Cynulliad Cenedlaethol Cymru The National Assembly for Wales
Y Pwyllgor Iechyd a Gofal Cymdeithasol The Health and Social Care Committee
Dydd Mercher, 8 Chwefror 2012 Wednesday, 8 February 2012
Cynnwys Contents ........... Blaenraglen Waith—Trafodaeth Bellach ynghylch Sesiynau Tystiolaeth Un-tro Forward Work Programme—Further Discussion on One-off Evidence Sessions Ymchwiliad i ofal Preswyl i Bobl Hŷn—Trafodaeth â Jean-Pierre Girard mewn Perthynas â Thystiolaeth Ysgrifenedig a Gomisiynwyd gan Gydweithredwyr Cynyddol Cymru Inquiry into Residential Care for Older People—Discussion with Jean-Pierre Girard in Relation to Written Evidence Commissioned by Wales Progressive Co-operators............. Papurau i’w Nodi Papers to Note
Cofnodir y trafodion hyn yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir cyfieithiad Saesneg o gyfraniadau yn y Gymraeg. These proceedings are reported in the language in which they were spoken in the committee. In addition, an English translation of Welsh speeches is included.
Aelodau’r pwyllgor yn bresennol Committee members in attendance
Mick Antoniw	Llafur Labour
Mark Drakeford	Llafur (Cadeirydd y Pwyllgor) Labour (Committee Chair)
Rebecca Evans	Llafur Labour
Vaughan Gething	Llafur Labour
William Graham	Ceidwadwyr Cymreig Welsh Conservatives
Elin Jones	Plaid Cymru The Party of Wales
Darren Millar	Ceidwadwyr Cymreig Welsh Conservatives
Lynne Neagle	Llafur Labour
Lindsay Whittle	Plaid Cymru The Party of Wales
Eraill yn bresennol Others in attendance
Jean-Pierre Girard	Arbenigwr ar ddatblygiad a rheolaeth sefydliadau cydweithredol, dielw a chilyddol (enwebwyd gan Gydweithredwyr Cynyddol Cymru) Specialist in the development and management of co-operative, non-profit and mutual organisations (nominated by the Wales Progressive Co-operators)
Swyddogion Cynulliad Cenedlaethol Cymru yn bresennol National Assembly for Wales officials in attendance
Stephen Boyce	Y Gwasanaeth Ymchwil Research Service
Llinos Dafydd	Clerc Clerk
Catherine Hunt	Dirprwy Glerc Deputy Clerk
Joanest Jackson	Uwch-gynghorydd Cyfreithiol Senior Legal Adviser
Dechreuodd y cyfarfod am 9.34 a.m. The meeting began at 9.34 a.m.
Blaenraglen Waith—Trafodaeth Bellach ynghylch Sesiynau Tystiolaeth Un-tro Forward Work Programme—Further Discussion on One-off Evidence Sessions
[1] Mark Drakeford: We agreed in last week’s meeting to allocate three of four potential one-day inquiries. We agreed to pursue an inquiry on wheelchair waiting times in Wales. We also agreed on a separate day on venous thromboembolism prevention and a third day on still births in Wales. There is potentially one further day available. That will not be until near the end of the summer term, probably in July. We said that we would come back to it today, partly because some of us were attending a seminar last week on how new medicines are approved and prescribed in Wales. It has been pointed out to me, so I will point it out to all of you, that given the fact that this final one day would not be until the end of the summer term, we do not have to fill the slot this morning. There may be some advantages in retaining a little flexibility in the committee’s timetable, in case other issues emerge during the next month or so and due to the fact that there is a bit of uncertainty about how soon some of the legislation might come our way. However, would anyone who was at last week’s event in particular want to reflect on that in relation to the one day that we have?
[2] Lynne Neagle: It was an excellent event last week. Well done to you for organising it, because it was very informative. The event illustrated that there are significant problems in this area, so I want to keep the option open of looking at the issue of access to medicines more formally. My only concern is whether it would be possible, given the obvious complexities of the issue, to do it in a day and to have a meaningful outcome.
[3] Mark Drakeford: William, you were there.
[4] William Graham: Yes. It was worth while. An issue raised that I found interesting, which I explored afterwards with health professionals, was that it was difficult for health boards to plan ahead because they were unaware of new techniques in surgery and general improvements—the chap from Velindre NHS Trust mentioned this in particular. That does not seem to have been picked up. They were aware of the issue, but there does not seem to be a mechanism for it. So, you could spend a tremendous amount of money on a facility that is out-of-date within 12 months.
