National Assembly for Wales

I'd like to welcome Members this morning and those watching in to the Health and Social Care Committee. This is a hybrid committee meeting this morning, with some Members present here in the Senedd, including myself, and other Members and witnesses joining the meeting virtually. There are a few adaptions in regard to the Standing Orders as a result, but, other than that, all other Standing Order requirements remain in place. The meeting this morning is bilingual, so Members can ask questions and witnesses can ask questions in either Welsh or English. Right, there we are; that's it for the housekeeping situation this morning.

So, I move to item 1. We have no apologies this morning, but Rhun ap Iorwerth will be joining us later in the day. And if there are any declarations of interest, I'd just ask Members to state those now. No.

In that case, I move to item 2. And item 2 is in regard to a COVID-19 update from our witnesses this morning. So, I'll ask our witnesses to introduce themselves for the public record, please.

Bore da—good morning. My name is Felicity Bennée, and I am the co-chair of the technical advisory group for Wales.

Bore da—good morning. My name is Dr Rob Orford, and I'm the chief scientific adviser for health in the Welsh Government.

Bore da—good morning, everybody. I'm Dr Frank Atherton; I'm the Chief Medical Officer for Wales.

Can I thank you all for joining us this morning on what is our second formal meeting of this committee, but is our first substantial meeting where we've got witnesses attending? So, thank you for being with us this morning. And can I also thank you for your evidence paper in advance of the meeting? That's very much appreciated, and I'm sure that, due to the current situation, sometimes that evidence provided may quickly go out of date. That's the nature of the issues that we're in. 

If I can just ask some general questions to start, we're asking really for an update on the current and emerging picture for COVID-19 and where you think the key pressure points are, and also how Wales is comparing with the broader international picture in terms of the number of cases, rates and success in reducing those numbers. I wonder which of the witnesses would like to go—. Dr Atherton.

Maybe I'll kick off, Chair. Thank you for that. I'll probably bring Fliss in just to deal with some of the detail on the international comparators. But if I was to ask in a nutshell where we are in Wales with the pandemic, it would be to say that we have very high levels of community transmission at the moment. That is translating into some degree of harm in terms of people going into hospital and requiring care, but much less so than in the first and second waves. And if I just paint a bit of detail around that, when I say community rates are high, they're actually very high in Wales, as they are across the UK—over 500 per 100,000 cases at the moment. And we've seen the cases go up, really, during the last two or three months—really June, July and August we saw—[Inaudible.]—cases, and that's continued in September. We had a bit of stabilisation last week, and then this week the numbers have gone up again, the rates have gone up again, which is probably a reflection of the schools going back, because we know that when schools are in session there's more community mixing generally. So, that is the picture.

One thing that I look at very carefully is the over-60 rates—the rates of disease of over-60-year-olds—and they have stabilised and are decreasing slightly, which gives me some comfort, because we know that it's older, frailer people who come to harm from coronavirus. But the current wave, really, is transmitting very much in the under-25s. The under-25 rates are very, very high in Wales, and particularly in the 10 to 19-year-old age group, where there's a lot of transmission. As I say, that is translating into some degree of hospital activity, hospital harm, and the number of coronavirus patients in Welsh hospitals has been steadily increasing over the last month, but it's not been increasing, again, as quickly as it did in the second wave particularly, so there's been a steady increase, and that rate of increase has now declined a bit. So, it's rising still, but it's rising more slowly. That really reflects the fact that, I think, the vaccines—. We've had a very successful vaccination programme here in Wales, and that has not broken, but it's weakened the link between the high rates of community transmission that we have and the levels of harm in terms of direct harms of people requiring hospital treatment. So, that's all very good news, really.

But I do have worries. You asked for what the pressure points in the future are going to be, and I do worry about winter. We are going into winter with very high levels of hospital activity. Some of that is coronavirus related, some of it is related to the catch-up and non-COVID activity, but there is a prospect, of course, of seasonal viruses coming our way in the winter months as they usually do every year. Last year, we had very little in the way of flu virus circulating, but this year we are anticipating a probable resurgence. So, the winter is likely to be quite a difficult one for the health and social care system. I think that would give you, hopefully, a broad overview.

In terms of the international comparator that you asked for, I'll ask Fliss to just lead off on that and I might go into some of the detail.

Thank you, Dr Atherton.

Diolch. It continues to be ever such a difficult question to ask to compare any country with another, because the situations and the approaches are so different. At the moment, internationally, the UK is something of an outlier, and Wales is a bit of an outlier within that in terms of the number of cases we have, but we also have very, very reduced NPIs—non-pharmaceutical interventions—by comparison to a lot of countries. At the moment, the major upswells are in eastern Europe, particularly Romania, Montenegro and Serbia, where cases are the highest in the world and still rising. Even in places like China, with quite significant capacity to control the population, there are outbreaks occurring that are quite significant. On the other hand, there are also large amounts of cases being released in places like Brazil that don't indicate new sets of outbreaks, but a release of data that's all come at once in terms of deaths. So, we've got an understanding that their previous wave was much worse than we understood.

