Official Report: Minutes of Evidence

The Chairperson (Ms Maeve McLaughlin): You are very welcome. I am sure that you found the previous session interesting and informative. We have, from the Department, Chris Matthews, director of mental health, disability and older people; Kevin Keenan, assistant director of social services, older people and adults, from the board; and Sean Scullion, acting director of the elderly and community care unit, from the Department. You are very welcome. I invite you to make your opening remarks, and then we will open it up to questions or comments.

Mr Chris Matthews (Department of Health, Social Services and Public Safety): Thank you very much, Chair. We are here this afternoon to provide an update on progress against recommendations that flowed from this Committee's review of supported living for older people. I am not going to take up too much time with introductory remarks. The detail of our update is in the paper, and we will just take questions on all that at the end.

In the paper, we provided an assessment of where we currently are against the recommendations, as well as some background on two issues, which are linked in this area, namely the DSD review of Supporting People and the proposals for a phase 2 of the dementia project being taken forward as the Delivering Social Change programme. There are a couple of points that are worth making at the outset to help frame the discussion. I will use the terms "supported living" and "Supporting People". My DSD colleagues were very keen that I defined those at the outset.

"Supported living" is terminology in the health and social care field. It is an umbrella term for a package of measures that can include housing support, which also includes domiciliary care and supported housing. The Supporting People programme, which is led by DSD, provides purely housing-related support. The aims of the approaches are very similar. Supported living schemes are partnerships between DSD and Health and Social Care (HSC), so, as your review showed, there has been a bit of confusion around how those two things interact. There may well still continue to be confusion, but I am trying to clarify how those two things fit together.

The point that I want to make before we go into questions is that one of the first things to recognise is that supported living as a concept has proved to be very positive for the people who have lived in supported living schemes. It demonstrates very clearly the benefits of partnership working across different bits of government and the HSC and what can be achieved when you take resources from different bits of the system and put them together.

One of the other strengths of the model is the flexibility. I have visited three schemes since taking up post late last year, and they are all different in a number of ways, but the one thing in common across the facilities is that they provide a very positive and supportive environment for the people who live there. All the residents that I spoke to were very happy with the situation that they were in. To an extent, as well as the definitional issues, the flexibility has caused some of the issues, which this Committee's review and earlier evidence sessions highlighted, around describing what supported living is, how it fits together and our approach to it. It extends across quite a wide client base outside older people. In some ways, it could be difficult to agree a definition that applies across the spectrum of clients, but that is one of the things that we need to address. The existing schemes, because they emerge from the Department of Health, DSD, HSC and the Housing Executive, as opportunities arose, in some way, supported living is a product of a bottom-up approach, and it grew organically as opportunities arose in each trust, as opposed to a top-down model. That is partially one of the difficulties with looking at it as a strategic issue rather than needs provision.

The other thing is that there are links into the Transforming Your Care (TYC) concept of home being the hub of care. Leaving aside the other issues that you have just heard about TYC, the idea of home being the hub of care is a durable one and one that we have shown in the different approaches that we have taken to [Inaudible.]

older people as having real strength and real demonstrable benefits. As your report points out, our approach has not always been ideal, and it has caused issues. While understanding how we got to where we are is important, our focus now is on where we go from here.

As I said, our paper covers a couple of the big pieces of work, in addition to your review, that are really going to influence how we develop the policy. The first of those is the DSD review of Supporting People, which is looking at the current landscape of provision. It is assessing whether needs are being met; it is evaluating how well the original policy aims are being delivered; it is also looking at the strategic and legislative framework; and, finally, it is going to take all that together and make recommendations to where we go next.

The second issue, as I mentioned, is the DSC dementia project, which also includes a dementia-specific supported living proposal for better analytics and review. More generally, I hope that our update on the Committee's recommendations sets out clearly how we intend to factor in your views as we take this forward. If it does not, I am sure that we will hear about it. As part of this, we need to engage with the key stakeholders that you reference and others. We need to make strategic links with other key pieces of work across the system, including OFMDFM's Active Ageing strategy. You have also correctly pointed out that we need to improve our analysis and planning to underpin new schemes.