[5] Mark Drakeford: For those who were not there, it was an interesting afternoon, but it was complex and many issues were raised. One of the issues raised by the people taking part was that while we have an All Wales Medicines Strategy Group and the National Institute for Health and Clinical Excellence, which are pretty good at looking at new medicines, new technologies and new surgical techniques are also being developed all the time and they have the same issues in relation to questions regarding whether they are cost effective, whether they work, and whether you should apply them and invest in them, but we do not have a process for scrutinising and approving those things.
[6] Darren Millar: Perhaps a wider inquiry into access to treatments may be more appropriate. I agree with Lynne, in that I do not think that it can be done in a day; it needs more time allocated to it. It need not be a long-winded inquiry, but a focused one on how people access these and on understanding the system, which can be unfathomable to me.
[7] Mick Antoniw: There is a costing issue as well, which we did not discuss because it is such a complex area, particularly with the drug companies, the patents and the way in which certain medications are flooded through at particular times and so on. It is a really difficult area, but it is an area that takes time, and that is part of the problem as well.
[8] Vaughan Gething: I agree with what has been said. It was fascinating, and very difficult, practical and ethical choices have to be made. I would be interested in looking at it in public in a short and focused way, but for more than a day. Lynne Neagle is right that it will probably take more than a day. However, I am equally happy to go along with the suggestion that we leave the fourth single day that we have clear for a period of time, because it is not until July and we can afford to give ourselves a bit more time, rather than having to make a definite choice today. That flexibility will be a good thing for us, as there may be other areas that we will want to scrutinise that are not available to us now.
[9] Rebecca Evans: I echo everything that Vaughan said. I like the idea of having that extra day open. It will allow us to respond to anything that is particularly pertinent or urgent.
[10] Mick Antoniw: We may also need some more thinking time on the legislation, time that is not necessarily part of the legislative process, but for some of the issues that may arise.
[11] Mark Drakeford: There seems to be a consensus around the table on two things. We want to return to the issue of access to treatment, which is slightly wider than just access to medicine, and we will ask the people who do the work for us to have a think about that, and to maybe bring us a note in a few weeks’ time as to what the shape of such an inquiry might be. We certainly think that it will take more than a day to do it justice.
[12] That leaves two topics from last week still on the table. However, we do not need to respond to them today. What I suggest is that, in our last session before we break for Easter, we come back to this issue to see whether any other things have cropped up in the meantime and what we know about the emerging legislative load that we may have to carry after Easter and decide whether we want to allocate that fourth day then.
[13] Darren Millar: There is just one issue. We agreed that we may revisit the PTSD services for veterans after the Welsh Affairs Select Committee reports. It may be that it reports well before the summer, in which case we could slot that in.
[14] Mark Drakeford: Good point. We will definitely come back to that.
[15] Lindsay Whittle: On that, Chair, I appreciate that a report will go to Ministers in April. However, post-traumatic stress disorder does not affect only veterans—and I have every sympathy with veterans—because there are other services, such as our emergency services, whose staff suffer from this as well. Do we know whether the report will incorporate that issue?
[16] Mark Drakeford: The Welsh Affairs Select Committee inquiry is on veterans only. However, you are right. We can certainly take a wider view of it, because it is certainly not only veterans who are affected by that.
[17] Darren Millar: The difficulty with that, if we are doing a follow-up to the previous committee’s work on PTSD, is that its work was veteran-specific. There are specific issues that veterans face that other people who may suffer from PTSD do not. Therefore, although I appreciate your point, it would be a much wider piece of work if we were to incorporate services for people who have experienced PTSD that is not the result of serving in the armed forces.
[18] Lindsay Whittle: I do not want to cloud the view of the veterans, because I am enormously sympathetic, but there are other people who have to deal with some pretty horrific incidents. I will not belabour the point.
[19] Vaughan Gething: We do not need to make a decision today, but I am not persuaded that we could not do an overview of PTSD, and how people who experience it are dealt with, without specifically concentrating on veterans. Otherwise, my concern is that we would then have to do two PTSD treatment inquiries. We need to give some thought to that without boxing off either option. We do not need to make a decision today, but let us think about whether we are committing ourselves to doing two inquiries on roughly the same issue, although I appreciate that there will be different aspects to how people experience PTSD and their aftercare that we would want to look at.
[20] Mick Antoniw: The danger of broadening out from the veteran-specific area is that you are moving into the realm of psychiatric and psychological services in a much broader way. What Vaughan says is right, as is what Lindsay said about emergency services personnel, but that begins to take us into the whole area of psychiatric and psychological services generally, from counselling to GPs to hospitals and so on. That would be a different type of inquiry.
[21] Vaughan Gething: Emergency services personnel may still be employed, whereas veterans are often not by the time they present for treatment.
[22] Mark Drakeford: We are committed to doing a follow-up piece of work, once the House of Commons Welsh Affairs Select Committee report is available to us. Lindsay has rightly pointed out that, although the focus of that is exclusively on veterans, when we come to look at it, we will want to be aware, at least, of the fact that there is a wider context in which those services are delivered. We might want to keep the issue alive in our minds with regard to how we want to address that work. Thank you very much indeed.