So, in terms of vaccination, Wales is still vastly ahead, as is the UK, of many different places. What we find when we compare with somewhere like Israel, which was very quick off the mark, but which plateaued very quickly in terms of first doses, and even earlier with second doses—. So, there is a good portion of the population that hasn't had its second dose in Israel, even though they've already bought in a third dose and are considering timing the fourth dose of the vaccine. So, it's a bit of a mixed bag, but, generally speaking, Wales is doing relatively well by comparison with the rest of the world, and by comparison with countries that are similar, except for Denmark. Denmark is a bit of an outlier in terms of Europe and, indeed, the rest of the world. They are currently in a situation where they have very low case numbers and they have decided that, although they are not going to treat COVID as an infection of extreme danger any more, they're pursuing keeping the number of cases low and have an incredibly high testing and sequencing and contact tracing around all of the cases they do find. And they are now, as a result, able to start doing those final openings up without too much concern. 

Can I ask you this question, Fliss? In regard to the sequencing to identify new variants, what's the current position in regards to that in Wales, and is that something that is still happening?

So, I'm going to pass over to Rob, because I'm fairly certain that he's got much more recent numbers than me. We do sequence a lot of cases here in Wales. 

That's fine. Dr Orford. 

Thanks very much. Yes, there's quite an industry of sequencing in Wales at the moment. I believe—I'll have to check my numbers—we've sequenced about 73,000 samples through the pandemic, and I believe we've uploaded about 66,000 of those sequences to the international database, called GISAID. So, it's prolific in Wales. The turnaround time for the sequence is really fast; it's about four or five days. It's even faster if they're doing outbreak analysis. They have done outbreak analysis in 24 to 48 hours, when they've looked at outbreaks in hospital settings. So, there's a great deal of activity. At a local level, they're using that information to inform outbreak analysis; at a regional level, they're using that information to look at the spread of clusters and larger trends in areas; at national level, they're using that information to compare emerging sequences to see if there are any signals of new mutations or signs of new variants. So, for Wales, if you look at the percentage that we're sequencing, it's around about 20 per cent at the moment, which is really good. And if you look at the total that we've sequenced [Correction: and proportion of samples sequenced], it actually puts us right up there, right next to Denmark, actually, internationally. So, they're doing a very good job. 

I think, in terms of variants, what we're seeing is we've seen different waves of types of variants come and go. Delta swept in—it took about seven to eight weeks to arrive en masse—and we're seeing a similar picture elsewhere, in that it's out-competing pretty much anything else on the block. So, we're seeing the same in North America, South Africa and places where there were other, more dominant variants. So, for now, we have delta, but it's still evolving and so we still do need to keep our eyes very much peeled on what's happening, and sequencing really gives us that irrefutable evidence of what's circulating in the population. So, it's quite important that we carry on doing it. 

Thank you, Dr Orford. If I can go back to Dr Atherton's earlier contribution, I just wonder if you could say, Dr Atherton, a little bit more about the trajectory in terms of when we're likely to hit a peak, and also in regards to any modelling that's being undertaken between now and Christmas, or when you expect that modelling to be available. I can see Dr Orford might want to come in on this, but if I could also add to that as well, what do you think the trigger points are in terms of your advice to Ministers changing? I ask that in the context of advice changing that might then trigger a change of policy by Ministers in terms of, perhaps, the need or requirement to bring in further restrictions. Dr Orford.

Thank you. If I start with the modelling and then hand over to the CMO, if that's possible—. So, there is a great deal of uncertainty at the moment in the modelling. As we open up, as there's more mixing, more things are going on, it becomes more uncertain. Some of the uncertainties that we have are things like the emergence of new and novel variants, whether they transmit faster or whether they impact on the immune system, whether that's acquired or natural. We are uncertain about the impact of seasonality, what happens when it gets colder, and we're uncertain about co-infections—what happens if flu plus COVID occur in Wales. And so the dynamics are highly unpredictable.

