standards are a step towards this, but much will depend on local interpretation and implementation. The Welsh Government should ensure that there is a robust system of monitoring whether these aims are achieved.

The Commissioner welcomes the emphasis on co-productive relationships to secure people’s rights to be able to express their views, wishes and feelings, to participate in decisions and to be supported through advocacy to enable them to do so. As ‘experts through experience’ older people should be equal partners in decisions taken which affect them. Older people have a wide range of valuable insights and perspectives which should be brought to bear on commissioning at all stages of the process. This means that older people should be engaged, and their voices should be heard, throughout the commissioning cycle, from population needs assessment, through commissioning strategy development, service planning and design, procurement and the monitoring of service delivery, to reviewing and distilling the learning to inform the next commissioning round.


Question 1.2 Do you think the standards set out in the Code will help to ensure Wales-wide consistency in commissioning processes and practice and reduce duplication and complexity?

The Commissioner supports Standard 3: “Collate relevant and accurate data to ensure that commissioning is based on meaningful data and ensure there is sufficient analytical capacity and capability to inform robust commissioning planning.”

However, Population Needs Assessments vary across Wales and more robust data is required to assess accurately the social care needs of the population and the extent to which those needs are currently unmet. Much of the data that is currently collected under the 2014 Act relates to existing service provision, and population data is not sufficiently disaggregated by age. There is not a clear picture across Wales of the numbers, characteristics and needs of older people waiting in hospital and in the community for domiciliary care, nor of those who are living with frailty and at risk of a life-changing event which may lead to their needing social care, nor of the residents of care homes as a population group.

Forecasts of likely future need for social care tend to be based on simple age-based projections. Robust data collection that reveals the characteristics of the people using, in need of, or at risk of needing, social care is essential if we are to effectively assess and meet the needs of the population. Data collection should also include factors such as the numbers of people living alone, the provision of accessible housing, and what types of services older people want to use. It is vital also that data is collected to ensure that social care services can respond to cultural needs and language needs.

Older people also make up an increasingly important part of the health and social care workforce in Wales. In social care, in both local authority run and commissioned services, 3-4% of staff are aged over 65. However, in local authority services, around 25% of the social care workforce are aged 56-65, while for commissioned services the figure is 15%.i It is essential that data collection on the workforce enables employers to give specific consideration as to how older workers can be retained as well as attracted. This might include looking at the language used in recruitment to make it more attractive to older people, in addition to highlighting any flexible working options and other employer benefits.ii Ensuring employees can fit around their own caring responsibilities is hugely important to enabling older people to seek, return and subsequently stay in employment. Granular, age-stratified data collection on the characteristics of the older workforce should enable better tailored and more attractive employment and retention offers to older people.


Question 1.3: Do you think the requirements in relation to Welsh Language will help to bring about consistency around the provision of Welsh language services and the active offer?

Being able to access health and social care support through an individual’s language of choice is incredibly important as set out on page 16 of the National Framework for the Commissioning of Care and Support in Wales document.

However, the Framework stops short of specifying that services must be provided in Welsh wherever someone requests it, and that market management should ensure that there is a sufficient supply of Welsh-language services to deliver this. The Commissioner expects, as a minimum, older people being able to receive services in the language of their choice, and not having to be sent far from home, or even out of Wales, where they cannot do so, to receive any service at all.

The challenge to consistency is around ensuring sufficient availability of staff at different levels, specialisms and geographical areas in order for organisations to be confident in making the active offer and being able to provide the service. The Welsh Government’s More than just words: Five Year Plan 2022-27 (More than just words ( ) is positive but more emphasis needs to be placed on helping
people to develop or improve their Welsh language skills in order to be able to offer care through the medium of Welsh. ONS data cited in Annex A of the Plan shows 16% of people aged 16 or older living in Wales in employment in ‘Human, health and social work activities’ the week before the 2011 Census were able to speak Welsh. This compares with 17% across all industries. Data from the latest census is not yet available.


Question 1.4: Do you think the requirements in relation to Equalities will help to promote and improve the rights of individuals receiving care and support and carers?

The extent of the disproportionate impact on the rights of older people during the COVID-19 pandemic, specifically those living in care homes, has been well documented. Many care home residents experienced potential breaches of their human rights, including their right to a family and private life and their right to not be deprived of their liberty without lawful authorisation. Many residents continued to have their lives restricted for far longer than experienced by the rest of society.