9.44 a.m.
Ymchwiliad i Ofal Preswyl i Bobl Hŷn—Trafodaeth â Jean-Pierre Girard mewn Perthynas â Thystiolaeth Ysgrifenedig a Gomisiynwyd gan Gydweithredwyr Cynyddol Cymru Inquiry into Residential Care for Older People—Discussion with Jean-Pierre Girard in Relation to Written Evidence Commissioned by Wales Progressive Co-operators
[23] Mark Drakeford: We are going to move on, because we have only three quarters of an hour with Mr Girard, who is here from Canada. He did a number of sessions in the Assembly yesterday. We will hear his evidence formally and in public. We will do it in the normal way. We do not have a research brief with questions for him, because we have the paper that he has provided. We will hear his evidence and then, as usual, Members will have the chance to follow that up with questions.
9.45 a.m.
[24] Good morning, Mr Girard. Welcome to the Health and Social Care Committee of the National Assembly for Wales. You are very welcome indeed. We are grateful to you for finding time in what I know is a very crowded schedule over a few days to spend three quarters of an hour with us. Between now and 10.30 a.m., we will begin by asking you whether you would like to make some introductory remarks. We have your paper, which is useful to us, but it will still be useful to hear directly from you. Members of the committee will, undoubtedly, have questions that they want to ask you and will want to follow up things. I will call people to ask those questions once we have had a chance to hear from you.
[25] Mr Girard: Good morning, everyone. Perhaps like some of you, English is my second language, so I will try to speak as best as I can, but sometimes I may make a mistake, as it is not my first language. I want to be clear, so if I mispronounce a word or anything, please feel free to ask me.
[26] The main reason I am over here relates to the question of homecare for seniors. You already have the papers showing what we have done in Quebec, but let me summarise quickly the very inspiring and innovative project that we have been conducting in Quebec for 15 years. Quebec being the only place in North America where we speak French, we have a strong sense of working together in Quebec society. So, in 1996, the Quebec Government organised a socioeconomic summit, gathering together a leader of a trade union, a leader from the women’s movement, a leader from a private enterprise and a leader from a civil society organisation. The challenge was to achieve two goals. The first goal was to try to find good ideas in order to cut the huge public deficit debt—all of you are aware of that issue. The second goal was much more challenging, which was to try to find new ideas in order to create jobs.
[27] The summit created working groups or clusters in order to work on these goals. I was a member of the social economy cluster. Over a few weeks, we worked hard in order to find inspiring ideas. The conclusion at the end of the process, bearing in mind the huge and growing needs of the ageing population in Quebec, was that we absolutely needed to improve services for the elderly, with a very clear view of what we can do in order to keep our seniors in their homes for as long as possible. At the same time, we said, if we can create something new, we can create jobs.
[28] We started with the idea of a network of domestic help social economy enterprises. In order to set up the initiative at the beginning, we had the agreement of the Quebec society leaders. It was really important to get that, otherwise it could not have worked. So, we had the agreement of all the people and the representatives of the public and trade unions. It was clear that the set-up of this programme would not substitute jobs: it was not a way to cut jobs on one side and recreate jobs on the other; that was not the purpose of the initiative. In order to start the programme, the Quebec Government agreed to initially give some limited time per month in order to help with the set-up of the enterprises, because, as you may know, the first years of a new enterprise are the crucial years for its survival. We call the main programme to guarantee this development PEFSAD, which is the financial assistance programme for domestic help services, and it is based on the following ideas.
[29] Every senior who wishes to use the homecare service from the co-operative has to pay a certain amount, so it is never free of charge. Every senior has to pay a minimum amount. We have what we call the base amount, which is C$4 an hour, and then a variable amount, depending on your personal income. Let me a give you an example. When you receive services as a senior from your homecare co-operative, it charges you C$20 an hour, so, generally, you have to pay a minimum of C$4 an hour and the balance then depends on your income. That was the basic idea behind this programme.
[30] We set up 104 homecare social economy enterprises, so it was exactly the same territory as that of our public health clinics, the CLSC. It was clear from the beginning that we did not want any competition between homecare co-operatives. So, it was in some ways a protected market. Why? It was for the simple reason that, if you have two homecare co-operatives located 20 km or 30 km away from each other and they decide to compete with each other, then there will be staff travel costs to pay, and, in the end, who will pay for that? It will be the user of the service. So, it was clear that we did not want competition between homecare co-operatives. That was another key idea of this programme.