What we do know from our models—and it's not just modelling we do in Wales, it's modelling that's done across the UK, and they're all brought together and compared through the forum of the scientific advisory group for emergencies—is that there's a kind of convergent thinking in that we might see a period of growth, followed by a plateau and then an easing off. So, we may see that; that's what the current modelling is showing us. We have new modelling that's going through the technical advisory cell group this Friday, which we hope to publish next week. But there is a great deal of uncertainty, as I described. So, the re-emergence of childhood diseases, respiratory syncytial virus, for example, could put a spanner in the works, and again, we may have stepped up some immunity debt in the system where children have been not mixing with friends and so they may be more susceptible to some of the illnesses that we traditionally see. So, I think it's something that we need to stay really close to. I think, in terms of looking at the data, we look at yesterday and ask what today might look like and tomorrow, we can be fairly certain about that. We can be quite certain about the next two weeks, slightly less certain about the next four weeks, but then when we look ahead to Christmas, that's really quite difficult, and we don't have a crystal ball, so we do need to look at all of the evidence, bring that together and then change the assumptions in the model. So, if, for example, we have information about a new variant that behaves differently, then we adapt the model accordingly and see what happens with the outputs, which are hospitalisations, ICU admissions, deaths, that type of thing. So, I'll hand over to Frank now, if that's okay, on the trigger points.

Thanks, Rob, and thanks, Chair. So, on trigger points, there's no one thing that I could point to that would prompt the Ministers to require further action or further intervention, really. I think what we've learned through the pandemic is that we have to look at a whole range of things, a basket of indicators. In the first wave, and the second wave to a large extent, we looked very closely of course at the R number, which reflected on whether we were in growth in terms of the pandemic or whether it was retreating. That's still useful, but it's less useful now that we have vaccines breaking that link or weakening that link between community transmission and hospital harm. So, we do continue to look at that. We look at case rates, of course, which are very high, as I say, in the community, but increasingly over the last recent months, we've looked at levels of hospital-related harm and the number of cases going through hospitals, which, as I say, has been increasing, but the rate of increase has reduced now. 

So, those are the things that we have looked at in the past, in past waves, and we continue to use in current waves. There is no hard-and-fast point in any of those figures where we would require as a nation further intervention, but we need to look at them in the round, really. We do that in Wales, of course, but we also do it across the rest of the UK. So, on a weekly basis, the chief medical officers for the four nations, including myself, look at the data from the Joint Biosecurity Centre, and look at the UK alert level, which has been at level 3 for quite some time. There is a lot of anxiety across the four nations, I would say, around the level of hospital activity, but, as I've said, some of that is COVID related, but much of it, of course,  is related to the catch-up, the fact that NHS services across the four nations are trying to recover lost ground to try to provide treatments that people have not been able to receive during the pandemic. So, there's a lot of pressure in the system, and that currently, I would say, is one of the main indicators that chief medical officers across the four nations are looking at in terms of advising Ministers.

Thank you, Dr Atherton. Unless any Member wanted to come in, I'll move to Gareth Davies for the next set of questions. Gareth.

Thank you very much, Chair. In terms of education, obviously we've seen disruption to schools and colleges, universities, since the pandemic. Is the priority keeping children and students in education in terms of that continuity? Because we've seen a lot of predicted grades in GCSEs, A-levels, and all those sort of variants of that. So, is the priority to look at keeping people in education in the long term despite some of the triggers or restriction levels that you mentioned in your previous answer?

If I may, yes, it has been noted and we've been identifying that children have suffered disproportionately during the first two waves and during the last 18 months in terms of their inability not just to access education in some cases, but also to access the socialisation and the play that helps them to develop. We also are aware that there is a harm that builds up from not being able to have social interaction that leads to the development of barrier immunity from exposure to other infectious diseases. In terms of what is reasonable, the Welsh Government lines are clear that schools should be the last thing to close and the first to open, and the reason that we can identify it as being appropriate is that children suffer far less from COVID than adults, not just in terms of severe illness—and there have been far, far fewer cases of severe illness in children—but also in terms of long COVID, where studies such as the CLoCk study have identified that there is significantly less likelihood that children will suffer beyond a period of four or 12 weeks at the outset from longer term damage. So, children can become infected with COVID, but children are far, far less likely to suffer as a result of it, whereas there are a number of social, mental health and long-term social cause harms that will occur if children are not able to learn. So, it's important that children still isolate, absolutely, if they are COVID positive, because the damage that could occur if a positive case is allowed to circulate in the community, whether it's school or in other settings, is significant. But they should be able to access education, whether at home or in school.

Thanks. We're seeing some elective care being postponed because of COVID-19 pressures, and pressures, obviously, on beds and staff. What sort of priorities are being looked at to bring back elective surgeries? We talk a lot about the backlog and long waits for your everyday things, shall we say. What sort of work is going on to restore some of those things that are seen as conventional in the public eye?

