National Assembly for Wales

Diolch, Gadeirydd, and good morning, all. Clearly, we're coming up to the 12-month mark, very fast approaching it, for the time we've been locked down, or subject to some form of preventative measures against COVID. I'm sure patients across Wales have been expressing some concerns. So, what are the key concerns you are hearing from patients regarding services and other issues, particularly linked to COVID in that sense?

Okay, who wants to kick off? Alyson.

I'll kick off, if I may. Thanks very much for the opportunity to give evidence today. Each of the seven CHCs have been, throughout the pandemic, hearing from people in their communities in a variety of different ways. Unsurprisingly, I suppose, given that we are in an international pandemic, lots of the issues that we've heard about across Wales have been consistent. What we have heard most consistently throughout the pandemic has been the admiration, thanks and support from everyone in local communities for healthcare and community workers, for their commitment, dedication and personal sacrifice to providing care for people in really difficult circumstances. We heard that at day one, and we're still hearing it today, so that's fundamental. Alongside that, in terms of the concerns and challenges, again we've had some consistent feedback throughout, and we've had issues that have come up and gone back down again over the period.

I suppose the key thing that we've heard throughout is that people want to know and understand what's happening in their area of Wales, what they do about their own care and treatment, and needing to feel informed and involved. Accessing services in new ways has been fundamental, and there have been benefits and challenges to that, both for patients and service users and for their families and loved ones. The impact of delays and waiting for care and treatment, the reintroduction of non-COVID services, as people often refer to, and the longer term impact on people's mental and physical health and well-being have been consistent themes throughout. We've heard a lot about being tested for coronavirus, and what's worked and what's worked less well in relation to that, and most recent, unsurprisingly, vaccination arrangements and recovery post pandemic have been the key themes across Wales, we would say. 

Thank you, Chair. I won't cover what Alyson has covered. One of the biggest worries for us, I think, and that local people have expressed, is referral-to-treatment time—when are people going to get their procedures. The number of people waiting over 52 weeks is currently running around 10 times normal level. Pre pandemic in November 2019, there were around 2,500 patients waiting more than 52 weeks. As at November 2020, which are the latest figures available, it was over 25,000. Similar issues for 32-week waits. Also concerns about treatment for chronic and enduring conditions, and one of the most worrying has been in relation to Lucentis and intravitreal injections for macular degeneration. Normally, people are seen monthly for that, and when they are diagnosed and they're set up for their injections, they're told that under no circumstances should they miss an injection—that it's really essential. 

We're concerned to hear that times between injections have lengthened to over nine weeks, and I'm informed by senior managers at Betsi Cadwaladr that patients have lost their sight. That's not 'might', it's not 'could'—it is 'have' lost their sight. I'm informed that there are plans to address this as a matter of urgency. I'm awaiting to hear what those are, and I will pass them on to the committee as soon as I do. 

Thank you for those answers; they covered a wide range. I suppose I just want to clarify, I understand the referral-to-treatment time, and that's going to be taken up in a few minutes by my colleagues, and you've highlighted certain services. Two things. Have patients taken on board the novel ways in which they're now interacting because, clearly, the virtual interactions are taking place far more now than previously? Have there been any issues related to that? And I suppose what I'm trying to work out is what the dominant issue is. Other than referral-to-treatment time, what is the most dominant issue you are coming across that people are worried about, concerned about? I think Geoff has just highlighted one particular set of conditions where staff or services were stopped. I suppose that's what I'm trying to work out. How much damage is those services being stopped doing? You've highlighted one. Is there any other type of damage being done by stopping services? 

Donna.

I think one of the issues we're finding in Hywel Dda is that people aren't sure and don't know what to do about their own care pathway. So, lack of communication is a big issue for many because they've waited maybe months to have an appointment in the first instance, and now they're having to wait so much longer, and they don't know when they need to take steps to chase this up themselves. And although in Hywel Dda the health board did say that it would communicate with everybody who was waiting, that is a monumental task, and when they've tried to do this for orthopaedic surgery, I think they've realised how complex this would be. So, to communicate with everybody on the waiting list is a really significant undertaking. For example, we've heard of people who had pre-op assessments the Friday before lockdown, and since then they've heard nothing whatsoever, and that's a big worry for people. 

Geoff. 

Yes, Chair. At different stages of the pandemic, people have worried about different things. Previously, it was B12 injections, but currently it is overwhelmingly the vaccination date. People are worried about when they're going to be called. They're now worried about the second injection and when that's going to happen. People are also concerned about fairness and equity. One of the side effects of handing it out to GP surgeries, which I think has been very, very good, is that now neighbours are getting—. There are some people who are over 80 and haven't had their injections, but their neighbours who are under 80 are now getting theirs. So, it is a worrying time.

Alyson, and then I'll come to Jayne Bryant, who's got a supplementary. Alyson.

Thank you. I think there are some services that people considered in some areas of Wales as being fragile before the pandemic that they're even more worried about during the pandemic. Mental health services is one. Dentistry and being seen by dentists is another. Eye care services. Those three themes we've heard about throughout the whole of the pandemic, and people are naturally concerned.

Excellent. Jayne Bryant.

Thank you, Chair. Good morning, everybody. My mother is a voluntary member of Aneurin Bevan Community Health Council, so I'm aware of some of the virtual visiting projects there. I just wonder if you could say a little bit more about that and some of the ways that you were all able to pick up some of the views of patients, because I think it has been an interesting time, and how you were able to gather the views of everybody.

That looks like one for Angela Mutlow. Angela.

Okay, thank you. Yes. So, we have—. Back in September and October, we launched a buddy project. That was in partnership with our health boards. We are able to speak to patients when they are accessing care, so we spoke to people in over 25 wards over multiple hospitals. I think, again, the key theme was that people really appreciated what staff were doing for them—that was overwhelming—but the loneliness shone through as well. Many people had their own phones; they had their own handheld device, so they were able to speak to their loved ones, but there were also patients who didn't have those devices, and it was really heart-warming to see that staff were going above and beyond to facilitate people to be able to speak to their family, and the chaplaincy service was doing the same. But even with that, it still wasn't enough, because people are lonely and they are becoming isolated in our hospitals, but they accept that the visiting restrictions have to be in place to keep everybody safe. Those were the two key themes that were consistent in every ward: appreciate that things are being done, but it was a key theme that came out, the isolation and the loneliness of people.

Very good. David Rees.

A final question from me, then. Clearly, as people are recovering from COVID, there are a lot of patients now that actually are back at home, back in the community, that are in recovery mode. What issues, if any, are you having from people who have experienced COVID and as to whether long COVID issues or other COVID-related issues are now appearing on your radar?

Yes. The numbers of people that we're hearing from in relation to long COVID are fairly low, but the issues that they're raising are very consistent. From the people that we are hearing from, we've heard about them feeling isolated, frightened, feeling alone, dealing with something new and unfamiliar that's perhaps bigger and lasting longer than they anticipated. For some of them who've contacted us, what they've said is that the level of understanding and support from GPs is variable, so sometimes they felt that they hadn't been listened to and been asked to go back home and rest, whereas other GPs, people have said that they have referred them on to other services, but that's been a little bit hit and miss.

I think it's really important for the people that we've heard from that Wales develops expertise and understanding together, between people suffering from long COVID and clinicians learning to respond to it as well. We've also heard some concern around things progressing faster and perhaps in a more focused way in England. We have heard about the fact that England have talked about rolling out long COVID clinics, and for lots of people that gives them a message that this is something that's important and they're having a real focus on. We know in Wales that they've introduced an app, and an app can be really useful for people who are used to accessing self-help, et cetera, but actually we know that, for lots of people, the human interaction and the ability to access services in real time, and for those services to be joined up, is really, really fundamental, so we think that there is certainly scope to learn from what's happening in England and see if it works and see if we can introduce that in Wales too.

Excellent. We're shortly, as a committee, doing a review into long COVID services. Geoff.

Yes. We are pleased to see that Betsi Cadwaladr have introduced an executive team member leading on long COVID, and they are considering the effects—things like chronic respiratory issues, the need for rehab and ongoing mental health concerns. So, we're pleased to note that they are really actively working on that.

Excellent. Okay, David, we need to move on. Angela, waiting times is partially covered already. A quick trot through waiting times, Angela.

Yes, I'll be really quick. Good morning, everybody. Thanks very much indeed for your evidence. I thought your 'Feeling forgotten?' report was really interesting reading, and as the Chair has said, we've already discussed some of the elements of it. But I wanted to know if you have any sense of the numbers of people who are actually missing from treatment services. You may be aware that Macmillan this morning published a report that said they reckon about 3,500 people are missing from cancer services who should be there, who should've come forward and said 'I need diagnostics.' Have you picked up anything along those lines? Do you have any sense of the numbers yourself of people who are simply not getting those diagnostic services that they want? That's the first question I want to ask.

The second question was talking about the diagnostic services, because we can't treat people until we know, obviously, what's wrong with them. Again, can you just give us a quick overview about the waiting times and about the availability of diagnostic services? Because many health boards say that they have reopened them up, that they are available, but there sometimes seems to be a bit of a lag that I've picked up, certainly, that GPs are reluctant to refer, people are reluctant to go and then, actually, there's a sort of virtual assessment of how urgent somebody really is, and of course, you can never really tell until you see somebody. I have a couple of other questions as well, but that's just to start.

Who wants to kick off? Geoff?

Yes, sure. I think Alyson can give a better national overview than I can, but I think, in some senses, Angela has answered her own questions. People are very, very worried about the risk of acquiring COVID. I think the vaccination programme will help with that. One of the most disappointing things for north Wales CHC was, in our joint services planning committee, to hear the director of planning tell us that it would be many years before they get to the position they were in pre pandemic. And of course, you will know that the position they were in pre pandemic was not great.

Okay. Alyson.

I think what we're not able to give you is any indication on numbers, Angela, but absolutely, in terms of recognising that many people are fearful of seeking help—still fearful of seeking help—during these times, and for others, exactly as has been described: we've had a mixed picture, with some people telling us that they've been able to access and be diagnosed quickly and lots of others feeling that it's taking far too long.

Donna Coleman.

Yes, I think one of the issues we have identified in Hywel Dda is, particularly for older people who are living on their own and who don't normally have a device, that's not their way of communicating, for them, getting into the system is difficult. Now they're having to stay away from GP surgeries, and whereas before maybe they even found the telephone difficult, maybe because they can't hear or it's a little bit bewildering to press '1', press '2' and negotiate options like that, they can't even pop into the GP surgery now to ask for an appointment. So, they are tending to stay away, and even if they get through that hurdle, having a virtual appointment or a telephone consultation is also something that they worry about, because they don't want to feel foolish because they can't hear or can't understand what is being said. And they may have sons, daughters and family members who live away and are having to stay away from them now, who would normally help them negotiate these things, but can't do it. And so, they're very worried about elderly relatives that they can't help any more. And trying to teach somebody to use a smartphone at a 2m distance, or at a 2-mile or 10-mile distance, is really challenging, because some people have never done things—. And even something simple like double clicking on an icon is something that they've never had to do and it makes them feel left behind.