In closing, it scarcely needs saying that the financial landscape is going to be very difficult going forward. While there are going to be challenges, that reinforces the fact that we need to work together on the schemes and get the best value out of our resources. Ultimately, taking a step back from supported living, our goal is to look for a spectrum of provision in which supported living has its place but in which the HSC has flexibility to meet the needs of all the people currently and in future. Thanks for listening to my introduction. We are happy to take questions.

The Chairperson (Ms Maeve McLaughlin): Thank you, Chris. I have a couple of comments first of all. With the Delivering Social Change (DSC) project, is it older people in general, older people with dementia or people with dementia, or is it all three? I am not clear.

Mr Matthews: DSC is dementia-specific. That will include older people, but it may include younger people who have dementia.

The Chairperson (Ms Maeve McLaughlin): So, it is people with dementia.

Mr Matthews: Yes. It is specifically about services for dementia.

The Chairperson (Ms Maeve McLaughlin): OK. Increasingly, the evidence that we were seeking was indicating what we all know in relation to the ageing population. We know it down to geographical areas and the increases of levels of dementia, but there are very specific needs in relation to older people with dementia. Are we suggesting that the Delivering Social Change project would provide us with that regional strategy or approach?

Mr Matthews: We already have a dementia strategy, which covers the near term. The phase 2 dementia project will look at the longer-term issues that you correctly identify. Phase 1 is very much about current provision and dealing with the situation that we face now.

Phase 2 is about understanding the challenges that will be ahead of us. We know, for example, that, by 2051, which is quite a long way off, the number of people with dementia is likely to triple. That means that we need to start thinking now about the radical changes that we will have to make to provision to deal with that.
Phase 2 is really looking to the future; it is going to feed into how we develop a dementia strategy and think about service provision. There are always the competing interests of dealing with what is still in front of you and dealing with the operational challenges you face on a day-to-day basis. We need also, then, to create the capacity to head off from that and think about this big issue that is coming towards us, which we maybe have not thought about enough yet. That is really what we are attempting to do with DSC 2.

The Chairperson (Ms Maeve McLaughlin): Just so I am clear, why would that be the responsibility of a Delivering Social Change project?

Mr Matthews: That is a good question. That came out of discussions in OFMDFM, I think. Also, the programme is in partnership with Atlantic Philanthropies, and it may have been something that Atlantic Philanthropies was interested in. It predates my involvement; it is something that I inherited.

The Chairperson (Ms Maeve McLaughlin): Is the regional strategy for supported living or supported housing not the responsibility, for example, of the board or the Department?

Mr Matthews: Yes. If the DSC project were not happening, we would have to do it anyway. It is part of trying to integrate our thinking on all these different things. It is about using the resources that we have most effectively by combining a number of policy strands to deliver a coherent approach. I think, also, that if we have opportunities to look at things in partnership with other people and other experts, then, we should take them.

The Chairperson (Ms Maeve McLaughlin): Basically, you are saying that, if Delivering Social Change was not happening, the board or Department — who would have to do it?

Mr Matthews: Supported living would be a matter for the Department, HSC and DSD.

The Chairperson (Ms Maeve McLaughlin): Does OFMDFM monitor the project, or where does that sit?

Mr Matthews: OFMDFM monitors the programme overall, and we, on individual projects, report into a central programme board chaired by OFMDFM.

The Chairperson (Ms Maeve McLaughlin): The conversations that we were having were partly about the definition of supported living or the lack thereof. The paper indicates that the Department will first consider how to reach an agreed definition and then how to communicate it to key stakeholders. But one of our recommendations had been to involve stakeholders at the start of the process when making decisions about the suitable definition, rather than just informing stakeholders at the end. Maybe it would be useful to clarify that for us.

Mr Matthews: First, the DSD review of the Supporting People programme will tell us what its view of Supporting People will be. If you can put it in these terms, the Supporting People programme is like the bedrock on which we have built the supported living programme. All of the schemes we are talking about are a partnership that is driven primarily by housing need. What HSC brings to that is domiciliary care. In some ways, the defining of supported living is a prelude to the policy on supported living. In other words, we define what we mean by supported living in terms of the policy outcomes we want to flow from it. The DSD review will examine how the Supporting People programme has gone. We are involved in that, but the programme is much wider than healthcare provision. For example, it deals with homeless people, as well. That process will allow us to understand with DSD where the emphasis in Supporting People is going to be and how we bring in the supported living policy, joining with it in such a way as to ensure that our needs and its needs are met going forward.