Additionally, the Commissioner is aware of instances where a resident has been asked to leave a care home, their home, because of a disagreement about the way in which a service is delivered, leading to a breakdown in relationship between the care home and the resident’s family. It cannot be acceptable for an older person to be asked to leave their home because they or their family have sought to uphold their rights.

To identify action that can be taken to strengthen the rights of older people living in care homes in particular, the Commissioner has established a UK-wide group of expert organisations. One of the areas of exploration has been in relation to introducing a ‘rights-based contract’ in care homes. A rights-based contract would clearly set out the duty on social care providers to uphold specific rights. Such an approach would embed human rights (and other legal rights) into day-to-day service delivery, ensuring that upholding residents’ rights is at the centre of everything that staff do.

The Code of Practice refers to the seven principles of effective and ethical commissioning which underpins the Code and must be embedded within commissioning practice. Whilst the Commissioner welcomes the inclusion of inclusive coproduction within the principle of ‘Relationships matter’, equitable relations cannot be achieved without ensuring that people are informed of their legal rights and supported to participate in discussions, for example through the provision of advocacy. Similarly, Standard 1 requires Local Authorities and Local Health Boards to evidence that the commissioning of care and support services is coproduced with individuals in need of care and support. Ensuring that people working in the care and support sector know the rights that people have and that these rights are actively promoted is essential to enabling a culture of co-design. Moreover, Standard 3 requires that commissioning and resourcing decisions be based on evidence of assessment of what services will best deliver the outcomes
that matter to individuals. Again, ensuring that staff both know and actively inform people of their rights is essential to effective ‘what matters’ conversations.

The Commissioner welcomes the inclusion of compliance with human rights within the commissioning standards and that commissioners must have due regard to the principles of equality and diversity in carrying out their functions, ensuring that diversity and equality are central to the provision of care and support services. It is positive that this section includes reference to the UN Principles for Older Persons. However, it is unclear why other relevant documents have not been included in this list such as the Welsh Government’s Age friendly Wales: our strategy for an ageing society, the LGBTQ+ Action Plan for Wales and the Advancing Gender Equality in Wales Action Plan.

Effective data collection on equalities will be key to ensuring that older people’s rights are upheld. The Commissioner is aware that it is the intention of the National Office for Social Care to ensure that data is used more effectively. However, the Code of Practice does not propose to introduce additional data collection. Current reporting requirements for social services do not require data to be collected on age. Therefore, basic information on the implementation of the Social Servies and Well-being (Wales) Act 2014 and the effectiveness of care and support services cannot be viewed through the protected characteristic of age. The impact of this largely renders the experiences of older people invisible. Similarly, we do not collect data at a national level on the number of care home residents that are asked to leave their home, the reasons for this and whether the eviction was connected to a recent complaint. In a recent letter from the Deputy Minister for Social Services to the Commissioner, it was stated that the use of ‘top up’ fees or ‘additional payments’ for people requiring care home accommodation would be monitored in terms of compliance with this National Framework. However, there is no new data requirement to collect information on the number of people being asked to contribute towards a care home placement in the form of an additional ‘top up’. Therefore, systems for monitoring the extent to which older people’s rights are upheld remain unclear.


Digital inclusion and access

The Commissioner is concerned that the statement on digital inclusion and access on page 16 of the National Framework does not take account of the still significant number of older people, including carers, who do not have access to the internet or lack the confidence and skills to engage in this way – the latest figures from the National Survey for Wales show that 29% of people over 75 do not have access to the internet at home and 32% of over 75s do not use the internet.iii

Whilst increasing the use of digital technology can offer potential benefits to those who can access it, it is also important to recognise the risk of excluding those who do not want to, or are unable to, access care services in this way. The expansion of digital services must be done with people in mind. This means upskilling the workforce to preserve the human element of any means of communication and offering flexible options to carers who need to access care records.

In November 2021, the Commissioner used her legal powers to issue formal guidance to local authorities and health boards in Wales, setting out the action they should be taking so that older people can access information and services in an increasingly digital world, to ensure older people’s rights are protected and upheld.iv Local authorities and health boards were asked to provide details of the action they are taking to ensure older people can access information and services via non-digital means, and that older people who want to get online are supported to do so.v
The National Framework should include a reference to the guidance.