Lessons that some of us are still learning. Aneurin Bevan, the view from there, Angela? Something similar?

Yes, very similar to my colleagues. At the beginning of the pandemic, people were really anxious about attending for their urgent appointments. What we saw the health board doing in some cases was calling patients to have a conversation with them to try to allay some of their anxieties. Very similar to my colleagues, really, but like Alyson said, I'm not able to provide any numbers, unfortunately, Alyson—Angela, sorry.

No. Thank you for that, and—

Hang on, Angela, I've got Geoff indicating. A brief intervention, Geoff.

Yes. Just to say that I'm pleased to see the developments in diagnostic imaging centres still moving forward, and I think that that's going to be—. To have discrete, separate diagnostic imaging centres that people can access rapidly is going to be key to recovering the referral-to-treatment time issue, post pandemic.

Good point. Sorry, Angela, you've got the floor.

Yes. No, that's fine. So, I don't want to name and shame, but I'm going to ask you a question that kind of slightly asks that. Obviously, some health boards have really got to grips with this and are moving at pace, and have reinstigated diagnostic services and urgent services quicker than others. Do you have a sense of which areas of Wales are really struggling? Also, you are the people—. The CHCs come in and challenge the health boards. Have you had pushback from health boards in general, or in particular, about getting those backlogs moving again?

Again, I've spoken to a few and they've said, 'Yes, yes, you're absolutely right, but the reality is that we don't have the doctors, we don't have the nurses, and we can't run both services—NHS normal business and NHS COVID pandemic fighting business—at the same time.' So, have you anything that you can tell us about that, and about where the real blocks for the waiting times are? Because we need to start addressing those and getting those backlogs down.

Geoff to kick off.

I think that the difficulty that they have, Angela, is that a lot of the traditional ways of getting rid of RTT backlogs are not open to them. So, for Betsi Cadwaladr, you would send people to Gobowen or to the Countess of Chester.

Yes.

They have their own capacity issues now, and really won't be accepting—. Similarly, with the private hospitals in Chester and the Wirral, they are fully occupied with either people who have chosen to go private now because of the problems of waiting, or contracts with English health boards.

There are also difficulties with—. Locums would be a way that you would have done it before, but it is extremely difficult, and I think that there are going to be—. The traditional solutions don't work and there needs to be some innovation. I remember in the 1980s when we faced similar problems, just due to long backlogs, there were specialist hospitals set up to do—. There was one in Warrington set up just to do non-complex joint replacement. I think that we may be looking at something like that. It's not going to happen on its own.

Angela.

Angela.

Yes, so—

Sorry. Too many Angelas. [Laughter.]

You can never have enough Angelas. [Laughter.]

Absolutely. In respect of Aneurin Bevan health board, we not seeing any pushbacks. But, what we are seeing is, traditionally, where diagnostic services could see up to maybe 10 to 15 people a day, they can now only see two or three people a day because of the social distancing and the PPE and the arrangements in the waiting room. The logistics of seeing a patient now are very different. So, I agree with what my colleague Geoff has said. It is very different, but it's not a pushback, it's just that the difficulties of keeping of everyone safe and the risk assessments mean that services can see fewer people per day.

Yes, good point. Angela.

Yes. Thank you. I remember that the Minister, in a session some time ago, did say that the reality—because of resources and the way that the pandemic has worked—is that we are looking at five, six, or maybe even seven years now to catch up again. I have had that conversation with Donna, for example, and Steve Moore. Having fought to get the waiting times down, now, of course, they've expanded. I think it's really interesting what you had to say, Geoff, about the idea of having specialised hospitals. You talked about Lucentis; I've had a lot of people come to me about the need for corneal transplants, cross-linking and all those kind of things, and of course, all of that's stopped. Apart from taking forward that kind of idea of specialised areas—if you like, the quick and dirty, the things we know we can do without complex requirements—are there are any other key areas of waiting times, such as cancer or screening services, or anything like that, where you think we really must concentrate first on?

I think screening services is a fundamental and has been one of those common themes throughout. People are really, really worried about missing that early opportunity to identify and treat conditions so that they are able to recover and survive. So, that's fundamental. What I would say, though, in terms of moving forward and looking to tackle these long waiting lists, is that what we have seen, within the NHS, is much more joint working between different parts of the NHS—so, primary care practitioners working closer together, working with other healthcare professionals, working across the primary care and secondary care divide. It's going to be really, really important that the lessons learned from that, and the ability to identify where things can be done differently, perhaps by different healthcare professionals, need to be embraced. The learning from this period cannot be lost and must be used to drive forward services in a way that has worked successfully in many ways for people during this time. 

Excellent. Geoff, briefly.

It's mental health as well, Angela, absolutely. It will be overwhelmed.

Good point. Angela, are you done?

I am done. Thank you, Chair. 

Moving on to testing now. Lynne is the queen of testing. Lynne. 

Thanks, Chair. Can I ask you please what your experience has been of the way testing for COVID has worked during the pandemic, and also for any comments you may have on how effective the contact tracing side of things has been and whether people are being contacted in a timely way, and whether they're getting the support they need? Thank you. 

There we are. Alyson—

Shall I kick off? 

Yes. 

I think we've had quite a lot about testing. In the early days of testing, the concern was about getting access to a test or perhaps having to travel long distances to a test centre. For people who didn't have cars, or didn't have access to help to do that, that was a real issue for them in the early days. As things developed, that noise died down, if you like, and then what people were expressing concerns about, and have been consistently expressing concerns about, is the timeliness of receiving results. That has been a fairly consistent thing around where people are talking about being isolated at home with families, unable to do anything, obviously, until they have those results. And we've heard about households who were tested at the same time getting the results back at different times, which has put everything on hold. The other consistent theme, I guess, has been around the contact tracing side of it, so lots of concerns about how quickly people were contacted, and how completely people were contacted. We heard from people who said, 'I know the people I've been in touch with, some of them have been contacted, others haven't', and that's been an area of concern. 

Then finally, I suppose, the area of concern was around the consistent advice from contact tracers. Lots of people were told that they'd be contacted every day, and then were not contacted every day. Lots of people were told late in the day, for example, that they needed to self-isolate within their own family, and they hadn't been doing that because they hadn't been told that. All of those things have been worked through, and in recent times, the level of concerns around test, trace and protect have been really, really quiet. One of the concerns community health councils have around that, and we know that health boards have, is that actually people are now maybe not accessing the tests now when they need to, and that's really fundamental. So, the communication around that and the communication of how important that plays, as we all recover from COVID, is vital.

Excellent. With apologies, there is dazzling sunshine here in Swansea—well, as is the norm really—so, that’s why my lighting is going a bit skew-whiff. Geoff, you indicated.

Yes, I did. The capacity and the speed has built up in north Wales. They’ve done about 0.5 million tests so far. It’s interesting to note that about 21,000 of those were positive. Turnaround from test to result is now averaging 100 per cent complete in 24 hours in north Wales. It’s pretty good.

Excellent. Lynne.

Thank you, Chair. I wanted to ask about shielding. Shielding is in place now until 31 March. Have you had any contact with shielded people, and if so, what kinds of concerns have they been raising?

Shall I start on that?

Alyson and then Donna. 

Just to say that this time around, we haven’t had anywhere near the kind of feedback and concerns that we certainly heard at the start when shielding was first introduced and when we had lots of concerns from people about, 'Should I or shouldn’t I be shielding?' 'I should have had a letter, shouldn’t I?' 'Where’s my letter?' 'Where can I get it from?’ All of those things that we heard at the start are not happening this time around, so we are not being bombarded by concerns from people because they really don’t know what’s going on. So, I think that’s really helpful. That said, we know from previous feedback what people are concerned about in relation to continuing to shield and that is things like being left behind and forgotten behind closed doors, the continuing impact on their mental health and well-being, a loss of confidence in terms of going out and interacting with people, losing contact with friends, missing out on family life and family development and a worry about losing their independence forever. Some of those things can be addressed through some of the bubbling arrangements, but those are the enduring concerns, I think, from people who are shielding.

I echo everything that Alyson has said. I think, in terms of shielding letters, one of the issues we were having from Hywel Dda was people needing them for their employers, and that was having an impact for them, because in terms of—again, linked in with the track, trace, protect system—the delayed results, people were noticing that it was having a financial impact for them. That’s what they were worried about as well, and whether their employer would perhaps think about letting them go, simply because they weren’t able to come into work. And linked in with that as well, we were looking at issues of travel if people were shielding—if you need to travel to get a vaccination. Lots of people have been asking us questions, and sons and daughters from away as well: ‘Can I take my mum to her vaccination appointment, if she’s shielding—is it safe and how can I do that?’

Excellent. Lynne.

Thank you. Finally from me, the committee’s heard concerns that some people were discharged from hospital without COVID testing and I wondered whether that was something that you had encountered, really.

Geoff. 

We’re getting mixed messages on that. We’ve asked about that specifically. Some people are saying that they were tested before they went home; other people were saying that they weren’t and that they were worried that they were perhaps positive and that they were going to pass it on. I know that they are now testing all patients to be discharged to nursing homes, but in a worrying development, some nursing homes are not accepting patients back, even when they test negative. That appears to be due to outbreaks in nursing homes or insufficient staff. As soon as I hear from the health board, I will let you know.

Can I ask Angela? Because I’ve certainly dealt with some people who’ve been discharged in Gwent without a test, so it would be interesting to get your perspective.

At the beginning of the pandemic, we were certainly hearing from people who weren’t tested before they were discharged and they were discharged still being positive. Sometimes, family members were driving them home and not actually aware that they were still positive. So, that was a theme at the beginning of the pandemic. Now we have received assurances that everybody who is discharged is actually tested before they leave, and we’re not receiving any concerns from family members or from the patients themselves.

Thank you. 

Jayne Bryant to wrap up the session. Jayne. 

Thank you, Chair. Geoff, I think you mentioned in one of your answers that the feedback you're getting more is overwhelmingly now about vaccinations, and you said that some of the processes that people are worried about are when they access a second vaccination or where they will be on the list. Can you tell us just a little bit more about that and how that's developed over this time?

I think after Christmas, when we knew that it was coming, people were particularly anxious. The start wasn't auspicious and went slowly, but here in north Wales it has very, very rapidly picked up, and I have to say that the organisation is excellent. They're doing about 30,000 vaccinations a week. We've heard that they could do well in excess of 100,000 vaccinations a week if they had the vaccine, now that the GPs are up and running. There have been a number of teething problems. We've had people reporting that they've had a call from their GP, and then a few days later they get a call via the health board to go to one of the mass-vaccination centres. That seems to be being addressed. These are problems that come up. We hear about the problems, they're fixed, and then we don't hear about them again. So, that's very reassuring.

The worry that people have now is they've had their first injection, when are they going to get their second one. Then the debate, nationally and internationally, about the space between the vaccines, I think, is occupying people's minds and worrying them. And, of course, in the vacuum of official information and comment, we have all sorts of stuff flying about on social media, and that doesn't help. One of the themes that we've had recently in north Wales is, because we have a lot of staff who live across the border and work in north Wales, people are saying that it's not right that English staff are given Welsh vaccines. But they're working in Welsh hospitals with Welsh patients. So, that's something we couldn't support. I think it's important that the NHS in Wales just continues to demonstrate that things are picking up apace after a slow start.