[31] As I say, 104 enterprises were created in 1997, and since then, they have developed their services, and I have updated data to share with you today, based on the 2011 survey. The set-up of this network created 6,000 jobs, mostly for single women without any specialist skills or qualifications—generally, they had a lower level of education—so it was very useful for job creation. It was really a good thing. On the other side, these enterprises serve up to 81,000 individuals, most of them seniors of 65 and over. Ultimately, therefore, we are talking about 6 million hours being delivered every year by this network. From the Government side, with regard to the cost of this programme for Quebec, we have a population of 8 million, and the cost is C$55 million. So, it is an impressive amount, but recently the Quebec Government made a comparison between the money spent on these homecare activities and the cost if the seniors were moved from their homes into public residential care. The average cost to the Quebec Government per individual in the domestic help programme is C$5,000 per year. When we talk about public residential care, it is C$55,000 a year. So, it is really clear where the Quebec Government should put the money. Of course, when you arrive at a certain point in your life, you do not have a choice about moving into residential care, but the Quebec Government decided to do the best that it could to improve the programme in collaboration—and this is really important to understand—with homecare co-operatives. The Government does not work alone on this—it works in collaboration, because the homecare co-operatives have the best knowledge of the needs of the local population.
[32] There is one last point that I would like to share with you before giving you the floor: most of the organisations decided to use what we call the multistakeholder co-operative model. What we mean by that is an organisation that finds a place in its governance for the service users, that is, the seniors, for the workers—mostly women—and for what we call supporting individuals and organisations, so this is a third category of membership for this co-operative organisation. We find room for everybody in the governance structure of the organisation, which is the board of directors. Of course, as you can figure, it is not easy for a senior of 65 or 70 years old to be a board member. However, what we have learnt over time is that a training programme needs to be developed in order to help board members, not only the senior members, but the workers, so it is very useful in order to develop their knowledge and the skills we need in order to manage an organisation with an annual turnover of C$1 million, C$2 million or C$3 million. So, in a few words, that is the idea of the homecare co-operative in Quebec
[33] Mark Drakeford: Thank you very much indeed. There was a lot to take in there in a short time, but it is supported by your paper, and I am sure there will be questions that Members will now want to ask.
[34] Mick Antoniw: Thank you very much for that interesting introduction. Before the setting up of the co-operative, was there a social trend towards increasing use of residential care? Therefore, has the co-operative and the development of homecare effectively minimised the growth of residential care as a means of looking after the elderly and so on?
[35] Mr Girard: At this time, it was clear in the view of the Quebec Government—and again, I am not a representative of the Quebec Government; I am only an academic— that it would like to do everything it could in order to keep seniors at home as long as possible. So, it was a clear view, and this view has been shared with the leaders of Quebec society, the women’s organisations, trade unions and so on, which means that we have a large agreement around this idea of keeping seniors at home as long as possible, but—and it is important to keep this in mind— by improving quality of services. So, since we created this network, we developed training programmes for workers in order to help the workers of homecare co-ops to improve their quality of services for the elderly. We tracked very closely the improvement of the quality.
[36] Mick Antoniw: Just to follow on from that, is there also a non-co-operative homecare service, and is there any reason why the co-operative has not moved into or worked in the residential side itself? Why have you cut that off from being part of the overall provision?
[37] Mr Girard: On your first question, it was clear in the mind of the leaders at the 1996 summit that we needed to improve quality of services for the elderly, but most of the elderly in Quebec do not have a lot of money. They are not targeted customers for profit enterprises in this market, so we did not have any major problems with private enterprises when we decided to set up this network. Again, this network runs without any competition—you have a protected market. I live in Montreal, and in my area, as a senior, if you wish to use the services of homecare co-op, you only have one phone number; you do not have two or three, because if you wish to go to another place, you will not receive the subsidy from the Quebec Government. It is a clear link between the two.
10.00 a.m.
[38] When you talk about residential care, at this time in Quebec, we have a few new projects of housing co-operatives that have decided to open their doors to seniors suffering from a certain loss of autonomy. Those are the only new things, but otherwise, at this time, in Quebec, on residential care, we do not have very inspiring ideas. On one side, we have a public solution, and, of course, the problem with the public solution is the waiting lists. Your name is placed on a list but you have to wait two, three, four, five or six years. It is a mess. On the other side, you have a private solution, but the problem is the cost—it could be double or triple the cost. So, in practical terms, when you go into public residential care, you pay an average C$1,500 a month, but when you go into private care, you pay at least C$3,000 or C$4,000 a month, which is a very big amount for a senior, as you can figure. So, we do not have any inspiring ideas related to the question of residential care in Quebec at this time.