I cannot prejudge the outcome, but there might be general agreement that it has worked well. In our opinion, supported living is a good system, but it might be that the emphasis and certain directions are changed. The emphasis might be more on dementia, for example, or on programmes of care. That would mean that HSC needs to think about developing other schemes for our older people and how to deal with the TYC focus on keeping people in their own home. They are not necessarily ever going to be in conflict or rub against each other.

I suppose the issue is that it is a two-stage thing. DSD will produce its report, and then we will take that and decide what it means for supported living. That second approach is where we will bring in all of those stakeholders and say, "This is what we think our policy outcomes ought to be. This is the definition we think gets us to that. Do you agree?". It is quite bureaucratic and long-winded because, essentially, you are pulling together lots of different bits of work.

The Chairperson (Ms Maeve McLaughlin): Is there room at that stage to influence?

Mr Matthews: Absolutely, because the supported living side of things is still our policy. DSD is limited on where it goes with its policy; it is going to be a partnership. It is not going to do anything which causes us any great difficulties. Likewise, we are not going to run off to something that it cannot support. Essentially, it is a partnership between the two Departments. In some ways, because of the way it formed, which was out of opportunities that emerged from each trust, we are learning what has worked. We are working backwards as opposed to having a top-down approach, which has its benefits, but also its disbenefits, as we have seen with the issues around the definitions.

Mr McCarthy: Thank you very much for your presentation. I note the Department's correspondence in relation to the recommendations. It is fairly positive; there is only one there that concerns me. Recommendation 8 suggests that you collect more data on the number of people. You noted that recommendation and stated that you accept the need for effective data. However, you go on to give the reasons why you are not doing that. You say that it would be resource-intensive. The trusts ought to have all of the information to hand, so I do not think that that would be a significant resource. It should not be detrimental to providing the data that will help see what we will need well into the future.

Mr Matthews: I can see where you are coming from. The recommendation is right, because you are right: we do need to understand more. We need better analytics and better capabilities to project into the future. The issue we had there was more about trying to drive this through an analysis of domiciliary care provision. I think that there are something approaching 25,000 domiciliary care packages across the system. Trying to analyse those in respect of a person's candidacy or suitability for supported living would be difficult when there might be other ways to get the same answer. I think that the DSC project is going to look there to see whether there are proxy indicators or other indicators that are short of going out and canvassing domiciliary care users. Part of the reason for that is its sheer scale and the resource intensity of it. Furthermore, if you start asking people who are in a programme of care, "Have you thought about a different programme of care?", you might unsettle them a little bit, because they might think, "Are they trying to move me on to something else? Are they thinking of making any changes?". However, we need to know more about it, and we need to be able to plan for the future more effectively; that is definitely where we need to go.

Mr McCarthy: Finally, is there a timescale? Did I hear you mention a date by which this will be completed and our recommendations will be fulfilled, etc?

Mr Matthews: No. We hope to be able to give you that at any future update. We had hoped that the DSC report would be available by now and that we would have been able to give you a bit more clarity. As we understand it, it is likely to come out in the summer. That will help us go on from there. The other thing is that, because the DSC proposal has not been fully agreed through all of the ministerial mechanisms, there is an issue on the timescale on that. We hope to be able to give you more clarity the next time we give you an update on this.

Ms P Bradley: I sit on the Social Development Committee as well, so Supporting People is something I hear about every week. We have had many, many briefings, and, as you say, it covers many things, including homelessness. When Minister Storey took up his position, one of his first commitments was on Supporting People. That was really good. Again, it shows good interdepartmental working amongst both Departments. During so much of the evidence we received on Supporting People, I remember thinking, "That's more to do with Health than it is to do with DSD." So, it is good. I also like the fact that you mentioned planning for the future. That is something that has not been done in respect of housing in Northern Ireland. Planning for the future has not been done for years. Even if we look at welfare reform and all of those issues, we can see that we do not have the suitable housing or accommodation for people. I absolutely welcome it. I think it is excellent. Whether we have Transforming Your Care or anything else, this is the model that people want, never mind what a service requires. Kieran has asked most of what I wanted to ask, but where exactly are we? What point are we at now that we need to push to take it further?