The virus doesn't recognise national boundaries, I have to say.

No, it doesn't, really.

Alyson.

Just picking up on Geoff's point, it's really, really important that the health boards and the Welsh Government are able to respond quickly to people's fears and worries because of what they hear on social media. Messages on social media, information on social media has that ability to reach people so quickly. We've heard in recent weeks, for example, about lots of young people being concerned about the impact of the vaccination on fertility. It's really, really important, when things like that happen, that both the Welsh Government and, if it's contained in an area, health boards are able to target the messages to those groups, using community groups, using the third sector, so that those kinds of issues are addressed and the facts are put out there as soon as possible, so that that social media storm is addressed as quickly as possible.

Okay. Jayne.

I think that's a key point, the point around communication, maybe, isn't it, and making sure that everybody's got those messages out. That's fine from me, Chair.

Good. Any other vaccination issues? Aneurin Bevan first of all, and then Hywel Dda before we wrap up. Angela.

Just to say, like my colleagues have said, we've seen lots of really positive experiences where people have had the vaccine and they've been made to feel safe, which is lovely to hear. But there are lots of common concerns, like Geoff has already mentioned, where people are worried that they're going to be missed. They're all trying to get hold of the service, picking up the line, to make sure that they're on the list and not going to be forgotten. So, I think, like any area of the NHS, it all comes down to clear communication and the health board learning. So, any feedback that we're receiving, we're feeding straight into the health board so they can continually learn throughout this programme. But it’s a mammoth task, and I think, in Gwent, we hit 74,000 people yesterday, which is amazing. But it's one of those processes that the health board needs to continue to communicate with their populations so people can understand what’s next.

Excellent. Donna Coleman to wrap things up.

In Hywel Dda, obviously people, like everybody across Wales, are really keen to have their vaccine. There seemed to be a bit of a slow start, but, obviously, it’s gathering momentum now. There are lots of questions people have got about it. They don't understand always why some people are being seen in a GP surgery, whereas the person they live with might be going to a mass vaccination centre. Again, there's the issue of travel, which affects us in rural Wales, as getting to a mass vaccination centre at half past seven in the evening may not be as easy for some people as it is for others, and again, family members trying to advocate on behalf of their loved ones to make sure that nobody misses out.

Sorry, I was just wanting to thank GPs in north Wales for so enthusiastically taking up the vaccination programme. It's really made the difference.

Great. We've got the GPs on next, actually, so I'm sure they'll be pleased to hear that.

Diolch, Cadeirydd. Good morning, all. As we keep reminding ourselves, it's been 11 months almost since the pandemic really started—perhaps even 12 months if we look at the first number of cases across the UK. And I suppose, in that time, what we try and find out is how the progression of COVID has happened, and how your members, the concerns from your members—whether it's GPs or whether it's pharmaceutical practices, pharmacists—are being raised by your members, and are there any new ones emerging now that perhaps you hadn't been aware of maybe in the first days of lockdown?

How's my screen working? Peter Saul to start.

Thank you very much indeed. Well, it's apparent that it's a marathon rather than a sprint, and one of the things I would say is that I think all health professionals—I'm speaking for GPs here—are weary, like the rest of the population, and it's taking its toll; it's taking its psychological toll. We know from our members that many of them are working at much higher levels than they were pre-COVID, and I'm sure hospital colleagues and pharmacy colleagues are in much the same situation. So, that's the staff.

What's happening, how's the emphasis changing? Well, we feel much more confident because we're perhaps more familiar with the condition and how it's going to be managed. I think the new variants are causing some concern, a lot of stuff we don't know about them, what the impact will be on transmission and how we're going to get out of this.

But turning to practical things, I think two practical issues I'd talk about are the vaccination roll-out, which, in general, has been very good. We're really pleased that Wales is leading the home nations in terms of its vaccination rates. I'm so proud of my members and GPs. In many areas of Wales, every single practice has signed up to offer, or said they're willing to offer, vaccination. So, there's been such engagement by the profession, and I'm really pleased about that. There are some hitches with the vaccinations, like, for example, I was talking to my practice manager earlier, and she was pointing out that we're not quite sure how many patients to invite to our clinics, because we're not certain how much vaccine we're going to get. So, we have to wait till the vaccine arrives before we can invite people, and, obviously, the less notice people have, the more inconvenient it is, particularly since we're relying often on carers to bring patients up to the practice. So, vaccine supply remains an issue, but it's one of those things.

Some of the organisational aspects of vaccine delivery—it's being run by health boards and clusters, so there seems to be a little bit of confusion around the edges with people being given duplicate invitations. We've heard reports of some patients having their invitations missed, and we were really pleased to note that Powys health board has got on their website a form that patients can complete, or anybody can complete, if they think somebody's being missed out. So, I think that's one issue that we're a bit concerned about—making sure that nobody is missed out.

And then the other the thing that I'm sure that other colleagues will be talking about is climbing out of this. The fact that we have been preoccupied, that, undoubtedly, we've not been able to focus on some of the regular work that we would have liked to have done, that we've had reduction in screening services, we've had reductions in access to diagnostic tests, and I think the cost of that will be delayed diagnosis of conditions that, perhaps, we could have done better with had we known about them earlier.

And then I'll finish with dealing with the inevitable waiting lists. It's going to be years before we get back to the way we were, because of clearing the backlog. From a community point of view, what that means is that we as GPs and our teams are looking after people who should perhaps be having more specialist support and diagnosis management, but we can't get them there, so it puts additional strain on us, but it also probably provides a sub-optimal level of care for the patient. But this is a fact of life, and I'm just stating it, not really complaining about it. 

Great, and we'll drill down to some of those issues later on with colleagues, particularly the vaccination points and the waiting-time points. General comments, Mark, first, then Suzanne. Mark Griffiths.

Thank you. Obviously, the issue that has been with us has been the amount of work that we've had to do, really, since the start of the pandemic, with extra calls on our services for things such as advice, and having the GPs carry on working, but working behind closed doors, has meant there's been an access issue for patients, and they have generally come to us with these issues. So, that's been a problem since the start of the pandemic, and what we did in late summer was we did an audit of this advice that we've been giving, and basically, the figures came out that it was approximately 15.5 consultations per average contractor that were extra consultations that amounted to one-hour-forty to two hours of a pharmacist's time. Putting it into consultations, that was 11,000 consultations across the whole pharmacy network, which came out at 86 consultations per GP practice that we saved.

And the other aspect of the survey: we asked about accident and emergency, and 3 per cent said that they would have gone to accident and emergency. So, that amounted to 2,000 appointments per week that we had saved. So, that gives you an idea of the extra work that we've had to do on top of our day job.

Obviously, the other aspect of summer to Christmas was flu vaccinations; I know that GPs had to do it as well, but I'm sure you've seen our press release in that we did nearly 40 per cent more vaccinations this year than we did the previous year, on top of what we had to handle with COVID. And it would have been higher than that if we'd had access to the Government vaccines earlier, so our November figures were a lot lower than they should have been, but as I say, we still did roughly 40 per cent more vaccinations.

So, we've been coping with extra workload, and unfortunately, the second spike coincided with our busiest time of the year, which is Christmas. So, December was a particularly stressful month, I have to say. There were a lot of people looking forward to some days off, as you can well imagine. So, they did have a little bit of respite, but it has, I would say, slightly calmed down in January, but it's still way above our normal workload.

Issues going forward for us will probably be things such as issues like holidays not being taken this year that have to go into next year, so we're piling up an issue there with regard to time off and how we're going to cope with that next year, providing of course we come out of this satisfactorily. If not, then I think I'm just going to be piling up even more of a problem as the time goes on.

We've indicated that we obviously want to get involved with the vaccination programme. Obviously, we want to get as many people vaccinated as quickly as possible in a safe way with limited wastage, which is what Public Health Wales—that's their motto, and we totally agree with it. We want to fit into the system as best we possibly can, and we feel that later on in the process—possibly from group 5 or 6 onwards—is when we can probably be very, very useful, because you're then talking of the working population, for whom the convenience of using a pharmacy would probably be of use.

Obviously, we've got approximately 713 pharmacies—well, we've got 713 pharmacies, not approximately—we've got approximately 600 sites that are vaccination approved, so if we only did 10 per site, we would be doing 6,000 per day, which, when you add up to all the other sites that are going on, that would be a considerable amount of vaccinations. So, we're ready, willing, and I consider ourselves able; it's just we need the call, and we need to be told when we want to do it, but please give us plenty of notice, not a couple of days' notice. Let's get ourselves organised so we know where we are.

Great. We'll be coming to that later, and I suppose that a bit like Jayne Bryant earlier with family members involved with the witnesses, I'd better declare that my daughter is a pharmacy assistant as well. Suzanne Scott-Thomas.

Thank you, Dr Lloyd. Yes, just to reinforce all that's been said, I think we're all very well aware that COVID has provided us with additional challenges and services to deliver across the whole areas. That includes primary care and it also includes our acute services. The vaccines have certainly added another big challenge to the pharmacy profession across all areas, and just to say I think pharmacy has been front and foremost in the strategic planning and the operational logistics that these very complicated vaccines have posed to us. But I think it has been met with huge enthusiasm, and to endorse that Wales is doing very well in the delivery of the vaccine roll-out. But we are using the same staff across the health boards to provide the leadership for the vaccines, and again, the same staff are being used to stretch the services across into field hospitals as well as cope with the additional demands that the additional patient numbers into acute care are giving, and across into primary care as well, as we heard from Mark. So, I think what's different as we go on is realising that we have to maintain a lot of these services—vaccines, field hospitals—they're not going to be switched off at the end of March. This is something that is going to continue. And also then, how we build back in the normal business as usual, I'll call it, then, to address perhaps the unmet need that has been ongoing through the time we've been addressing the COVID response.

So, I think staff are now realising that they are tired—I'll reiterate what everybody has said. Staff are tired across all professions, and are at risk of burnout. The Royal Pharmaceutical Society did a survey in 2020 that showed that about 89 per cent of the members were saying that they were at risk of burnout, and that was across all areas. But we know that, what we're hearing at the moment is that there are plans to switch normal services back on, and I think you've got to take into account the well-being of those staff who, as Mark said, have not had the holidays that they would have normally had, not had the breaks—it has been full on. I think that is the term I would use for the last year, and that's got to be taken into account. Some staff may need to be moved from their normal areas of service and expertise, such as intensive care units, to give them some time out. How do we build all that in to our turning back on of normal services so we take staff well-being into account?

One thing we've got to have is, we've been planning at a frantic pace, I think, with everything, and everything is done on a just-in-time basis, but what we've got to try and move towards is a more sustainable plan for vaccine delivery, for the new normal and the use of the additional, wider field hospitals. That has to be a balanced plan and, I have to say, a well-resourced plan so we take staff well-being into account.