One of my roles, of course, as well as being chief medical officer, is medical director of the NHS, and so this is something that I take really quite seriously. You'll be aware, I'm sure, that the health and social care system has accrued a huge backlog of unmet need over the last 18 months or so, and all of the health boards have developed plans to try to recover some of that elective care. Now, that's really quite difficult in the current context, for a number of reasons. First of all, hospitals, of course, are still dealing with coronavirus itself. We have as of yesterday just short of 650 cases with coronavirus-related issues in Welsh hospital beds. That's one issue and the pandemic clearly hasn't finished. The second issue is that hospitals have to work in a very different way, and so the efficiency of managing patient flow is much less than it was, and this relates to higher standards of infection prevention and control, a greater use of PPE, more testing of patients as they go through the system, et cetera. So, all of those things do slow down care and mean that productivity is actually less in the NHS.

Now, you're right to say that, in recent weeks, some areas have had to pull back on that recovery effort, and that really is because of the high volume of activity in hospitals and the pressures that the health and social care system generally is finding itself under. It feels very much almost like winter already, and many of our clinicians, who of course have had a difficult time over the last year and a half, are expressing concern that this feels like winter already, and yet we're really only into the start of autumn. So, the health and social care system is extremely busy, and it's proving quite difficult to catch up. That's going to take some time—months, years, for the whole backlog of cases of untreated patients to be caught up. But that is a priority for the Minister, I know, and that is a priority that's been translated into all of the local health boards, and they're all developing plans to deal with that.

The one other thing I should say is that COVID and the current pressures are getting in the way of dealing with that backlog. Health boards have a local choices framework, and they have to make difficult decisions sometimes. They really are attempting to move on with the backlog of patients, but sometimes the necessary urgent care does get in the way of dealing with that and slows it down. 

Thank you very much for that answer. Just finally, I want to bring up the modelling system that was covered in a previous answer to the Chair's question. It's long known that you've used the Swansea University method of modelling, which has been reported to be—. With a little bit of a critical eye over it, it can predict the worst-case scenario, and it's a bit of a crystal-ball method where it's been determined to predict further and future restrictions coming into place. You said in a previous answer that we don't have a crystal ball, but the Swansea University method provides that in a way. So, in terms of restrictions and the current set of restrictions being eased, does the current model give you those future predictions, or is there a plan in the future to look at a different method of modelling? 

I see, I think, Dr Orford, you put your hand up, and I'll bring in Fliss straight after. Dr Orford. 

Thanks very much. The models are really helpful but the models are driven by the assumptions that we put into them. We try and round on what we think is the most likely case scenario, what we think the future might look like, but we also then push the model to say, 'What would happen if?', so we can come up with a reasonable worst-case scenario. That doesn't mean to say that's what the future will be like; it's what the future could look like. None of these are crystal-ball gazing. 

In terms of emergency preparedness and planning, it is expect the best and prepare for the worst, and so we have to have a reasonable worst case. In terms of what the future could look like, we hope and we think the future's going to be a difficult future with COVID, but one that's sustainable. We think there'll be other pressures along with that, and it may be that every year we have a seasonal virus that's an additional pressure on the system that we need to deal with, so that's future A. There's another future, where something left field happens, where a new variant comes along, and it takes off even more or it gets around the immune response. That's future B, where we're back in an epidemic. And then there's future C, where it's an endemic and we're just learning to live with it at much lower levels. So, in those three scenarios, we really do have to think about them and plan, but the doomsday scenarios are ones that we test out with assumptions that we put into that model. It doesn't mean to say that they come true, but in emergency planning we really do need to think about, 'What we do if?' It doesn't mean to say that we would do it. I'll pause there.  

Fliss Bennee. 

Just following on from what Rob said, I wanted to highlight two things. One, the Swansea model is fantastic and we've been iterating it over time and testing it, but that model itself is one of many that we use at the scientific pandemic for influenza modelling group, SPI-M, across SAGE and what happens is many, many universities, as well as public health groups, come together to look and see what their different models do under certain circumstances. But what we feed into the models is not, 'This is what's going to happen'. What we feed into the models is the policy scenarios and the infection scenarios that we can come up with, to say, 'Okay, what would happen if we introduced an opening up of this much at this point in time?'. So, earlier on in the year, we were asked to model the policies of releasing to level 0.5 on 7 August and what that would look like. And we saw that if you open up society, then you get a rise in the number of infections. So, it's likely that, if we're asked to say what it would do to the expected process of the infection if restrictions were added back in at this point, then we would run those models and see what happened. The reasonable worst case is never something that we expect to follow, because we would expect to see that, as we started to approach the point of inflection—the point where the exponential starts to take off and doubling times put us in a point where people's lives and the NHS are in really quite severe danger of being completely overrun—then there would be choices made that would avoid us getting there. So, rather than saying, 'The model says what's going to happen', we work to think about what might happen, and then we run the model to see what that would look like.

Thank you. Jack Sargeant.

Thank you, Chair, and good morning to all witnesses. Dr Atherton, in opening you quite rightly raised the successful vaccination programme in Wales, and if I may, Chair, I'd like to put on record our thanks as a committee, as a newly formed committee, to all those who worked to make that a success, and for all they will do in the future. Without them, it wouldn't be possible. So, if I could put that on the record, Chair.