Despite age being a protected characteristic, ageism is an often neglected area of equalities. Ageism is the stereotyping, prejudice and/or discrimination against people on the basis of their age or perceived age. The Centre for Ageing Better’s ‘Ageism: What’s the harm?’ report sets out the range of negative impacts ageism has on everything from mental and physical health to financial wellbeing and It is essential that practical steps to recognise and challenge ageism are put in place by Local Authorities and Health Boards, including staff training and specific policies on age inclusion. This should improve the experiences of older people whether as workers or as people in need of care and support and ensure that older people have the same opportunities for care and support as other adults.
Research published by 55/Redefined and Reed Talent Solutions on the impact of ageism in the workplace highlighted that one-in-five over 50s said they want employers to have a clear strategy to address ageism in the workplace, demonstrating the important role that organisational culture plays in whether older people feel welcome.vii Despite this, however, work undertaken by the Centre for Ageing Better in 2021 showed that just one in six employers said that they were very likely to introduce policies on age inclusion in the workplace in the next 12 months.viii There is an opportunity for Local Authorities and Health Boards to take a lead on this issue.

Question 1.6: Do you think the statutory requirements and guidance in the Code will help to improve outcomes for individuals receiving care and support and carers?

The focus on service quality and the outcomes that matter to older people is welcome. The focus of commissioning processes to date too often has been on contractual frameworks and service specifications rather than the quality of life of older people receiving care and support. In the Commissioner’s view, service quality and outcomes should include:

• upholding older people’s rights;
• protection from service termination;
• ensuring that everyone has access to their own funds;
• access to independent advocacy to ensure people are able to participate in decisions that affect their lives.

It is essential that the aims of service quality and outcomes are consistently applied throughout the commissioning process, from population assessment, strategy and planning through procurement, service delivery and monitoring, and review and implementation of lessons learned. Currently commissioning intentions can be diluted or negated by the procurement process, and there is a lack of shared intelligence and joint working in contract monitoring to ensure that older people are safe, well cared for and enjoy a good quality of life, and that lessons learned are used to inform the next iteration of commissioning. Contract monitoring should gather data which indicates to what extent commissioning intentions, quality and outcomes are being delivered, and should be analysed and used to inform the next commissioning round.


Question 1.7: Do you think the statutory requirements and guidance in the Code will help to refocus the fundamentals of the care market away from price towards a value measure based upon service quality and overall cost?

The fragility of the social care market has a direct impact on the Welsh Government’s ability to drive change and, consequently, has a direct impact on the lives of older people. The Commissioner is aware of instances where a social worker has advised residents and their families who are concerned about the quality of their care not to ‘rock the boat’ as there is no other appropriate provision available. The Code should ensure that commissioners exercise their market management responsibilities to ensure a stable social care market in which people are not forced to accept poor quality care and potential breaches of their rights for fear of service termination.

The care home market is fragile partly because the arrangements currently in place for funding care homes are inconsistent across Wales, and do not always reflect the true cost of care. The care home market is being sustained by inequitable fee structures in which self-funders may be subsidising the costs of publicly funded placements, and care homes charge top-up fees – the latter sometimes explicitly forbidden in guidance – with a concerning lack of readily available redress for people who wish to dispute top-up fees.

The Public Accounts and Public Administration Committee recommended that the Welsh Government issues binding restrictions, to limit the areas where top-up fees are charged, and implements a robust independent redress system. It was disappointing that the Welsh Government rejected both these recommendations.

The Welsh Government said in its response to the Public Accounts and Public Administration Committee that it might be prepared to provide further clarification about top-up fees, subject to consideration of the Expert Group report, and would be prepared to consider changes to existing regulations and frameworks in the context of any new system.

In subsequent discussions with the Commissioner, the Deputy Minister for Social Services stated that the National Framework for the commissioning of care and support in Wales would set standards and principles for commissioning practices and bring consistency of approach to the charging of top-up fees.

Whilst the Commissioner welcomes the new National Framework and greater oversight of compliance with it, she also believes that greater oversight is needed from the Consumer & Marketing Authority (CMA) as the body that monitors compliance with consumer law.