Excellent, full answers there. David.

Yes, thank you. Very full answers, and actually they lead on to a few things that I know my colleagues will ask questions on in a minute. Therefore, I'll just stick to the last question for myself. For people who are recovering from COVID, clearly there are various symptoms and conditions they experience as they recover. Some have tight chests, some have difficultly breathing, some will have sore throats, and so on, and there's obviously long COVID. I suppose the question I want to ask to both Mark and Professor Saul is—how prepared are your members for that type of approach? Because this is, I think, going to be something that is more than simply just somebody asking about a chest cough, and saying, 'How can you help me?' It's an implication of having had COVID, and many people across Wales are now going to be experiencing that.

Peter Saul, chronic COVID?

Yes, it's something that's raising its head above the horizon. We were pleased to see the launch of the chronic COVID app. That's helpful. We acknowledge that most of the care of long COVID patients will be through primary care—GP practices and their teams. That will work providing we can increase educational support; I think educational support for colleagues is really important, so that they're given the educational tools to recognise and manage it in effective ways. As a college, we've already started work on that. It will also rely on easy access to diagnostic tests, because we have to rule out other things to make sure that symptoms are not due to something else that we need to do to treat appropriately. And also, really fast-track specialist access where we might need to refer them to a neurologist or a rheumatologist where we need some additional support. So, yes, GPs are up for managing this with the right sort of support, both educational and from secondary care. 

Excellent. Mark, on chronic COVID.

Not a lot more to add, really. Obviously, I think we will get quite a few coming in to us, so an educational package would be useful so that we can recognise the symptoms, and then it's a matter of being—. Part of the process of being one of the gatekeepers of the NHS would be to refer these people on to the right places so that they can get the right treatment. 

Excellent. Suzanne, anything to add to that? 

Just to reinforce what Mark said, I think the education of all healthcare practitioners is essential in understanding what long COVID means, and I think that's something that is developing; we still don't really fully understand what the implications are. We are learning through our own members, actually, who are suffering long COVID from contracting COVID earlier in the wave, and that's something we are continuing to do to upskill our members in how best to manage it. But it's many and varied—it's mental health, it's physical, so having that multidisciplinary approach is fundamental to managing and supporting the people in the community. 

Excellent, and this health committee will be undertaking a review into so-called long COVID shortly, actually. David, are you happy with that?

Yes. If we've got time, I'll come back to something I want to ask, but at the moment I'm okay.

Great. Moving on to Angela, some of the issues have been touched on, but I'm sure you've got fleet of foot these days, young Angela. 

Thank you very much, Chair. Thank you, everybody, for your evidence. I just want to talk about the whole process of treatment times, waiting times, waiting lists and so on and so forth. Peter, in your evidence it was quite interesting, if not rather gloomy, your comparisons to the Ebola crisis and the whole non-COVID harms but, of course, we are seeing that at the moment. You also say that there has been a bounce back of people coming into GP surgeries asking for help. Can you just flesh that out a little bit more? Has that bounce back been sustained, and although people may now be coming back to you, are you then finding it easy or not? Throughout Wales, are there particular areas where it's more difficult to then refer people on for further diagnostic investigative treatment? 

Thanks very much. So, first question was patient demand or identification that there's a problem. So, yes, that fell quite dramatically at the first stage, and then over the summer it picked up to what we would call normal levels. I've seen probably a bit of a dip more recently. I think it's partly the population is thinking—. It's their perception of health services at the moment, and I think the perception, quite rightly, is that we're actually quite focused on delivering vaccinations. So, people tend to say, 'Oh, I don't want to bother them, it'll wait until—'. And the message that we need to get across, that we're trying to get across is, 'We are here, yes, we are doing vaccinations. We don't want to have to be doing non-essential things like a letter to your employer to say that you need something at work, or whatever, but we are there and we want to see you if you have any concerns about other health matters, if you think you might have a lump, or something like that.' But you're right, I think that there is a reticence in the population still to come forward. 

Moving on, I think you were saying, 'What's the impact of that?' We're storing up—

No. How difficult is it for you to—? Once people get to you, how difficult has it been for you to then push them further up, if they require more investigative work?

Yes. We've seen limits in hospital access. Once upon a time, for example, in my part of the world, we could just refer people straight for an x-ray. They could turn up at the x-ray department. That's been limited in the sense that now they'll all have to make an appointment, which is understandable, but also a lot of the requests are being reviewed and seen if they can be put back, because some of the procedures, for example, are quite intensive in terms of hygiene and cleaning and things like that, so the capacity has been reduced.

The other thing is that clinics—. When we do want to refer somebody, many clinics are not operating at full capacity, many clinics have been cancelled, and, of course, surgical procedures have been much reduced over this last period. Patients: I think patients are, if you like, complaining less to me. Previously, I'd often get people coming in and saying, 'Oh, you know, it's six months' or, 'It's a year I've been waiting for this particular procedure; is there anything you can do to hurry it up?' People aren't saying that now, because I think that they are understanding about the situation in the health service. But I think as we move out of the current crisis, hopefully—please God—later this year, I think that there is an unidentified demand of people saying, 'Well, actually I'm in quite a lot of pain with this hip and I've been waiting 18 months, what can you do about it?' because they're realising if we get on top of this that we've got other things to do. So, I foresee increasing concerns raised by patients as we get on top of things from the COVID point of view.

Angela.

Are any of you able to identify any particular areas of concern that you may have? A previous witness, for example, said that the whole ability to deliver Lucentis, and to keep that chronic care programme going, was falling by the wayside, so people are literally losing their sight. Would you look across the whole space and say that we've got a real problem in—I don't know—breast cancer referrals or whatever? I'm not sure if you're aware, but this morning Macmillan published a report basically identifying that they felt there were about 3,500 people who are missing from the cancer diagnosis pathway, and both Macmillan and Tenovus report pushback from health boards and the Government as to how they might plan to be able to combat these waiting lists. I just wondered if any of that chimes with you at all, across the space.

Peter and then Suzanne. Peter.

Yes. You mentioned, Angela, about ophthalmology services. That is an important area and patients are missing their appointments. I don't know if you're hearing from optometry in this group, but they're an important area who were almost picking up some of the slack by doing some of the things that the hospital clinics should be doing in terms of monitoring some of the conditions, so they've had an important role. I think one of the ways out of it is to try and think differently. We've learnt much more about remote consulting, video consulting, telephone consulting, and hospital colleagues are taking this up as well. I think one of the answers is that, when we come out of this, we are going to have to work more efficiently and more effectively and more in partnership with our patients, and probably perhaps asking more of patients as well in terms of managing their conditions, and I think this is a positive way forward.

May I just ask on the pharmaceutical side, because, of course, waiting times are also for people with chronic conditions where they need constant check-ups or tweaks to medication? Is there anything where you feel that the pharmacies could—? Already, I know that you provide a range of services in-house, not just flu vaccines, but you'll do diabetes and all this. Is there anything else or any other areas that have really leapt out because of this pandemic, where you sort of think, 'Actually, we could take this on board' and thereby help to relieve some of the waiting times on, particularly, chronic care management?

Excellent question. Suzanne then Mark.

Yes, thank you. I think all the points are leading us to look at all the healthcare professional knowledge and expertise that we've got across all health sectors. And we've got to shift the traditional model; this is a huge opportunity to shift, as Peter has said. You know, the optometry model is a classic where, if we use prudent healthcare principles, then we're shifting that care, and chronic condition management is probably one area where we could look more closely at who does what, when. So, you're releasing the key professionals to do what they do best and then others can contribute and upskill, contributing to that total multidisciplinary team. There are some enablers we'd need to do that, such as shared patient records, et cetera, but that's all very doable. And with the IT infrastructure that is starting to emerge from this, why wouldn't we do that?

I think the other area you talked about in terms of waiting lists, one indicator of that, perhaps, is the use of medicines. And we know in Wales that we have potentially a high opioid burden in the communities, and that is only going to go one way at the moment if people aren't addressing their pain needs. So, I think one area we could look at differently is managing people on these waiting lists, so that they're not being prescribed medicines that can be beneficial, but also very harmful. We need a different pathway for them, perhaps, so that they're fully involved in knowing what those medicines can do, and pharmacists are well placed to provide that advice to patients, so that they're well informed about what they're taking, but also whether there are alternatives. Could we be using maybe some non-medicine interventions? And we have some really good pharmacists leading in the world of pain as well, who we can use to inform that. So, it's about looking at things differently and seeing and recognising what healthcare professionals we have out there and what they could contribute to lots of different pathways, and that is something that we will be working on with everybody to make sure that that can be done.

Excellent. It takes a pandemic. Mark.

Yes, obviously, Suzanne has stolen a lot of my thunder. [Laughter.] But what I would say is that we are fantastically placed, with the common ailments scheme, to be taking a lot of the less serious consultations from the GPs, so that they can spend more time with what they consider to be the more serious conditions. I think with the advent of independent prescribers in Wales and the idea that every pharmacy by 2030 will have an IP, I think that that is going in the right direction. Obviously, the pandemic has put a bit of a spanner in the works in that, in that it's very difficult to get in with your mentor, but let's hope that this is just a minor blip along the road. Other than that, pharmacy has been more or less business as usual, just more business than usual.

One aspect that probably needs highlighting is the amount of deliveries that are being expected by our patients now, who are shielding or don't want to come out because they don't want the risk. There are instances where people's delivery services have tripled in demand since the beginning, so these types of things have caused us issues. But, as I say, most of the other points have been brought up by Suzanne.

Excellent. Angela.

Yes. Just one final question, then. And again, this one's more for you, Peter, and it's about mental health. We know that mental health has been severely affected by the pandemic and we know that there will probably be—. And I'm not talking about the really chronic psychological conditions, but particularly low-level anxiety and depression, and people need to go somewhere and there's going to be a backlog there, or there is a backlog. Has your college given any thought to how that may be managed—I'm guessing that, for most people, their very first stop will be to go to their GP and say, 'I'm feeling really sad, I'm really anxious, I feel sick'—so as to how those waiting times might be handled?

So, again, one of the roles of the college is educational support, but also pressurising NHS Wales and the Welsh Government to support further development of community-based mental health services. Now, some of those will be self-service, if you like, app based and using new technologies. That's happening in some places. Some will be practice-attached mental health workers, which is really, really valuable. But, other areas are probably easier access to help when it is needed.

There still are issues, particularly with adolescent mental health and, in some areas, with adult mental health, and we need to make it easier to get access for our patients there. Yet, you are quite right: it is going to, I think, dramatically increase this year. It's one of these groups of people—. Or, these are a group of people who fall into that category that I was talking about before, where they don't really want to bother the doctor because they don't see it as important. And it is important because it is impacting on their lives and well-being.

Thank you. I'm done, Chair.

Moving on, Lynne Neagle.

Thanks, Chair. Can I ask about testing, please, and what the experience of your patients has been of the quality and timeliness of support from test, track and protect—test, trace, protect?

Peter, you kick off, and we'll come to Mark then. Peter.