I am interested in hearing the witnesses' views on how concerned they might be about the uptake of vaccines in a particular cohort, one being the younger age group, and secondly within our BAME communities here in Wales. I'd like to know what is being done to overcome this, and perhaps within answering that question, the witnesses could let the committee know what strategies are being developed to tackle the various misinformation, which may cause vaccination hesitancy. There is significant evidence out there that there is hesitancy, and this can be linked to misinformation.

Thanks for that—really, really interesting questions—and thank you for your acknowledgement that the NHS and the care system have done a really, really good job. I mean, to get to the levels of vaccination coverage that we have in Wales really is quite a staggering achievement over such a short period of time. 

We do worry a lot about people who are not vaccinated. As I've said, we have very high levels of community transmission at the moment, and so essentially anybody who is not vaccinated who is moving around in our community is at significant risk of acquiring coronavirus. Although the rates of vaccination are extremely high, it still means that there are significant numbers of people in Wales who are not vaccinated. And you're right to point out as well that those unvaccinated people are not equally spread in the population. Clearly, the younger groups have only more recently come on stream in terms of eligibility for vaccination, so we're still working through those. But we have had, and we've been monitoring very closely, the disparity both on socioeconomic grounds and in our black, Asian and minority ethnic communities—the gap in vaccination status. That has been an issue. We've had a monitoring group looking at this and coming up with suggestions as to how we can address that.

The good news for me is that the gap that we have seen in those vaccination coverage rates has been declining over time. We've actually been narrowing the gaps, which is good news. The way that that has been achieved, really, is through a number of things: first of all, of course, through very targeted messaging, messaging in the right languages, of course, and working very closely with faith and community leaders, particularly in Asian communities here in Cardiff in particular, but in other parts of Wales as well. Making access to vaccines as easy as possible is really important, and so, although most of us will have had our vaccines through mass vaccination centres, there have also been pop-up clinics that have been established. We've used faith-based organisations. Many of the mosques around Wales have turned their hand to become vaccination centres as well. So, making it as easy as possible for people to get those vaccines I think has been one of the hallmarks of success. There's still a gap, and we have a policy in Wales of not leaving anybody behind. 'It's never too late' is our philosophy. If you've been hesitant, if you've not come forward for the vaccine, it's not too late, we can still make that possible, and health boards are working to that basis.

On vaccine hesitancy, I'll ask Fliss to maybe say something on this, but my view is that it's not a major issue here in Wales. Obviously, there is some misinformation that has spread around on social media, and that's worrying, of course, and it does deter some people from taking up the vaccine. We've always had the model—and it's true of vaccinations generally—that 70 per cent of people will likely come forward and take things up very easily, 20 per cent are sitting on the fence and would like a bit more information and advice, and 10 per cent are probably resistant. That probably has held true for the COVID vaccine, and we've targeted, certainly, the 20 per cent who are wavering with information to try to help them to make an informed decision that would be in their best interests.

I think just one final thing is that vaccine hesitancy here is much less in the UK, generally, than it is in some of our European comparator nations, or, indeed, in the States or other parts of the world. So, I think we're fortunate that, by and large, the Welsh population have behaved in the best interests of themselves and their communities by coming forward for vaccination, and that is reflected very much in our very high vaccination rates. But Fliss may want to add something on the hesitancy issue. 

Diolch, Frank. In fact, I was fortunate to represent Wales at an international UNESCO conference on vaccine hesitancy a couple of months ago. The issue, really, is that there is a great deal of disenfranchisement that's occurred as a result of COVID and the restrictions that have occurred, not just in Wales, but across the world. And the fear and the anger that that drives can lead people to be much more open to especially the sort of anti-vax conspiracy theories and simple answers that are offered. And it's absolutely imperative that, when we look at hesitancy and anti-vaccination campaigns, we counter them not just with reason, but also with empathy. The understanding that whether or not people have come to their point of belief because they've been pushed there, or because there is some underlying reason or thing that has made them feel disenfranchised, is absolutely vital, and it's important that we work with trusted community partners to build up people's understanding, as well as encouraging them to come and get vaccinated.

I would suggest that there's been quite a lot of support for local authorities and local health boards not just doing things like providing the pop-up vaccination centres that Frank was talking about, but things like offering transport for people who may not have access, understanding things like if you are a single parent with children who you need to look after, perhaps you are hesitant to get the vaccine, because you are concerned that if you get side effects—not because you think it's a particularly dangerous thing, but if you get side effects, who's going to look after your kids? So, getting volunteers to support people and getting information that will allow people to come to their own choice rather than seeking to push something upon them is the way that we would choose to combat anti-vaccine hesitancy. Thanks.