Mr Matthews: I may create a hostage to fortune here, but I would say that, within the next six months, we will have some statement of intent from the Department based on what we know about Supporting People. We should, by that stage, have more clarity around the DSC project as well.

Ms P Bradley: When is the DSD one due to come to its conclusion?

Mr Matthews: I understand that it is likely to be the summer. There is a delay of a few months there.

Ms P Bradley: So after the summer recess we will be looking to come back with a definite plan of action.

Mr Matthews: What that should be is a statement of intent that there will be that process of engagement around what we want to achieve. One of the lessons for me from the Departments working together is that, because it has been driven out of people's needs rather than departmental policies, it has had a completely different emphasis in how we have put it together — "Here is what we need to achieve for a group of people; here is the scheme that achieves that for them." Then we have kind of worked backwards and asked what that means for each of the Departments. In some ways, that is the way that those things should be driven, but it creates a bit of confusion as you work through. The Departments have very defined structures. These programmes sort of cross over between the Departments, but that should not really get in the way of what we produce at the end of it. I hope that, within the next six months, we will come back and say, "Here is where we're heading with this." There are a number of schemes already in the planning.

Ms P Bradley: And there are already some models of good practice.

Mr Matthews: Absolutely. You would probably —

Ms P Bradley: In the Social Development Committee we went to visit several supported living environments, and there were already some very good models.

Mr Matthews: You come away with a sense that those guys know what works. The flexibility is working with the different providers, who all have different expertise in different areas. They are so much more agile than the Departments in a lot of ways, because they can see solutions and reconfigure themselves so much more quickly than the Departments can. There are a lot of benefits and positives in the scheme. It would be a shame to allow the sort of bureaucracy that gets caked on that to take away from the fact that the supported living approach has worked very well for people. The challenge for us is to harness that and not allow the bureaucracy to get in the way of it, while paying due regard to all of the due diligence and that sort of stuff.

Ms P Bradley: I know that you contacted all of the trusts to ask what their specific needs were, but we are looking at a Province-wide model.

Mr Matthews: Yes, absolutely. We are looking for an outcomes-based model across the system that will allow the flexibility for each trust to meet the needs of its client group, but has basically a shared understanding —

Ms P Bradley: The trusts are not really that different when it comes to client groups.

Mr Matthews: There is a commonality, but it is just that we have an agreed understanding of what we are trying to achieve with it and how it is appropriate. The supported living schemes, for the right client group, are extremely effective, but you need to make sure that you get that right, because there could be people who would benefit from being more independent who should not go into the schemes because they would have a better life outside a scheme, and people who need more support than a scheme can give them. Part of it is understanding what we try to deliver with the schemes and, as I said at the beginning, to understand what the spectrum of provision is and to make sure that the trusts all have the flexibility to meet the needs —

Ms P Bradley: I suppose, coming from the Chair's point earlier, if it is a wider-based consultation — the trusts are not always best placed to say what they need. It needs to be a wider consultation as to what is required for the people of Northern Ireland.

Mr Matthews: The benefit of bringing the housing associations into this, with all their different expertise, is you are learning from what they are doing. The L'Arche scheme on the Ormeau Road, which is in a different programme of care, works in conjunction with people who have learning disabilities and people who are homeless. The benefits across those two groups have been enormous, and everyone has benefited from that. However, that sort of thing only happens when you have that flexibility, and might not have happened if it was driven from the top because the processes within government are sometimes too inflexible. Not to do us down completely, but there is a definite benefit in the way that this came about, which is due to that flexibility.

Ms P Bradley: That is great. I look forward, then, to September, Chair, to see where we are then.

Mr McKinney: I might be repeating the point, but can you just outline exactly what we are getting in six months' time?