Yes, well, GPs haven't been directly involved in testing. We advise patients when we suspect that they might have COVID that they should get a test done. It seems to have settled down. I'm not getting complaints. I'm not hearing complaints from patients about the difficulty of getting tests. Everybody seems to be able to get a test relatively easily, and they seem to get the results in a timely fashion.

Track and trace, I'm not in a position to comment about that. I don't really know how effective it is, because patients don't tend to report to me that they have been contacted or questioned about it. So, yes, my summary is: testing was patchy but has improved and is generally delivering reasonably well at the moment.

Some people would say that it's a weakness of the system that general practice was not involved from the start in the testing situation, but we'll—. Mark, do you have anything to add?

Not really, because it's the same with—. The only evidence that we have is that, when we've needed to get somebody tested within our group of care workers, it has been done very efficiently, I have to say. Track and trace, I haven't got direct evidence, but I have heard that it has been a little patchy on occasion, with regard to how they are treating the pharmacies, if it's one of the people who work there who has tested positive. I think that, as long as you are using the right PPE and you are going through the right procedures, there really shouldn't be an issue. I have had people working for me who have tested positive, but I have never, ever had a contact from track and trace. So, no, I have to say that it has not been an issue for us.

Suzanne.

Nothing to add in terms of experience of track and trace, where I can only say that, where staff have been involved, it has always been very efficient. It was a little bit slow to start with, which could have led to staff needing to take more time off if it was a negative result, and trying to get them back into the service. That has improved. The efficiencies have stepped up. There were some concerns around our community pharmacy, and getting them tested at some point, but I think that, as Mark said, that has improved as well. I can't speak from a patient population, but from managing staff and keeping staff in work—which is essential at this time, when we can sometimes have up to 20 per cent of our staff off at any one time—we must have an efficient process and it has improved.

Back to Mark. 

Just to add, at the start of the pandemic in March and April, we were having some issues with PPE, because some of the quality of the stuff that we were receiving wasn't up to standard. So, some of the staff were a little concerned about their own welfare, and obviously their families' welfare. So, we did have to go out and get what I considered to be better quality PPE. But that was fairly short-lived, and ever since, access to PPE has been excellent and very timely. 

Excellent. Back to Lynne. 

Thank you. Can I ask about shielding, then, which is in place now, obviously, until 31 March? What role has primary care played in shielding? And if I could ask Dr Saul about the role that GPs are currently playing in making sure that the shielding list is up to date. Because I know of people whose conditions have begun since the original shielding list and they've gone to GPs, who've said, 'Oh, no, this isn't a matter for me, this is Welsh Government.' Clearly, it's important that people who need to be shielded are on that list. 

At the beginning of the pandemic, the shielding was a bit here and there, hit and miss. People got letters from the Welsh Government, and people were coming to GP practices saying, 'Look, I haven't got a shielding letter and I've got this condition.' So, what we were doing is we were adding them and we were putting codes onto the system. What happens, I'm led to believe, is that the Welsh Government pulls out the codes from GP systems and sends letters to patients that they're on the shielding lists. Now, if the codes were not there, or if they were the wrong code, then patients could get missed out. So, the first stage was really about correcting those codes whenever possible. Obviously, it's often down to human error, inputting error. It wasn't a huge problem, but it affected a significant number of people and we accept that. 

Since then, GP practices have been careful about putting—when people have got new diagnoses, making sure that they're on the right code, and keeping the codes up to date. It's those codes that really determine whether somebody should be shielding and whether, in fact, they'll get a vaccine in the group that is the 'under 60 but at risk'. That will be determined by those codes. So, we would urge anybody who thinks that they have been missed out to phone up their GP and have a word and make sure that they've got the right diagnosis code on the system.

Thank you. We've heard, I think from this panel, prior to the second phase, that there were issues with sustainability of medicine supplies. How is that going now? Has that improved?

Mark, go on. 

There's been a few shortages through the year, but nothing that hasn't been manageable. I can't honestly say that there's been any real supply issues. It just obviously takes more time to actually get some drugs, whereas normally you just put it into the computer and it comes in the next day. You have to chase around a little bit to get things. So, it has added to the workload, but I can't say that any of my patients—and I haven't heard from any of my colleagues that there's been any serious supply issues during the pandemic. 

Good. Suzanne. 

I think, as Mark will reinforce there, we are well used to dealing with medicine shortages. It's nothing new, and I think we have well-rehearsed systems and processes in place now so that we are reducing the risk from medicine shortages and protecting the patients. But, sometimes, as Mark says, it does add to the workload in terms of where you are sourcing them. 

In the acute care sector, with the huge increase in managing patients in the ICU environments, that certainly has put pressure on medicines specifically for those patients on ventilators in particular. Through the first wave the supplies had to be very closely managed, both on a national level and a local level. I think, in Wales—I am a chief pharmacists by trade—we managed very well, I think, on a mutual aid sort of system and worked very closely together to manage those limited stocks so that none of our patients were at risk of running out of medicines at any time. We were moving stocks around Wales to make sure that we were addressing the greatest need. That has been much better through the summer and into the second wave.

We are starting to see some pressures on certain supplies again, as, again, the patient numbers have increased across the UK, but again, we are managing that, I think, very effectively and there is currently no risk to patient care. It's something we've got to keep a very close eye on on a day-to-day and a week-to-week basis and it is part of our day-to-day work now that medicine supplies are managed very closely. COVID has put an additional pressure on our logistics teams within the acute sector and in primary care to ensure that supplies are meeting patient demand.

Okay. Thank you. And finally from me, then, on hospital discharge, concerns have been raised with the committee about people being discharged from hospital with COVID. Has that been a concern that's been raised with you at all—whether that's to care homes or back into the community without knowing that they're COVID-positive?

My experience from north Wales is with the rainbow hospitals—the emergency hospitals being used for discharges, or that have been used for discharges—with patients who it's felt don't need acute intensive hospital care, but are still COVID-positive. So, they've gone there until they're COVID-negative. I'm not aware, but I wouldn't necessarily know, of the situation in care homes—whether they have had to accept COVID-positive patients. But I would have thought they'd be reluctant, and understandably so, to do that. I'm sorry; I can't really help any more with that question.

Okay. Thank you.

Okay. Moving on, because we're sort of out of time. Lynne, are you okay with that?

Yes. Thank you, Chair.

Jayne to wrap things up, and we'll try and free a few microseconds for David Rees's question as well. Jayne.

Thank you, Chair, and good morning, everyone. You've touched on this at the outset around the vaccination process. How do you feel that the speed of rolling out the vaccination has been going?

Who wants to kick off? Peter Saul.

Sorry, I don't mean to monopolise this, but GPs have a tendency to do things like that, don't we? The vaccination roll-out—it was initially a little bit slow and disorganised. We had concerns about care homes—very slow to get started. It was slow to get started with key staff in Welsh hospitals, compared with England. But I have to say, it seems to be gathering force and we don't really have—. There are little problems here and there, but it seems to be working reasonably well. And, as I say, I think that's been helped by GPs being involved and now pharmacists being involved to deliver it.

Suzanne. You're on—

Can you hear me now? Thank you. Yes, the pace initially was probably due to the complexity of the initial vaccine that we had—the Pfizer vaccine. It's a very difficult vaccine to manage logistically—to store it and to move it around is increasingly difficult. So, I think once we got to grips with that, I think now the experience and the delivery is much easier, and we've got the AstraZeneca come on, which is a much easier vaccine to handle and to move around so that we can widen the delivery model of the vaccinations. So, I think I agree with Peter; it is gaining a lot of pace and we are now getting to the targets, I feel. I'm saying 'we'—I'm speaking with my health board hat on rather than by RPS hat on. It's difficult to differentiate the two. I think, as I alluded to, what we've got to look at now is that sustainable service, because one of the legacies, I think, of COVID, is going to be vaccination. It's not going away. It's going to be with us for a long time to come. So, that's something that we've got to get—. We've got the initial service at pace, but we've got to look at the sustainable solutions now.  

Great. Jayne, are you okay?

Can I just come back, Chair? Whether it's GPs or pharmacists who are involved within the roll-out now, how are you feeling about how we're moving forward? For GPs, anyway, do you feel your involvement—are you happy with how things are going? With pharmacists, I am aware that Community Pharmacy Wales have got an active list for community pharmacy involvement in the vaccination programme. I'm just wondering if you are being utilised as much as possible. What do you think is preventing you from being utilised more than you are at the moment?

Mark, do you want to elaborate or make any other comment?

Yes, by all means. There's been a pilot site in north Wales—not last weekend, the weekend before—that proved to be quite successful, and I think there's quite a lot of learning from that. So, we're hoping that things will—. When the health boards are ready for us to help out, we are more than happy to help out. Now, I would suggest, with the amount of vaccination that's going on at the moment, it's very, very difficult for me to sit here and criticise, because they're doing really well. I don't want us to be set up to fail. What I want to do is to be set up to succeed, and as I say, I'm quite happy for pharmacy to be—. It could be an area in Wales where there's an issue with regard to availability of the vaccine—then we'd be more than happy to be looking at stepping into that position. But I think our role will be—[Inaudible.] I think later on is when we will be very, very useful, and if the vaccination is like the flu vaccine, that it has to be done on a yearly basis, then, obviously, the GPs and ourselves are going to have a lot of extra work, which we're more than happy to accommodate. The beauty of us is that we're in the community, so it does help with that type of thing. So, people having to travel any extra distance—we, hopefully, can cut that down to make it a better patient experience. But, other than that, from my own personal point of view, I'm just happy that the whole thing is working so well at the moment. It's really nice to see the NHS succeeding at something very well.

Excellent. Peter, briefly.

Give us the vaccines and we'll get you the arms. Basically, that's the limiting step—how much vaccine supply we've got. And the other point I'd make is, building for the future, how we incorporate this, probably for the next few years on an annual basis.

Mark is volunteering an arm.

I had mine a week last Friday, thank you very much. Just one point. Can somebody tell Mr Drakeford that pharmacists have to be on their premises to do what their normal day job is? We can't be manning the vaccination centres during working hours. Because he's making that point at lots of his public announcements, and we can't do it. We've got a day job to do. If they're out of hours and things like that, we're more than happy to help out, and on weekends and things like that. But our day job is full on, and by law and regulation, we have to be on the premises. I'm sorry to have a rant.

No, no—I'm sure he's watching this along with the many millions of people worldwide. Final question, briefly, David Rees.

Thank you, Chair. I will not take much of your time, because I'm sure we're already over time. But something that hit me is the variants that we are now experiencing. Clearly, viruses do mutate—we expect probably more variants, possibly, if we don't get on top of this worldwide—but they also present different symptoms. The traditional symptoms of the loss of taste, the high temperature, the cough are added to now. Because I know that some of them are more like cold-like symptoms. How much of a challenge is that to both the pharmacists—somebody may come in with those types of symptoms, not thinking it's COVID—and the GPs, who identify who has and who hasn't got COVID now? Because this is the picture, and I've seen it in my own family. My wife had the loss of sense of smell and taste; my daughter had a sore throat. So, the different symptoms now are identified, so how much of a challenge is that for you?