[39] Elin Jones: Thank you for this is interesting session. To give you a comparison, in Wales, when social enterprises develop, they tend to develop at a very local level, before perhaps spreading out into different areas, because it is an interesting model. However, this is very much about the central planning of a social enterprise network, if I have understood it correctly. That is very interesting; I like the idea of central and national control and development. However, what I am finding hard to understand is how it starts on day one. You said that there were something like 100 enterprises on day one. That would have meant quite a lot of set-up costs at that point for the Quebec state, I guess, before any income came on board from the users. So, I am interested to understand the initial set-up of what has all-Quebec coverage—I guess that there is no area of Quebec that is left without this service. So, what was that first year like?
[40] Mr Girard: That is a good question. When we talk about central development, I want to make it clear that we first have a formal agreement at the beginning with the leaders of Quebec society, but, after that, we agree that the development will be taken care of at the local level. It is crucial to understand that. So, we have this national agreement, but, at the end, when it is time to offer the delivery of services, it is run by the local homecare co-operative. It is really important to understand that. Of course, the homecare co-operative is provided with some subsidy over the years, but it decides everything for itself. So, if it has a surplus at the end of the year, then it has the right to decide what it is going to do with that surplus. The Government does not have any control over the surplus of the co-operative. It is really important to understand that, because this is the key idea of the empowerment of the multistakeholder co-operative, otherwise it looks like a para-state organisation, which is absolutely not the case.
[41] On your question about day one, of course, before starting this project, we already had services for homecare, but not a very good service, because it was done by voluntary organisations, with voluntary contribution, so you never knew whether it was good work. So, you could have a job that is done by a woman on the black market—if you understand what I mean; I do not know whether that is the right phrase. So, when we decided to set up the programme in 1996, we agreed to create a selection process with a very clear rule. So, in some cases, existing voluntary organisations decided to transform themselves into a homecare co-operative, respecting the rules of the programme. As I say, it was clear that we only wanted one homecare co-operative, or domestic health social economy enterprise per territory—we did not want more than one. So, in some regions, two or three existing homecare voluntary organisations decided to merge and create one organisation. In other cases, a new organisation was created from scratch, but it always had close links with civil society organisations.
[42] Of course, in some regions, we have some tension between organisations, because they say, ‘Oh, you give preference to this organisation instead of that one.’ However, in the end, after a few months, it was clear that it was a successful operation. The selection board in each region was made up of people from all kinds of civil society organisations. It was not under the sole control of the Quebec Government, so it was a way to promote the involvement of civil society. After a few months, up to 1998, it was completed, and since that time, with the exception of some minor problems, it has worked really well.
[43] Elin Jones: You might not know this, but on the issue of set-up costs, because people had to be employed from day one in order to generate the demand, would that significant investment have been provided by the Quebec Government at that point?
[44] Mr Girard: Yes, following the socioeconomic summit, we had the agreement of all the leaders, including the Quebec Government. The First Minister asked different ministries to do the best that they could in order to support the setting up of homecare co-operative networks. For instance, the economic development ministry offered some kind of subsidies for the first and second years. The health and social affairs ministry also delved into its pockets in order to offer a special fund for the first years. However, since 2003, there has been enough, and the programme has run through PEFSAD—the programme d’exonération financière en soutien à domicile—which is the main programme that subsidises the users of services. So, it works with only that.
[45] What may be another important point to share with you is the fact that an existing huge co-operative in Quebec, Desjardins co-operative bank—it is a huge organisation with C$180 billion of assets—has decided to offer the best help that it can for the development of homecare co-operatives. How did it do this? It did it in a different way, by offering space in the building of the local credit union, promoting the idea that retired Desjardins employees must not only use the services of homecare co-operatives, but get involved in their boards of directors. The company also buys publicity in the pamphlets of homecare co-operatives. So, in those ways, Desjardins has supported the development of such organisations.
[46] Vaughan Gething: That is a really fascinating example of unified purpose from Government and the public, private and third sectors. I am interested in the structure that you mentioned of the multistakeholder co-operative. I would be interested to hear more about how that structure is made up and how those co-operatives are run in terms of decision making, because there must be competing interests and pressures when it comes to costs, where workers will want wages, and service users will want to suppress those costs, and the quality of care as well. I will ask my second question now as well. On the issue of quality, how does each co-operative measure success? I know that there was a point about the number of users, but how do you monitor the quality of the care that is provided and then compare that with what existed before the co-operatives were created, 15 years ago? Are you able to show smaller numbers of people going into public residential care, bearing in mind that you have, as we have, a rising older population? So, how are the co-operative structured, and how do you measure the success of the co-operatives in operation?
[47] Mr Girard: As I said, multistakeholder co-operatives are based on at least two or three categories of membership, namely the service users, the workers and the communities supporting the organisations. If you wish to become a member of such a co-op, you have to pay a minimum cost of C$10, which is nothing. It is C$10 to buy your social share, so I would not say that it is an economic barrier. This is in total respect of the co-op principle of open doors. So, it is your choice to become a member of the co-operative; no-one pushes you into it. It is your choice, but at C$10, it is not so expensive, and when you leave the co-operative, you get your C$10 back.