Thank you for those answers. I think you're right; it's clear, isn't it, that the more we can do to make the vaccination programme accessible to the public, the better. But we are currently rolling out, obviously, the current vaccination programme, which we've talked about, the new vaccination programme for 12 to 15-year-olds, of course, the booster vaccine, and again, as discussed earlier this morning, the flu vaccine campaign, which is particularly important. I think it was Dr Atherton again who mentioned that there's an expectation of issues around flu this year that we perhaps didn't see over the last 18 months or so. In terms of all those programmes, then, and again, looking back at the great work of our NHS staff, volunteers and all those who've delivered these programmes, is there enough capacity to be able to deliver the current vaccination programme and all those others that I've discussed? And just on the importance of the vaccine, I wonder if you could comment on any evidence—. I know that the First Minister has previously pointed to evidence from Israel, where the level of immunity from the vaccine dips over time. So, again, on the importance of delivering this booster programme, I wonder if you could add further to the evidence that's already out there.   

I'm very happy to start off on that. There's one thing that I forgot to mention when we were talking about your previous question about equity of coverage. There is one group that I'm particularly worried about, which I should just flag, which is women of child-bearing age and pregnant women in particular. The uptake rate in that group is not as high as I would like to see. It's about 60 percent at the moment, we believe, and we are seeing pregnant women coming to harm in terms of requiring hospital admission. So, we are actually planning a campaign at the moment, contacting midwives and all health professionals to make sure that pregnant women have good quality information and access to services.

On your question on capacity to deal with this, it is a complex array of vaccination programmes at the moment, of course. But, health boards have had some heads up. In terms of the booster dose, we were expecting the JCVI to, last week, as they did, announce that a booster dose was recommended, for the reason of vaccine waning effectiveness, which I will come back to in a second. So, they have all been prepared for that, and largely that has been done, as with the first round and second round of the vaccines—    

Dr Atherton, you have just gone quiet all of a sudden. Perhaps just lean forward a bit and—

I beg your pardon, Chair.

That's it. Lovely. Thank you.

My apologies. So, indeed, the booster programme will be delivered through mass vaccination centres, and health boards have been preparing for that for quite some time. The 12 to 15-year-olds also largely will be done through the mass vaccination centres, which are established, so, it's fairly straightforward to turn them to that process. There will be some schools that the health boards will work with to administer through the schools, but mostly, that will be done through the mass vaccination centres.

The flu vaccine is a very different matter, in as much as we have traditional approaches that have worked very well in Wales for delivering the flu vaccine. General practices across Wales have procured doses and are ready to go with the flu vaccine. Community pharmacies are the other outlet. So, it works in a slightly different way. So, I'm confident that we do have capacity to deliver all three of those programmes. Obviously, the people who are working on those vaccination programmes are not working elsewhere in the healthcare system, and so it does lead to some knock-on consequences in terms of healthcare provision elsewhere.

On the waning effectiveness, Rob may wish to come in, but we saw evidence of that very clearly—. Every couple of weeks, we have catch-up call with Israel and the CDC in Atlanta just to look at where things are in terms of the vaccination programmes. Israel was, I think, the first country where we started to see the waning effectiveness of some of the vaccines, and hence they have moved to a third, booster dose, as we heard earlier. There were some very significant differences between our programme here in Wales and the Israeli programme. We are, I believe, seeing reduced vaccine effectiveness over time, but not perhaps as quickly as Israel did. The programme in Israel had a three-week interval between the first and second doses. We had a longer interval, and that appears to have given longer lasting immunity. Israel did start off its programme much earlier than most countries, actually, including the UK. Therefore, people have had longer to experience that waning immunity.  

It is absolutely a fact that the vaccines are still working. They are still protecting us. If they weren't, we'd be seeing a lot more problems in our hospital sector. But, we take the JCVI advice very seriously, and now is the time to embark on a booster programme. In fact, I know anecdotally a lot of healthcare workers have already been called up for that, and we will work our way through the priority groups, as we did for the first and second waves, starting with the most elderly and most vulnerable people in care homes, et cetera. So, I'm confident that we can roll the booster programme out as effectively and efficiently as we have in the previous doses. Rob, I don't know if you wanted to come in on the vaccine effectiveness and the waning immunity.  

Yes, sure. We are measuring and monitoring population immunity through time, and we publish that each week in our COVID situation report that's on the Welsh Government website. I think there's now growing evidence that we're likely to see waning immunity over time. I think it's less likely that we'll see significant waning on the real benefits of vaccination, and that's preventing deaths and serious illness, but we're more likely to see waning in transmission, so people will be able to give and receive coronavirus.