A big challenge, I would say. Mark and then Peter. Mark.

Yes, I absolutely agree. It's all about keeping us as informed as possible on what the current likely symptoms are. Obviously, we all know about the taste and everything else, and the fever, but if it's deviating into something else, then we need to keep up to date as much as possible and the information needs to be given to us as quickly as possible so that, when these people present themselves to us, we can push them in the right direction. And I think that's the big issue at the moment. The virus is quicker than us at the moment, I think.

Yes. Clever virus. Peter, and then Suzanne can have the final word. Peter.

I think that it shows that there’ll be a continual need for testing into the future. The other point I'd say is that we need, probably, better near-patient testing. So, we've all heard about lateral flow tests. These are—. You get an answer within maybe—I can't remember—10 minutes or thereabouts, and they’re potentially quite useful. They have to be used in the right way, otherwise their accuracy is quite low. But we probably need to develop better methods of doing this, so that when a patient turns up and you are thinking, 'This could be a COVID diagnosis, but it maybe isn't’, but you need to do something there and then, you can actually offer them a test, a clinical test. I don't mean as a routine for people, but, in a clinical situation, where a patient is consulting. So, better testing, I would say, is part of the answer.

Suzanne to wrap things up.

Thank you. I think one thing I have learnt through COVID is that it is a continually and fast-paced changing environment. You can never say, 'I know it all' or, 'We've dealt with that matter.' It is something you have got to be continually on top of and continually keeping up to date. And I think, for healthcare professionals, that is a huge challenge to do on top of managing the day job and treating patients. So, I think everybody is right in terms of what we need to keep going, going forward, in terms of testing and rapid access to that, and taking no chances. But keeping on top of the huge amount of data and information that is coming out, I think is going to be a key issue, and how we keep our healthcare professionals informed and up to date is something that we must build in to sustainable services. And particularly for community pharmacists and pharmacists, it's time out to keep that professional practice up to date.

Diolch, Cadeirydd. Morning, all. We'll start very easily. What views or perhaps key messages are you getting from your members now—better perhaps than what they would have been before, but what are your now key messages that you hear from members relating to their experiences of COVID-19, and perhaps how they want to see it moving forward? So, who wants to start?

Olwen to start, and then Richard, then Lisa.

Diolch yn fawr iawn—thank you very much. I think probably our biggest challenge around the second or what we might call third wave of COVID is actually the workforce's capacity and fatigue that they're experiencing with having to deal with such—not only the COVID pandemic itself, but also trying to maintain their normal day's work; so, running a non-COVID service and a COVID service in parallel. And, of course, some of the issues they're finding is that this is causing extra strain, especially when we're probably going to be wanting to go back into running full medical services across all aspects of medicine come the spring. And, really, the challenges that our medical workforce have been having are issues around psychological well-being, moral injury and burnout. And most of us work in the communities that we actually live and serve in, and therefore it's—. We're all in this together, but we're a proud group of clinicians, who possibly might not come forward and actually say that we're suffering, so I think it's around our well-being and looking to how we can actually support each other, but also be supported as we move on into post-COVID pandemic scenarios.

Mr Johnson.

Thank you. Good morning. I would agree with everything that Dr Williams has said as regards the severe psychological and physical effects we've had on the workforce. Obviously, as the Royal College of Surgeons, we're very keen to get things and elective services and planned services moving as quickly as possible, but we can't expect the staff to go and start working flat out straight away; there is a period of rest required, of reflection. And I think, as staff do reflect on what's been happening to them, and what they've seen, the psychological effects of the pandemic are going to affect staff at different times and at different rates. So, I think there's probably a huge unmet known of how staff have been affected by this.

Yes. Lisa.

Yes, absolutely. I think my colleagues are right: the strain on the workforce is really quite incredible now. People are very, very tired. I think there are issues, which I'm sure the committee might well have specific questions about, in terms of access to testing, access to the vaccination programme, access to risk assessment, access to counselling services and support. All of these are creating strain on the workforce in the NHS and in the social care sector.

I think one of the things that we're very mindful of is that we went into this pandemic situation with a minimum of 1,600 nursing vacancies in Wales, and that's a very conservative estimate. So, we went into this with a workforce that was already stretched and working beyond normal shift patterns in order to cover the day job. So, where we are now is a situation where our members are suffering because they see the standards that they would expect of themselves and their colleagues suffering, and patients suffering as a result of that.

Okay. David.

The key message I'm getting from all of you is clearly fatigue, exhaustion and the long-term impact upon people's mental well-being following the pandemic. That's the key message. On the latter point, before I go on to a question on long COVID—on the latter point, is there sufficient support in place? We keep being told by health boards that they are putting measures in place. Is there sufficient support in place at this point in time to support your members with the trauma and the experiences they are facing on a daily basis, because I'm sure many are going to be struggling as a consequence of this?

Okay. Olwen.

Yes, I think there's probably the support in place. The difference is around, actually, its accessibility and people's realisation that they actually require support. I know that sounds a really bizarre thing to say, but people need to be asked are they okay and actually signposted, and we need to do that. Certainly, what we've found, talking to our doctors in training, they have been really good at accessing support; when it comes to more senior members of the medical workforce, not so much. In the first wave, yes, there were some very obvious well-being services, drop-in sessions. In the second wave, we've not seen them as predominantly, as obvious to access. But, again, coming back to—. The thing is, if you've got a very stressed workforce, with lots of rota gaps, with lots of people working extra, where do they get the time to actually go and look after themselves? I think that is an important thing to consider. So, going back to what my colleague from the Royal College of Nursing was saying—if you're going into a pandemic with lots of gaps in jobs, you've got to move forward and look at that in a realistic way. 

Richard Johnson. 

I think, as Dr Williams said, there are services available. Whether those services would be sufficient if every doctor came forward is another question. I think the medical fraternity tend to think they're okay, and don't seek the help that they need. But I think it is available for those that do feel that they need it.

Lisa Turnbull.

Our understanding is that the service is available for nurses. However, we're less clear as to whether that service is available for healthcare support workers. We were very pleased to be able to meet with Minister Eluned Morgan this morning, and we raised this issue with her, and she has committed to looking into that, because, clearly, people are seeing things that they would never normally see, and they are being traumatised by that, and it's important for the whole team—healthcare support workers, and also porters, receptionists, everybody—to be able to access these services. So, we would like clarification that those services are indeed available for everybody.

Excellent. I feel a recommendation coming on. David.

Thank you for that. It's very helpful. Obviously, we also experience—we're starting to see long COVID coming through the system, and I suppose what we're trying to work out is: have you yet assessed the impact of long COVID upon the work you undertake and the members undertake? And of course, for example, there'll be some members of yours who actually will be experiencing that themselves as well. So, what are the implications that you see of long COVID on the future delivery of services, and particularly for patients?

Lisa Turnbull to start this time. Lisa—Lisa Turnbull.

I think the honest answer is it's too early to tell. It's not something we will have a great deal of expertise in, but one area that we are conscious that will be looming is actually some of the mental health impacts, such as post-traumatic stress disorder, which we know tends to manifest itself later, after the period of—[Inaudible.]—so, one of the things that we are concerned about, for example, is that services, including occupational health, in the NHS are actually prepared for the next year—for the next year, next possibly two years—in terms of supporting staff back into the work process and supporting staff in work, because the occupational health service itself needs to be developed in order to have those resources, and that would also include the physical aspects that you describe of long COVID.

Richard Johnson.

There's nothing being specifically raised by our members at the present time about the effects of long COVID, so it's really quite difficult to comment on that, but I'm sure it's something that will rear its head as time goes on.

Okay. And Olwen Williams.

I think one of the things that our members would like to see is the establishment of multi-disciplinary teams, so that there is actually a long-COVID service available for everybody across Wales, and we welcome the launch of the app for people suffering with long COVID and the self-care aspects. But we're aware that this isn't a one-system disease; it is a multi-system disease, and these people need support in a much longer way, and to be taken seriously as well. So, they need psychological support as well as rehabilitation, but also things around people developing diabetes, cardiac problems, respiratory problems, dermatological and joint problems. So, it might be that we need leads in each health board that actually take this on board, I think possibly with GP input as well.

Good. I can feel another recommendation coming on. David, are you done?

Yes, thank you.

Great. Moving on to another vexed issue, Angela.

Yes, thank you, and thank you very much indeed for your evidence session today—or for your written submissions. I just want to talk about waiting times, and I'm actually on the Royal College of Surgeons page, because I think your numbers are stark. You say that there are now 529,269 people in total waiting for some kind of elective treatment in Wales, and that this has been a growth from some 22,000 a year ago to 231,000 waiting more than 36 weeks. This does not take away at all from the extraordinary efforts of the NHS in fighting this pandemic on behalf of all of us, but we talk a lot about non-COVID harms and how important it is that we don't let other people fall by the wayside, so I wanted to first of all ask your views on—. I was really interested in your recommendation about COVID-lite sites should be established at pace throughout Wales. Now, this is something we have talked about in the Senedd, and I've also spoken about it to my own health board, and we're always told that this is incredibly difficult to do, that hospitals aren't neatly chopped in two so you can have one building for one and one building for another. But I'd just like your feedback on it, because, to the layman, COVID-lite sites sound like such a brilliant way forward that would allow us at least to get going. I don't know who'd like to start.

It sounds as though that's one for Richard Johnson to start, anyway, and then we'll come to Lisa and Olwen.

I agree. The figures we're talking about on the waiting list are eye-watering figures, and it almost seems an impossible situation. The effect on patients waiting for surgery, even if it's just planned surgery, is quite devastating both from a physical and a psychological point of view. It's going to take many years to clear the backlog, but I think, in the meantime, we need to be offering patients—health boards and Welsh Government need to be offering patients—support to manage their conditions while they're waiting. We've got societies like Versus Arthritis who've got their 'beat the pain' services and I think we need to be working with the third sector and the voluntary sector a lot more to allow those patients to be supported. I think you're right; I think, at the start of the pandemic, we agreed that elective services should be stopped to support the pandemic. We're now nearly into the second year of the pandemic and I think we've got to stop calling it a crisis; I think we've now got to realise this is what we're actually dealing with now. We've got to be setting up services that are working alongside the COVID response, not against the COVID response. And the idea behind the COVID-lite sites is that we get protected capacity that is safe for patients and for the staff as well, where we're not continuously starting and stopping services. It's very easy to stop services, but it's a lot more difficult to get them back up and running again. We had a problem with waiting times to a certain extent before the pandemic started, so we do need to increase our baseline capacity, because we cannot be expecting staff to—. There is talk about staff working 24 hours a day and at weekends. That is—. That's just not acceptable. We need to be allowing staff to work at the times that gives a good work-life balance that will allow them to continue.

If you have green areas within hospital sites, as soon as the community rates of COVID go up and the admissions go up, those sites become compromised very, very quickly, and there's no way that surgeons are going to operate on major cases with the threat of the patients catching COVID while they're in hospital, because we know that mortality can run at 25 per cent and the pulmonary complication rate runs at about 50 per cent. So, yes, COVID-lite sites aren't easy. They've been looking at surgical hubs in England and they seem to have been working, so I think there's got to be a lot more collaboration at a regional level to allow these things to be set up. 