[48] Of course, in the day-to-day running of the multistakeholder co-operative, you have to manage the tensions between the users on one side and the workers on the other. The user will look for the best way to cut costs while, on the other side, the workers would like to improve their salary, which is only normal. Part of my life also involves working as a consultant; I work with some executive directors of homecare co-operatives in order to develop their skills to manage these tensions between the workers and users. Otherwise, if you do not know how to manage them, the co-operative is going to be a troubled one, as you can figure out. However, if all stakeholders agree with the mission of the homecare co-operative, which is to offer the best-quality services for the best possible cost, it can be a very successful example.
[49] I will now jump to your second question, on how we can measure success and monitor the quality of services. You have the stakeholders sitting on the board, but, moreover, we also have a category of supporting members—very often, we have a representative of the local public health clinic. It is like a glass: everybody can see inside and examine it carefully. If we have a problem, everybody can take a look inside. As a senior who is receiving services from a homecare co-operative, if I feel dissatisfied, I pick up the phone and call the co-operative and say, ‘Look, I’m not satisfied with the quality of the services’, or the behaviour of the employees—whatever it may be. Right at this moment, the co-operative will make a short-time follow-up. If that is not enough, we have another step in which the user can call and make a claim. We do not have what I would call a national tracking system for quality at this time—maybe someday, but up to now, it seems that our example of homecare co-operatives works well, so we do not have a major problem in terms of quality.
[50] William Graham: You kindly gave us an outline of how the multistakeholder system works. In practice, are there any particular tensions that you have identified?
[51] Mr Girard: Yes; as I said, in every multistakeholder co-operative, since we are gathering different stakeholders together with different interests, it could become a battlefield if you do not have the skill to manage the tensions or differences of interest between them. However, it is not impossible. We have a training programme for the executive directors of such organisations. We also have a training programme for the chairs of such organisations. As you can imagine, being the chair of the board, where you have the interests of the workers on one side and the interests of the users on the other, can sometimes be challenging. However, over the 15 years that we have been running this example, we have developed a tool to help people to manage such tensions or differences of interest.
[52] William Graham: Presumably, all the enterprises have model rules, or is any individuality allowed?
[53] Mr Girard: Sorry, I missed a word. Could you repeat that?
[54] William Graham: Yes; do you have model rules for all, or is any individuality allowed?
[55] Mr Girard: Okay. In Quebec, we have a very clear Cooperative Act, which closely follows the co-operative principle coming from the International Co-operative Alliance. In this Act, we have a provision that explains the rules that the co-operative must follow. Having said that, every co-operative’s general idea comes from the Cooperative Act in what we call a bye-law. The bye-law is the adaptation to the co-operative’s needs of the important provision coming from the Act. That is how it works.
10.15 a.m.
[56] When we talk about bye-laws in co-operatives, it is a document of around five or six pages that sets out the information related to the board composition. So, for instance, you can decide, as the board of a multistakeholder co-op, to give up to one third of the seats to supporting members, but no more, because we want to be sure that the control stays with the users or workers, never in the hands of supporting organisations. This is very important information regarding the co-op. For example, it could be decided that, from 10 seats on the board, five or six seats could be given to the user representative, one or two to the workers and the balance to the supporting members. It is up to the co-op to decide how the board will work.
[57] Mark Drakeford: We have around a quarter of an hour left, and four people still have questions to ask. I will go to Lindsay, Lynne, Darren and then Rebecca.
[58] Lindsay Whittle: Good morning. Welcome to Wales. Is there any independent financial audit of the co-operatives? We are all living longer—I am sure that the same is true in Quebec—so what happens when some of the older members of your co-operative become mentally infirm?
[59] Mr Girard: In the first case, I am not sure that I have fully comprehended your question. Homecare co-ops have a second level organisation, which is a federation of homecare co-ops. In this way, they can share, for example, ways of managing the day-to-day operation of homecare co-ops. This gives them access to knowledge related to the legal dimension, the business dimension and ways of improving marketing among senior members of the community. So, this federation plays a crucial role in sharing knowledge among homecare co-ops. As you can imagine, the organisation also lobbies the Quebec Government.
[60] In relation to your second question, as I said at the beginning, we do not have a very inspiring solution at the moment in Quebec regarding the question of residential or nursing care. So, when senior citizens in a homecare co-op arrive at the point at which they need to move into residential care, it is tough, and they need the support of their families—hoping that they have family members nearby. Otherwise, once again, we do not have a useful solution for that, because you have to put your name on the waiting list for public residential care and you are crossing your fingers, hoping that it will not take too much time. Otherwise, you need money. If you do not have money, you cannot go into private residential care—it is simply too expensive. So, I am afraid that I do not have any good ideas to share with you in relation to this question.