Mr Matthews: In six months we hope to be able to give you a general statement of the outcomes that we want from supported living, how we see it fitting into the wider programme of care for older people, and to overlay on that, if we can, what issues we are looking at into the future.

Mr McKinney: So we are getting a kind of statement of intent and then a plan for a three-year project of analysis.

Mr Matthews: The analysis will be a separate thing, specifically about dementia and provision in the longer term for dementia. In terms of supported living, it is really, in the immediate term, just to deal with the uncertainty around what we mean by supported living. A lot of what came out of earlier evidence sessions and this Committee's report was, "You are talking about this thing called supported living but you don't seem to know what it is; you can't explain it to us." What we hope to be able to do once DSD has finished its review is say, "Here's what we mean by supported living; here's what we want to achieve with it." From that will flow the policy and operational consequences.

Mr McKinney: Three years on the dementia project does not suggest urgency to me. Does it to you? We welcome the Atlantic Philanthropies consideration, but does three years suggest any urgency?

Mr Matthews: There is an issue about the timescale we are looking at. If we are thinking in longer blocks of time, three years is probably not that long. Would we like to be moving forward more quickly? Sure.

Mr McKinney: Why are you not?

Mr Matthews: Because there are some difficult questions in terms of the analysis and information available, and the sorts of data schemes that we have not set up yet that we need to establish. We do not really have a good understanding, as we discussed earlier, about what information is available and how to analyse it. Because of the way these schemes grew up, and because there was not a top-down approach, there has not been a data model coming in underneath that as we would do with a more strategic programme, so we are trying retrospectively to work out how we analyse this and understand it more effectively.

In truth, that will have to happen for both supported living more generally and the dementia programme more specifically, because we know we have an acute challenge in dementia. It is a long-term one, sure, but we need to ensure that any steps we take or policies we develop now set us off on the right track for that 10-, 15- or 20-year horizon that we need to be thinking about. Would it be better if were further on? Absolutely.

Mr McKinney: Will that include a general assessment of older people as a group and their needs in the widest sense?

Mr Matthews: We have a separate programme of work looking at adult social care, again in the longer term.

Mr McKinney: What timescale is that?

Mr Matthews: We are starting an analysis of that that will look at probably a shorter-term horizon. There are reforms coming through in England and Wales, so we need to know what our local response will be to that. We will also look at the same issues in terms of the demographic shift and what we need to think about now as a system to deal with the fact that the population of older people will grow fairly dramatically. The working population is also going to get smaller, so the things we are doing now will probably not be sustainable 10 or 20 years from now.

Mr McKinney: Out of the conversation that took place before with the unions — you were there for that; forgive me if you think this is unfair as a question, and tell me if it is — but are you doing that now in the context of TYC, or what plan are you doing it against the backdrop of?

Mr Matthews: TYC does have an influence on our thinking, in the sense that the home is the hub of care. You could say, probably truthfully, that you can extract the idea of a home as the hub of care out of TYC and it still remains a valid model.

Mr McKinney: Yes, but what targets and measurements are you putting that against now?

Mr Matthews: One of the recommendations is how you set targets. We are in the process of working through getting the data for that one. What sort of targets do you need to set? What sort of targets are going to be helpful in the context of getting people into the right programme of care?

Mr McKinney: Targets are important, and reporting to people about targets is important too. Is the TYC team being dismantled?

Mr Matthews: The TYC team in the board? If I understand correctly, it is a mainstreaming process rather than a dismantling one. TYC is not my area — [Inaudible.]

Mr Matthews: I am sure that you are going to write to the Department, but mainstreaming is not an uncommon way of making sure that the core principles of any piece of work are embedded into the operational delivery, and you may agree or disagree with that. As a model of making sure that something that has been strategically agreed is delivered at the front line, mainstreaming is a fairly common way of doing that, but on the specifics of what is happening with the TYC team —

Mr McKinney: I am conscious that it is maybe not fair to ask you, given that you are here on another thing. We will interrogate that further in the future.

Mr Kevin Keenan (Health and Social Care Board): Chair, just on a point of clarification, the Transforming Your Care team is still in existence; it is still progressing a range of initiatives that were contained in the report; and it is currently doing a stocktake of all of the 99 recommendations to see where those have progressed to. The team is still there.