They said it was going to be difficult to manage COVID, but the NHS managed; I think we need to start considering everybody else, which also includes the cancer care as well, because, even though we've been managing to do cancer work, it's obviously not at the same level as was done pre pandemic. 

Excellent. Lisa Turnbull next, and then Olwen Williams. 

I think the first thing that would be useful would be a very clear picture of what services have been stopped across Wales. We have asked the Welsh Government if they could publish some kind of status update on that so that we can see that national picture. That would be the first thing that would be useful in considering the situation. Secondly, there clearly needs to be some kind of strategy developed and put in place for how, going forward, we will be tackling the waiting list, the backlog, and how we will be building capacity to do that. 

I think the third point that's very important to make is there needs to be an awareness of the cost of both carrying on with elective surgery, or restarting it, and not doing it. There is a terrible cost from not doing it. There is a terrible cost, potentially, from doing it, simply because there are not enough nursing staff in the system. And we know that when there are not enough nursing staff, and there are staff with the wrong skills or not enough skills because people have been deployed—. And, remember, people are being deployed to different areas. We've seen community nursing supporting care homes—who's supporting community nursing teams? We're moving school nurses in, or we're moving different teams around. So, mental health is moving somewhere else. There aren't enough people to go around, and, when there aren't enough people with the right skills, we know that mortality increases—patient mortality. And that increases—research shows it's about 25 per cent. We've got situations with outcomes—falls, infection rates, poor outcomes. So, there is a risk from doing anything, and I think those risks need to be fully understood. 

With the COVID-lite suggestion, I think my initial response to that would be some scepticism, simply because where are the staff coming from? Where are these protected staff actually materialising from? I'm not clear we have them. Our nursing staff before the pandemic regularly worked 12-hour shifts, and then they were working four hours of goodwill on top of that. That was before the pandemic. People are working really, really long hours—almost 24 hours already. So, given the situation we're in, how can we move forward? I think the key to that would be planning an immediate, medium and long-term strategy for how to deal with this situation. I do respect what my colleague just said about this is the situation we live with—we can't just call it a crisis and then hope that suddenly it will go away; we have to live with it, and we have to develop a strategy going forward—but I'm not convinced there's an easy answer that simply hasn't been implemented yet. 

Okay. Dr Williams. 

Some of the things that we're talking about here as well are based around some of the health inequalities that we've seen within Wales, but also—and I'd like to stress I think that is something that we can tackle and look at in light of focusing on some people's needs in the way they're on waiting lists, whether it's still appropriate for them to be on those waiting lists, and what role intensive pre-rehabilitation has. Again, I appreciate that the last thing, the pre-rehabilitation, does mean that we need a huge investment in allied healthcare, in clinical psychology and pain services to actually support individuals who might not need the surgery that they've been listed for at that time.

Richard again.

Can I just point out that, when we're talking about COVID-lite sites, we're talking about using the current facilities that we have in the NHS? Those are not new sites; it's just a reorganisation of what we already have. So, we don't want to put new areas in. We've got 16 hospitals in Wales; surely there must be some way of deciding which is the most appropriate place to have them.

Can I just point out that the figures in our submission aren't our own submission figures? They are from the Welsh Government—waiting times figures.

Yes, absolutely. And I do not underestimate the difficulty of doing this, and I completely agree with Lisa. We can't magic people up out of nowhere. But nor can we, in all consciousness, allow patients just to languish on waiting lists that are going to take five, six, 10 years to recover, because not only does it cause these people, at this particular moment in their times, consequences for their own personal health, but actually it doesn't help us either as a society going forward, because, in a few years' time, the person who's just lost their sight because they can't get their Lucentis jab, for example, is going to be another person that we have to look after in a different way, by a different set of services, such as social services. So, all we're doing is pushing the problems around, and trying to find a solution is absolutely key.

Richard, I see you want to come in, but I'll just quickly ask one more question, because you might answer it. Because, again, I picked up from the evidence about the lack of planning. Because, you know, we talked about a plan—Lisa, you've just mentioned having a short-, medium- and long-term plan. Richard, you said this isn't a crisis, this is just the way it is. How are we with planning? Because I listen to health boards who say, 'Oh, we're going to restart'—well, they've been saying they're going to restart for weeks and weeks and weeks now. Welsh Government has pushed back on some of the planning, saying, 'We can't put together a plan for the backlog yet because we're too busy dealing with the pandemic.' So, can you perhaps just discuss where you feel we are with that, and what we can do to enable that?

Richard Johnson.

I agree. The health boards say they have plans. We've been trying to get some information as a college to try and help work out what the best way forward is. I think what we don't understand is what our capacity actually is, and, until we know what our actual capacity is— whether that's the number of theatres, the number of surgeons, how many operations you can do per list—it's actually very difficult to plan, and I'm not sure that within the NHS in Wales we understand what our baseline capacity is. Once you know what your baseline capacity is, then you can then work out how much of that you need to use and how much extra you need to use on top of that. Just coming back to the numbers quickly, I would say that those are the patients we know about. There's a massive unmet need in the community where patients haven't come forward yet and haven't been diagnosed, and therefore, even though the 500,000 number sounds extremely frightening, I'm sure it's a lot worse than that.

It's interesting you say that, because Macmillan just today published a report—

Yes, this morning, yes.

—saying that they thought there were about 3,500 missing patients requiring cancer intervention.

And I'm sure the planned care will be even worse—will be a lot more than that.

Yes.

Lisa Turnbull, you mentioned planning.

Yes. Yes, planning would be good. I think, with this second wave, the Welsh Government took the decision that the decision to stop particular services or how to respond would be at the health board level. Now, there is some logic to that, because, of course, in different regions in Wales, we're seeing different patterns of activity. One of the things I said earlier is that it would be helpful to have a national picture now of what that is. Because, certainly, we don't have that, and we're not sure, in fact, that the Welsh Government has that, to be quite honest. So, it would be helpful to see what that pattern is, and it would be helpful to plan from that going forwards, because there is merit in taking a national view as well as the regional view.

The other point I just want to put in here is that last year saw the publication of the very first health and social care workforce strategy for Wales from Health Education and Improvement Wales, and I understand that there are different work streams sitting under that now at HEIW. There's a mental health work plan, for example. All very laudable and something we'd welcome. What is the connection between that workforce planning and the COVID situation? What is the connection in terms of who are we commissioning for the future? What sort of staff with what sort of skills do we need next year, the year after and so forth? Those are the questions we would like to hear from Welsh Government, and very much, as a royal college, we would like to be involved and able to help with that process.

I can feel another recommendation coming on. Dr Olwen Williams.

My answer to Lisa there is that HEIW have just published the draft plan for 2021-22, looking at the workforce needs and looking at how many nursing posts they want to recruit and how many training posts across all the areas of health and social care. It's out for consultation at the moment.

Excellent. Angela.

Again, back down to the waiting lists, you talk about having a national elective surgery taskforce. I just wondered, have you posited that to the Government and what's been their response? 

Richard Johnson.

We have put that to the Government and there are some thoughts that that's where we do need to go to get things sorted out going forwards. We have tried to use our clinical voice through the Welsh board. I have asked the Welsh board whether they were prepared to come up with a plan on how to get elective services back on track again, but the first thing that we'll need is some information to be able to decide on that, as I've already explained, and that's not immediately available. But I think whatever plans are in place, the plans need to start now. We cannot wait until the second or third wave is over before starting to plan. We need to plan now, because otherwise, it'll be another three or four months down the line before anything starts moving forward.

Excellent. Angela.

I know we're short on time, Chair, but can I just ask one more question? What impact has the inability to carry out non-COVID surgeries and procedures had on training up the next generation across all disciplines? I'm assuming that if you're a trainee nurse or a trainee gastroenterologist, if you can't actually do any of the operations to practice to get your accreditation to move on up—. And again, at the top end, I'm assuming that people are still going to be retiring and nurses are still leaving the profession, so we're going to end up with this kind of gap in the middle, with lots of people at the bottom, perhaps. The Government's plans of recruiting more people are great, but they're going to take years to get ready to be in position. So, I just wondered if you could give us a quick overview of the effect that not being able to go ahead with all of our planned processes and procedures is having on that.

Richard Johnson to start.

Certainly from a surgical perspective, there's been a huge reduction in the amount of operative experience that our trainees have had. Take orthopaedics, for example; there's virtually been no elective joint replacements being done for nearly 12 months now, so the training has essentially stopped. Talking to our representatives on the Welsh board, probably more at the junior level, they are very despondent about the lack of training that they're getting, and I think if we're not careful, unless we get areas sorted out where we can start training again, our surgical staff are going to leave the profession, which is then going to have a knock-on effect on the long-term plans for sorting this out. We could potentially lose a whole generation of surgeons unless we get things sorted out pretty quickly.

An important point. Lisa Turnbull from the nursing perspective.

There's positive news. In Wales, the student workforce has been, this time around, kept in terms of its educational placements, rather than going into the workforce. And while that's obviously had a strain, then, on the ability of the workforce to work, it's been helpful in the sense that they are protected and therefore they will graduate, and therefore they will be coming into the workforce to help in terms of going forward in the future. So, that's been the positive news. Although there has been strain on placements, with some exceptions, minimum exceptions, the majority have been able to proceed. I would also draw attention to the excellent innovation that we have in Wales with things like virtual and robotic simulations, which have been incredibly helpful in terms of that practical experience. So, some real positive stories there. 

The one thing that I would just put in, which I think is relevant, is that we have mentioned retention, which is absolutely critical. In the first wave, we saw so many nurses returning to the workforce to try and help out. One of the questions that we would be asking is: what happened to that group? It shows that, with relatively little effort, the NHS could actually bring those people back in, potentially permanently. What work has been done to actually bring that group in permanently, and what work has been done to ask that group of people what would make them come back? That would be a really valuable lesson in terms of going forward.

Excellent. We are getting knee-deep in recommendations now. Olwen, what about the physicians of the future?

Yes, the physicians of the future. Our foundation doctors in year 1 and year 2, and our newly graduated medical doctors—the medical students that came into the workforce very early—have really stepped up to the mark. They have been phenomenal in providing services. But, in a way, one of the things that happened to them is that some of them weren't allowed to rotate from one job to the other, so they spent nearly their entire year with one team in one specialty. They sort of feel that they have lost a little bit of their training from that. With the doctors that are in the specialty areas, there is a very, very different reaction there, in that some specialties where there are a lot of procedures, such as gastroenterology—initially, there was a lot of concern around not being able to do ERCPs and gastroscopes, but we have managed to put that in place. But then, when you look at those training in very specific out-patient-based specialties, such as dermatology, rheumatology and sexual health, the fact that those clinics were only emergency clinics meant that there has been a little bit of delay in them getting their training, although we do feel that the feedback—. As a college, we have been meeting with our trainees every four to six weeks throughout the pandemic. We were able to resolve a lot of the issues. So, training has gone online. The simulation training, as Lisa says, has been fantastic. There has been a significant—. The colleges have had to cancel some exams, but most of the people have managed to progress from one stage to the other.