[61] Mark Drakeford: I think that the first question that Lindsay was asking you was to do with the financial affairs of a co-op. That is, who checks that things are being properly run?
[62] Mr Girard: Okay. I am sorry, I misunderstood the question. I am a little bit jet-lagged. [Laughter.] It is 5 a.m. in Montreal at the moment. Generally, at 5 a.m., I am doing other things and am not before a committee.
[63] Let me come back to your question. The question on the financial affairs is important, because, as I explained, homecare co-ops can manage an annual turnover of between, for example, C$2 million and C$5 million. It is compulsory that, at the end of the year, there is an independent audit. So, they will check their balance sheet and, at the end, if it is okay, they will sign it. If there is a problem, they will have to report it to the Quebec Government, because they receive a significant amount from the Quebec Government and we absolutely need this independent audit in order to be sure that there is good information and that that good information can be managed. So, that is the way it works.
[64] Lynne Neagle: Thank you for coming this morning and for your evidence. I wanted to ask about eligibility. Your paper said that people can be referred by a professional or they can self-refer. I was struck by the range of services that you provide—some of which would never be provided in my constituency, such as outdoor maintenance work. Does everyone who wants a service get one or is there a process by which you determine whether or not people are eligible for that service? My other question relates to cost. You set out the funding arrangements and said that funding was not a barrier to anyone getting this service. I do not understand how things work with the currency and so on, but would people on very low incomes have the full cost of their care met by the state? How does the state in Quebec manage such demands? Sorry; I know that that is a big question.
[65] Mr Girard: On your first question on eligibility, it is simple, in that you can use both ways. You can call the homecare co-op, for example, and say, ‘Hello, I am 60 years old and I think that it is time for me to receive some help from your organisation’. The co-op will say, ‘Okay, we need your name’ and so on, and employees of the co-op will arrange an appointment with you for two things. The first would be to evaluate your needs—for example, do you need to clean two or three rooms? They would also enquire if you had other needs, such as to help you prepare non-diet food. You might also need help with big works or to go to the convenience store—anything related to what we call ‘domestic help’. Our evaluation might say that you needed help for three hours a week. That is the first step.
[66] The second step, which is the most important for people, is the cost. We need true information relating to your personal income. We will then make an evaluation based on the fact that you receive, for example, C$15,000 a year. We estimate that you have this base amount, subsidised by PEFSAD, and then the variable amount. So, we estimate, having assessed your personal income, that we offer you the services at C$20 an hour, but with the Quebec Government’s help, it will cost you C$5 an hour. We would ask if you agreed with that. If you agree, I ask you to sign a form and, by signing it, you agree that the homecare co-op will deliver services every week for three hours. When we start new activities with new clients, over the first week, if we do not have enough time to do everything in three hours, we ask them if it is okay to charge them one more hour. So, we undertake a negotiation, because we need to adapt services closely to the needs of these people.
[67] As I said, our subsidised programme, the PEFSAD, offers the variable amount based on the income level of the person, so the minimum that the senior has to pay is around C$4 an hour. That is the minimum. You may not agree with that idea, but the basic idea of the programme was that everyone would have to pay a minimum for the service and that it would never be free. So, even if it is only C$4 an hour, which is really not expensive. You have to pay a minimum, so that is the way it works. If you do not have enough money, I do not know what the solution is for the other poor people. I do not have that information.
[68] Darren Millar: Your English is much better than my French.
[69] I wish to check something with you. In addition to the C$4 per hour contribution that the Quebec Government makes, you make reference in one of your papers to the tax credit, which is also available for homecare support. Is that a relief on the cost of care for those individuals who pay it?
[70] Mr Girard: Yes. The tax credit is another programme for elderly people aged 70 and older. It is a part of the main programme. So, it is another thing that you can use if you do not have enough money, but if you wish to have access to this tax credit, you have to be very poor. Otherwise, if you have a minimum revenue or income, you do not have access to that tax credit. So, it is for poor people. In Quebec, we have a strong sense of social solidarity: it is part of our socioeconomic model.
[71] Darren Millar: So, it is not a tax relief as such; it is a direct credit, which is another contribution towards the cost of the care.
[72] Mr Girard: Exactly, at the end of their years.