A really nice analogy is that of logs in a fire. So, if you have your vaccine, the logs become wet, but over time they dry. In a fire, the log could catch on fire but it's unlikely to be destroyed. So, I think we'll probably see that in the population, and there's already some evidence from Public Health England, and our own evidence is suggesting we may be seeing that now. So, I think there's good reason to suggest we need booster vaccines and vaccination in children to try and reach population immunity where we'll see, hopefully, a suppression of the epidemic.

I think I'll probably pause there, Frank, but the evidence has all been published. Everything that we do is published weekly. Public Health England publish all of their evidence, and SAGE, so for people that don't believe the evidence, well it's all made available for public viewing. Thank you.

Thank you both for those answers. And just sticking with the booster programme, I wonder if you could tell us what percentage of each priority group will receive the booster jab. And in terms of measuring and monitoring, as Dr Atherton rightly does, we too as a committee like to measure and monitor. So, I'm just wondering if we will be able to track the booster programme through the Public Health Wales figures in the same way as we currently do for first and second doses.

Can I answer that, Chair? So, yes, absolutely, the data will be available. In terms of the target, well the target really is to get a booster into everybody who's had a primary course of the vaccine. I don't have an absolute deadline for that, but the proportion of people vaccinated should be as high as possible; we should try and get up to the 90, 95 per cent rate as we have with the first dose. And the older groups in particular need to be protected. And the data will be available. Public Health Wales have been asked to produce that and to make that available in exactly the same way as it was for first and second doses.

Thank you. I appreciate that, Dr Atherton. Just one final question from me, Chair, again regarding data. Across the border at Public Health England, they are now publishing the vaccination status of COVID-19 cases, deaths and hospitalisations on a weekly basis. I just wondered if there's an intention to publish that similar data here in Wales.

There is indeed. And that's another issue we've asked Public Health Wales to look at, about how they can increase the availability of that data. It needs to be interpreted with some caution, of course, because when you have over 95 per cent of the population vaccinated, inevitably some people who are vaccinated will appear in hospital. What we do know—and it's the interpretation that is really quite important—is that people who are unvaccinated, or only partially vaccinated, are overrepresented in the hospital statistics and the death statistics, et cetera. So, when we do have those figures, it's important that we interpret them with caution. But, yes, we are committed in Wales to being as transparent as we possibly can, and to bring that information into the public domain, and Public Health Wales is working on that.

Can I just press? Is there a timeline when we'll likely see that data being published?

I don't know. I know they're working on it, even this week, so I would hope it would be quite soon, but I can't say exactly when.

Fliss wants to come in as well, I think, on this question. 

Yes, sorry, I just wanted to add another note of caution, which is that, given how highly pressurised our care services are, especially in hospitals, there's a real danger of the perfect being the enemy of the good here, in that it is quite easy to record whether or not somebody is vaccinated when they come into hospital, but what we really need, in order to have a clear understanding of what harm the virus is having, is to understand whether or not somebody is coming in with COVID and because of COVID. So, at the moment, it's possible that somebody could come into hospital as a result of trauma from a car accident, and they might be found to have COVID, and whether they are vaccinated or unvaccinated, it will not be the case that they have come to hospital because of COVID: it will be because of the car accident. And the measuring of that, the recording of that, at a point where we can see it in the stats is something that would take up healthcare workers' time, who are better used helping to treat people. So, there's a real kind of tension between wanting to make sure that we have all the information and wanting to make sure that we don't overburden people and that we don't make unreasonable interpretations of the data we have. And I wanted to share that with the committee: it's something that burdens me.

I tend to agree with that. I thank the witnesses for those interesting and good answers.

Thank you, Jack. And, Fliss, I appreciate that last comment—that's something for the committee to consider as well, I suppose. Can I ask Joyce Watson—? I think I may have seen a virtual hand being lifted. Did you want to come in on this block of questions, Joyce?

I did.

Joyce Watson.

It's not on COVID vaccines, it's on the measles, mumps and rubella vaccine. You talked about childhood transmission, and of course we all know that measles transmits around about this time of year, so whether we're looking at the uptake of the MMR vaccine and whether that's being reduced, or whether you're quite happy. If you haven't got the answer now, it would be a useful answer for us to know about, and the messaging around the effectiveness of that, and also the need to take that up.

Dr Atherton.

Yes, it's a really important question, because childhood vaccination, generally, is such an important way of keeping our children and young people safe in Wales. I haven't got figures to hand, but by and large, our basic childhood immunisation programmes have held up very well during the pandemic. So, I don't think that there has been any significant drop-off in MMR coverage, or indeed of the other primary vaccinations that children have. And that's good news because, as you say, measles is a seasonal virus, we don't want to see it coming back in Wales. We're actually trying to move in the UK towards the elimination of measles as a public health problem. So, that's good news in that regard. There are some other vaccination programmes that have taken a bit of a hit, particularly the school-based programmes. The human papillomavirus vaccination programmes, I think, have taken some downward hits and need to recover. And we, again, are working with Public Health Wales and with the health boards to find ways to get back on track with those vaccinations. But basic childhood immunisations, including MMR, are holding up pretty well.