Great. We need to move on. Richard, a brief word.

There was a very positive thing in that the fill rate for training posts in Wales was the best that it's been for years. I think that we have to look at that with a slight air of caution, because doctors weren't able to travel abroad, which has probably been the reason why that has happened.

Thank you. There's lots to say on waiting, because I think that it is the biggest health crisis that we now face after the pandemic. Unless you have a well population, it has such a massive impact on society in every other way. But I will stop, because I know that we are short on time. Thank you very much for what you've said.

Wise words, Angela. Moving on swiftly to Lynne Neagle.

Thanks, Chair. My questions are on testing. I would just like to know, please, what your experience has been of the testing regime during the pandemic and how effective you feel it has been.

Who wants to kick off? Lisa?

I think that it's working very well now. I think that there were certainly some issues at the start. Perhaps that is to be expected. I think that there has always been a little bit of difficulty in terms of what the policy is for different sectors. So, for us, for example, we have two groups of nurses working for the NHS—one based in hospitals, and another bigger group based in the community. Then, of course, there are nurses who work outside the NHS, for example in the care home sector. Similarly, there are care workers, of course, working out there as well. The other group, which is really important—and I will come back to this on vaccination—is agency nursing.

There has been some difficulty in terms of—. Even where we've got a situation where nurses in the NHS have got a very clear route in terms of access to testing, is that applicable to all across the sector? One of the issues that we found in the early days, particularly, was that our nurses on the ground did not know what the policy was or how to access it. We have solved that problem now, and that's excellent, and that's working very well. But, it is still helpful to have information on all of those groups of people that I have mentioned, so that everybody is clear, when they are working in teams, what's the route for everybody in that team, and do they have the same equal access.

Thank you.

Richard Johnson.

I'd agree that at the start of the pandemic, the testing was not as good as it could have been. There were issues with accessing testing and turnaround times for testing. But I think, as things have moved forward and the testing capacity has increased, it's become less of a problem, and we can access rapid testing now to manage patients at the front door of a hospital. I think the issue at the present time now is the use of lateral flow testing for the screening of staff, which seems to be very variable in how to access it throughout Wales, talking to our members. I think some areas are doing twice-weekly testing, particularly for surgeons going into the green areas, but that's not a consistent thing that's happening across Wales.

Okay. Olwen Williams.

I'd reiterate what Richard's saying—that the twice-weekly testing is very variable across the health boards and across different groups within the health boards, especially within the physicianary group.

Okay. Lynne.

Thank you. Another concern that's been raised with the committee has been people being discharged from hospital, either into care homes or the community, without being tested for COVID. I certainly know of people who've been discharged who are COVID positive. Is that something that you've come across?

One of the things that we were realising was that the flow through the hospital system back into the care homes was being delayed because of that at some point. I think the thing is that you've got to look at infectivity and not positivity. Testing someone—it was 14 days, now it's 10 days. But I do think that we have to be aware that being positive and being infective is not quite the same thing at times.

Yes, good point. Lisa Turnbull.

The point I would add to that as well is that one of the things that we're aware of, for example, is infection prevention and control advice and understanding outside the hospital—so, both in caring for people in their home and in caring for people in a care home. This is where, when you have the specialist nurse and the consultant nurse who can provide that kind of training, that kind of guidance—that's worked very well. I know that's been put in place in most areas now. But, certainly, at the start, that was very variable. So, you can understand that from the perspective of the person receiving a patient when they have no idea if that person is COVID-positive or not. What does that mean for them? How do they need to change their arrangements? What protection do they need for their staff? Because, ultimately, as well, there's the welfare of the other patients and so forth. So, I think that was an extremely difficult period. And certainly our understanding is that that has improved now and got a lot better—people are clearer about how to access that kind of guidance and support. That's the kind of thing we need to develop going forward so that it's one system and not, 'This is the system we have in hospital; we haven't thought about what the system would be outside.' It needs to be one system about caring for the patient and the staff.  

Richard, do you have anything to add?

Just to support what Olwen said. I think the issue we've got to be careful of is that we're not keeping vulnerable patients in hospital for too long, because when the rates of COVID in hospital are high, the risk of transmission, even with fantastic infection control procedures in place—the environment has a significant effect on spread.

Thank you. Thanks, Chair.

Thanks very much. To wrap things up, then, Jayne Bryant.

Thank you, Chair, and good afternoon, everyone. How have you found the speed of the rolling out of the vaccination and how things have progressed?

Lisa Turnbull.

Thank you, Chair. The first issue we'd point out is that we have been requesting more information from the Welsh Government on the roll-out. What we don't have, for example, is information about how the vaccination roll-out has been handled per sector of staff. We know from our own surveys of our own members, for example, that when we were talking in the early days of the pandemic about the roll-out of PPE or the roll-out of testing, there was huge disparity between hospital-based staff and community-based staff, and then there were further disparities between the independent sector as well. We do not know that that is the case. I'm not saying that is the case with vaccination; what I'm saying is, we don't know. And it would be very helpful to be reassured on this point by the provision of that transparent information. So, that's the first thing I'd say.

The second thing I want to say is: the area we are concerned about is agency nursing. We have raised this issue repeatedly at the vaccination board, and we've received a reply that it’s the responsibility of the employer. Of course it is; fundamentally, it is the responsibility of the employer. But nonetheless, agency nursing is a mainstay of the care home sector and it is a mainstay of many parts of the NHS. But we feel that NHS Wales does have a responsibility here as well, and what we would like to know is: how is that happening? How are health boards assuring themselves that the agency staff they use are having access to that vaccination programme? We have no idea. But we are picking up from our members, from the other direction, from the individual agency nurses, that they have rung their GPs and have been told, 'No. Go ask your health board.' And they've rung the health board and the health board's said, 'It's nothing to do with us. Ring your employer.' And they're in a veil of confusion. So, we have no idea what the situation is for an agency nursing out there, and we are extremely concerned about that. And that will also go, of course, not just for agency-registered nurses but for nursing staff, care workers as well.

I can feel yet another recommendation coming on. Richard—vaccination.

To be fair, I think, certainly from my own experience, the roll-out’s been pretty good. I mean, where I work, we have been targeting agency nurses to make sure they get vaccinated, and the same with locum doctors as well, particularly the longer term ones. I think the biggest issue that probably causes most emails is the guidance on the gap in between the first and the second doses. That was obviously something that was sprung on very quickly and caused a lot of angst amongst a lot of people. You can understand it, from a population point of view, but I think it could have been handled in a better way.

Fair point. Olwen Williams.

Yes, I agree—the gap. As a college, we support the need to use the vaccine as prudently as possible so as many people get their first dose. But, I think, with emerging evidence that's coming out as regards the difference between the Pfizer and the AstraZeneca, it'd be interesting to see how that goes forward, especially with AstraZeneca now showing that there’s potential that it prevents onward spread, whereas, I think, most healthcare staff have actually had the Pfizer.

Great. Jayne.

I was just going to come back in on that, Chair, around how do staff feel at the moment about this, the wait for their next jab. I know you've just touched on some of the anxiety that it's caused, but is that continuing, or do you feel that staff are understanding of the issue?

Who wants to start? Olwen.

I think staff are understanding of the issue, but what we’re aware of is staff actually reporting that, although they've been vaccinated with the first one, and understand that what it does is reduce the severity of the illness, they’re still presenting with COVID and COVID symptoms. So, that's causing more anxiety amongst the workforce, I think.

Okay. Richard.

I think the anxiety is still out there about the delay, but I think it's more down to they've accepted this has happened now. Most people have gone past the three-week recommendation and therefore, I think the other thing is they just need some confirmation that they are going to get the vaccinations within the 12-week time frame.

Okay. Lisa, on this point.

Yes. I think communication is the key, and I don't think communication from the health boards—. And this is where, again, I think a national perspective on this kind of communication actually would be useful. It needs to be absolutely reassuring. You need to keep repeating the same kind of thing. So, there's a whole level of anxiety here: when is the second vaccine happening? What is the roll-out plan? What's the timescale? Small things have been causing some anxiety in our members. Misinformation when there’s a vacuum, this is what creates anxiety. So, for example, what happens with the leftover vaccines? What’s the policy? How do we deal with that? Because we have to deal with it; we don't want anything to go to waste. So, misinformation about what that policy might be or how to access it, those are the kinds of things that have to been nailed down. When are friends and family—when are senior management and non-front-line staff involved? Really just being constantly reassured that this is the plan, this is what's going to happen, it's in place, it's happening. So, communication, really, on this one, is the key.

Richard Johnson to wrap things up.

The other issue about vaccinations is the high-risk patients as well. Obviously some patients are being vaccinated, but patients with solid cancers requiring major surgery—I think that's something that needs to be looked at. I know Welsh Government are following JCVI guidance, but some of the guidance that needs to be changed seems to be coming out quite slowly.

Okay. Done, Jayne?

Yes, thank you, Chair.

Angela—a brief supplementary.

I just wanted, actually, to pick up on—in a couple of different areas, you've mentioned the need for a national plan, whether it's been on getting elective surgeries back up, or just now, Lisa, you were talking about the vaccination side, and national communication. So, does anybody want to make any comment about what, obviously, appears to be a bit of a gap? Have we left too much to the individual health boards to shoulder this burden, and try and make it happen in their areas? Where do you think it's actually missing? Because Welsh Government certainly push at how to handle things, so I'm just trying to work out where the gap is—if there's a recommendation there that we need to firm up on.

Richard Johnson.

Looking at the waiting lists, the numbers are huge. Now, I'm not sure that an individual health board can manage without collaborating with their neighbours, and particularly it could be an all-Wales plan where all six health boards are working together. But, I think, whatever plan, the planning needs to start now. We can't just keep on talking about how we need to get a group together, the planning needs to start now, and we need to be planning, as I've said before, to the get the COVID-lite sites sorted out as quickly as possible, using the facilities we have already, not building new facilities, because, as Lisa said, if you build more facilities, you need more staff, and we just haven't got them. 

Lisa, on that point—plans.

I think there are two issues. I think one is the national perspective—having the national perspective or plan, and then taking it and communicating it. So, let's just take one aspect, as I mentioned earlier, about agency nursing. First of all, it would be helpful if someone at a national level sorted that out, but secondly, if they tell us, as the Royal College of Nursing, we can tell all our members, so we're all on the same page and we're all pushing the same messages. So, sometimes, what we're looking for—the information we're looking for—has already happened, or the good work has been done, but we need to know about it in order to actually push that out. So, more support from that national level would be very helpful.

The final word, then, Olwen Williams.

Really, this is about transparency of how we communicate as well. I'm sure there are messages out there that we just don't hear or see them. And the other thing as well is that—. I think one of the issues around plans is that different health boards go at different rates, and sometimes there's criticism that someone's slower than the other. This is not really a competition for people: we'll all get to the finishing line, but maybe at different speeds, and we all have to be in this together.

Great, as somebody once said. Cracking session. We're out of time, but excellent.