The Chairperson (Ms Maeve McLaughlin): Has the vacancy been filled — Ms McCreedy's post?

Mr Keenan: In terms of oversight responsibilities, there have been discussions within the board. My understanding is that Valerie Watts is taking oversight of that function within the board in the short term. Obviously, all of that will be in the context of the review of commissioning. We await the outcome of those processes. The TYC staff are still there, they are still badged as TYC staff, and they are still progressing the initiatives under that banner.

The Chairperson (Ms Maeve McLaughlin): OK. So there would be no concern that a chief executive of a board to take on a strategic direction and oversight of a key policy piece would be feasible.

Mr Keenan: The portfolio of the TYC team is very clear. It is taking forward a whole range of initiatives. It has staff who have got responsibility for those pieces of work, and they work very closely with people in other directorates within the board. Very many of those pieces of work are well under control. Basically, it is business as usual.

The Chairperson (Ms Maeve McLaughlin): So you are indicating that there is no risk despite — I am not getting into the previous conversation — the evidence base that is increasingly gathering around how we inject or, almost, resuscitate Transforming Your Care. In your view, there is no risk. You are saying that it is business as usual.

Mr Keenan: I have a very simplistic view of Transforming Your Care in the sense that the original report did not pretend to be totally new; it attempted to capture a whole range of initiatives and strategies that we have been wedded to and signed up to for many years. If we did away with Transforming Your Care tomorrow and we started off with a blank sheet of paper, very many of the projects enshrined within Transforming Your Care would be back on our agenda, because they are manifestly the right thing to do.

Fearghal asked about dementia. Dementia is writ large within Transforming Your Care, because the client group, arguably, that Transforming Your Care focused on most was older people and the challenge that they pose in terms of meeting their needs. One of the biggest challenges within the older people's programme is dementia. It is absolutely up there, right at the very top of the list.

Mr McKinney: I know that it is, but we are looking at a three-year plan to assess some of the needs around that. If you want to translate it down, a board commitment of £8,000 a year over three years for a plan is not telling me that you are heavily committed to this. Fair enough, you are bringing in money from elsewhere, but that does not signal to me that level of strategic direction.

Mr Keenan: Chris has talked to you about the dementia strategy, which came out only a year and a half ago or two years ago. We were mandated to take that forward. There is also the work that we are, I hope, fortunate enough to benefit from in DSD. Predating all that, the planning processes are in place. There are facilities in train. Facilities that you have visited have opened in the interim. Some of those have been focused on the needs of people with dementia, so do not think, on the basis of this discussion, that it is all up the road and it still has to happen. It is happening out there in real time, and our trusts have been progressing those initiatives for years.

Mr McKinney: I understand that, but we are also seeing scenarios where people who are in the early stages of dementia and who are getting care in the home are getting what one might feel is inadequate care in the sense of time allocated to them, and the stress that those domiciliary care workers are facing as the result of that. There is an urgency to try to scope out the demographic so that we can actually scope out the need. A contribution of £8,000 from the board each year over three years is not saying to me that that is the big strategic piece, and the fact that it has taken three years — or will take three years — to do it, when I think that there is an urgency to try to fast-track the data collection. I understand the direction we are going in. TYC was supposed to be over five years, and now we are starting scoping exercises that will take three years. I respect what you say about other actions, of course, along the way. I am not saying that nothing is happing and that we are only at the starting line. However, in terms of informing ourselves and getting best value and best outcomes, fast-tracking the information and data gathering might be an indication that, in fact, we will have quicker action to follow. That is merely the point.

Mr Keenan: I think it is probably fair to say that, from where I sit, the publishing of the dementia strategy had added impetus to the work that has been done. I said a few minutes ago that the fact that Atlantic Philanthropies has taken a very particular interest in this — it is providing funding, and it is making sure that we work very closely with the sister organisation — will add more impetus to try to address the needs of arguably the biggest challenge that I face in my working life, or even the board faces, in terms of the demographics that we are trying to address.

The Chairperson (Ms Maeve McLaughlin): Thank you all for that update. We will be watching it closely.