[73] Darren Millar: The other thing that I wanted to check with you—some of the questions I was going to ask have been answered—was that, as Lynne said, in this country, we would not traditionally regard many of the items listed as domiciliary care or homecare, but they might be provided in other ways, perhaps through supported housing models. So, it seems to me that it is a mix for us to consider, of supported housing with domiciliary care on top. How does the Quebec Government organise itself, because traditionally, in this country, both at a UK Government level and a Welsh Government level, we have created silos and approached things in a very separate way; for example, we say, ‘That’s a housing thing, that’s a care issue, that’s a social care issue and that’s a hospital care issue’. We have segregated it in such a way that can sometimes be a barrier to having a comprehensive package of support available to an individual. How does the Quebec Government organise itself to overcome those sorts of barriers?
[74] Mr Girard: As I said at the beginning, this socioeconomic summit, gathering the leaders together, has been a useful way to decide on an idea and then to implement it. We had a large discussion with different stakeholders in Quebec society. It was not easy; we had tough discussions that lasted weeks. It was not easy, because you have to find compromises and all organisations, trade unions and so on, have their own interests to represent. However, the main focus was: what can we do to improve the quality of life of our seniors? So, if everyone looks in the same direction, with strong leadership, what can we do to do the best that we can? As I said, when we had a clear view about the mission and the goals, everyone agreed to make some compromises and to go in a certain direction. It was an important change in the way that we view the needs of seniors. In Quebec, we arrived at a point when we needed to make a major turn in relation to that question.
[75] Again, it was challenging for some stakeholders, but they agreed and said, ‘Yes, we need to do something’. We are talking in general terms, but everyone has a senior in their family, so they can see what it means not only in theory, but in a practical sense, on a day-to-day basis, for their mothers and fathers, for example. After thinking carefully about that, and about what our future will look like in 10 or 15 years’ time and whether we felt comfortable with the result that we came up with, we agreed to go in a certain direction. It was really innovative in a western country, but we took the chance and, after 15 years, I would say that it is not so bad. We do a pretty good job, so, yes, it has worked.
10.30 a.m.
[76] Mark Drakeford: At the risk of disrupting our timetable and yours, I am going to squeeze in one very last question from Rebecca.
[77] Rebecca Evans: You referred to minimum income. First, what considerations are given to people’s personal savings when you are determining how much they pay for the care? Secondly, how are the co-operatives working with the training and skills sector to ensure that people have the right skills to do the care work and that they can develop their skills over time?
[78] Mr Girard: In relation to your second question, I will try to make this as simple as possible. Since the homecare co-op became something important, because we organised the sectors, we received the recommendation of an important training organisation or a para-public training society. With this recognition, it was easier to have access to special funds for a training programme to improve the skills of the workers. Just before I travelled to Europe, I checked a really interesting website that offers a sort of toolbox for workers in the homecare co-ops. It is a very good toolbox, but it is only in French, so I cannot show you and I do not have enough time to translate the information. I will try to explain it in a few words. It offers you a training programme for two or three months based on—I am not sure whether ‘peer’ is the right word in English—someone who has a good knowledge of your business helping you with the training programme. At the end of the training programme, there is some kind of test to ensure that you understood it and that you have carefully completed the training programme. I missed your first question, I am sorry.
[79] Rebecca Evans: What consideration is given to people’s personal savings when determining how much they have to pay?
[80] Mr Girard: As I said, at the beginning, when you call the homecare co-op, it will ask employees to meet you. They will look carefully at your average income over the past two or three years. Based on that information, you will get a clear idea of what subsidy you will receive from the Quebec Government. So, based on your income level, we will say that you will pay C$4, C$5, C$6 or C$7 or whatever. Over the next few months, if you have a change in your personal income, we will make an adjustment to the cost. The costs can change, depending on your personal situation. It has worked really well, but we need the exact information. If it is not clear at the end of the year, given that we are working closely with Quebec Government agencies, including the revenue ministry, we can check a person’s income for the past year. If they gave us the wrong information, we can see that. We can check the real situation of the individual with the Quebec Government at the end of the year.
[81] Rebecca Evans: So, it is based only on income, not on savings and other assets.
[82] Mr Girard: It is only the income side that we consider, not the assets.
[83] Mark Drakeford: Thank you very much indeed. That was a very informative session for us. There were some interesting issues of principle and detail, and we are really grateful to you for fitting us in and for answering such a wide range of questions in such a short time.
[84] Mr Girard: Thank you. It was a pleasure to meet you, and I hope that it will be useful when you are considering the future of homecare in Wales. Have a nice day.
[85] Mark Drakeford: Thank you. Diolch yn fawr.
10.34 a.m.
Papurau i’w Nodi Papers to Note
[86] Mark Drakeford: A yw pawb yn hapus gyda chofnodion y cyfarfod diwethaf ar 23 Ionawr? Gwelaf ein bod. Diolch yn fawr iawn.		Mark Drakeford: Is everyone happy with the minutes of the previous meeting on 23 January? I see that we are. Thank you very much.
Daeth y cyfarfod i ben am 10.35 a.m. The meeting ended at 10.35 a.m.