Where individuals experience issues with enforcing their consumer rights or their rights under Continuing NHS Healthcare, it is important that the Code and the National Framework specify easily accessible avenues of redress. Trading Standards is the statutory route for redress, but local Trading Standards Departments are frequently not sufficiently skilled in this area of the law to provide effective support. The alternative, accessing a private solicitor, is not an option for many individuals due to the costs involved. It is therefore vitally important to ensure that individuals know who they can contact when an issue arises and for there to be a swift resolution in response.

Consultation Questions- Chapter 2 – Pay and Progression Framework proposals

Question 2.1 The principle of the pay and progression framework is to offer a national framework that can support the principles of fair work. Do you believe it can support that ambition and the benefits outlined above?

The Commissioner welcomed the Welsh Government’s introduction of the Real Living Wage into the care sector and welcomes the draft pay and progression framework as a further step towards improving the pay of care workers, overall terms and conditions in the sector and career pathways for those who want to progress. Providing personal care is a skilled job, and this must be reflected in policies relating to pay and conditions. Opportunities for personal development and progression need to be actively provided and highlighted so people are able to use their skills and build a career within social care.
However, pay and progression in social care can only go so far in the absence of greater and sustained investment. Parity between pay and conditions for comparable jobs in the NHS and in social care is essential.
The Commissioner is pleased that, in Wales, the Welsh Government, employers and trades unions came together in partnership to establish the Social Care Fair Work Forum and that the Forum has broadened its focus to look more widely at other areas which are needed to ensure fair working terms and conditions for care workers, including health and safety in the workforce and workforce representation in the independent sector. The Commissioner looks forward to seeing the results of Social Care Wales’ data collection on the care workforce, and of the Forum’s independent evaluation of implementation of the Real Living Wage and its effects on recruitment and retention over the coming three years.

Consultation Questions- Chapter 5 – Part 9 – Statutory Guidance (Partnership Arrangements)

Question 5.3: Do you agree that the proposed amendments to the regulations and statutory guidance will help to strengthen regional partnership arrangements and the role of Regional Partnership Boards? Do you have any other suggestions about what could be included?

The Commissioner is concerned that, although some good work is happening on the ground, including on home from hospital projects and the development of the Trusted Assessor model, there seem to be few examples of Regional Integration Fund (RIF) projects integrating health and social care. The Commissioner is also concerned about whether enough is being done to accelerate and mainstream successful models, and whether RIF-funded projects are being co-produced with local people and local communities.

It is essential that the guidance ensures that RPBs: fully take on board the purpose of the RIF to accelerate uptake of integrated service models and then mainstream into normal service provision; involve local people and local communities in project design and production; spend RIF funding appropriately; report robust qualitative data as well as quantitative data on RIF-funded projects; ensure accountability for the results.

The Commissioner is also concerned that, despite the intention to offer three-year funding for voluntary and community sector organisations from 2022, with the possibility of this being extended by a further three years, there is a mixed picture of longer-term contracts being offered to third sector organisations. The cost of living crisis means that the financial sustainability of local providers is even more precarious than previously. The guidance should ensure that longer-term contracts and funding flow quickly to grass roots organisations to ensure the sustainability of services. RPBs should work in partnership with the voluntary sector to remove barriers to small local service providers’ engagement in the commissioning process.

i Health Education and Improvement Wales (2021), NHS Wales’ Workforce Trends (as at 31st March 2021). Available at: Social care workforce report

ii Centre for Ageing Better. (2021) Understanding and improving recruitment language, imagery, and messaging. Available at: understanding-recruitment-language-GROW.pdf (

iii Welsh Government (2023) National Survey for Wales: April 2022 to March 2023. Available at:

iv Older People’s Commissioner for Wales, Ensuring access to information and services in a digital age, November 2021 New guidance to ensure older people can access the information and services they need in a digital age – Older People’s Commissioner for Wales

v Older People’s Commissioner for Wales, Access to information and services in a digital age: Summary of responses from local authorities and health boards, September 2022 Access to information and services in a digital age: Summary of responses from local authorities and health boards – Older People’s Commissioner for Wales

vi The Centre for Ageing Better, Ageism: What’s the harm? (

vii See 55/Redefined and Reed Talent Solutions, The Unretirement Uprising (2022). p.17. Available at:

viii Ageism-harms.pdf (, p.13.

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