Fliss, you wanted to come in.

Thank you. Yes, I just wanted to highlight I do know that our uptake for MMR is equivalent with what we would see in others. So, the MMR uptake is absolutely on track, as with other years. And it is really important, you're absolutely right.

Thank you, Fliss. Mike Hedges.

Can I make three requests on vaccination before I move on to testing? The first one is that you tell us what order we're going to have the booster. Is it the same order that it was when we had the first vaccinations, because people are confused? The second one is that there are medical professionals—your colleagues—who are telling women that it may not be safe for them to have the vaccination. What are you doing to convince your colleagues that vaccination is right? And what analysis have you done from different GP surgeries, and identifying those where vaccination rates are low?

Shall I go first on that, Chair?

Thank you, Dr Atherton.

The order of boosters will be, by and large, the same order that we went through with the primary doses of coronavirus vaccine. If you remember, there were nine priority groups, going down to age 50. So, it will go in that order. And it kind of works because the Joint Committee on Vaccination and Immunisation advice is, of course, to give the vaccine six months after the second dose. So, many people, of course, have not reached that six-month period. So, people will be invited in that order—they'll get letters; they'll get, sometimes, a phone call. I know some colleagues who work in the health sector are already getting phone calls and that's how that will be managed.

Misinformation from health professionals is a difficult one. It's a minority issue I would say, but I am aware of issues that do arise. Most recently, as I said, I'm very worried about pregnant women, and I've had a discussion just this week with our chief nursing officer, Sue Tranka, who is going to communicate with all heads of midwifery, so that the midwives are giving the right message to that group. If there are specific groups of health professionals, who you're aware of, who need specific communication, then I'd be very curious to hear that and address that.

Most of the coronavirus vaccination, of course, has been through mass vaccination centres, through the hospital setting—relatively little of it through general practices. And of course general practices provide the flu vaccine programme, so the variation between practices and coverage is probably more relevant to flu. We do look on an annual basis at how we can drive forward the flu vaccine, but by and large, practices are very good at getting it out. I don't have data available at the moment comparing individual practices, but I'm sure that could be made available if we needed it.

And, Fliss, you wanted to come in.

It's worth noting that health and care workers, medical professionals at all levels included, are amongst the highest take-up of the vaccine that there are. Well over 95 per cent of the entire profession has had two doses of the vaccine and are beginning to get the boosters already. So, I agree with Frank, it's not something that you would want to give too much air time to because it is really quite a small minority of individuals.

[Inaudible.]—5 per cent of a large number usually gives you a large number with a large number of medical professional people in Wales. So, 5 per cent of several thousand is several hundred. But I won't take it any further than that.

I wanted to come on to testing. At what stage do we stop testing? You must have an end point to testing. In a 100 years' time, I assume they will not still be testing. So, what has to happen for testing to come to an end?

It's a good question.

Yes, I think it's an excellent question. It's actually one that is under active debate at the moment. Our test, trace, protect programme has been very successful at identifying people and helping to stop some transmission of the virus, but we have to be aware that the TTP programme is most effective when prevalence is low, so stopping transmissions. Contact tracing is most important with lower levels of transmission.

But testing, essentially, has a number of purposes: first of all, of course, it has a purpose in terms of identifying cases as they go into hospital so that people get the right treatment. That will need to continue. Testing also has a role in terms of contact tracing. That is less successful and probably less relevant as we get to higher levels of transmission and also now that we no longer ask contacts of cases to self-isolate, that also becomes less relevant. So, that does require some further thought and will probably change, but I don't think it will change immediately. There's a question about the timing as to when that will change, and that, as I say, is an active discussion.

Testing is also important in terms of protecting vulnerable settings and vulnerable individuals. Think about the care homes. I think that testing in the care home setting and in hospitals will continue to keep those environments safe. Schools, arguably, might be another area where testing needs to continue.

And finally, testing is really important for surveillance. Rob talked earlier about our ability to spot and identify early new variants. If we did identify new variants here in Wales or in the UK, we would need to rapidly ramp up our TTP programme again. We would need to make sure that we identify the contacts and go back to very rigorous contact tracing to try and stamp it down. So, surveillance is a final reason.

So, testing will evolve, but it will, I think, reduce over time. The timing for that, probably, is not now when we have very high levels of community transmission. I suspect it's something that we will develop as an approach over the winter months and probably make some quite significant changes in spring next year. We will do that, I would hope, in concert with the other nations, because having a four-nation approach on this is really quite important.

You talked about tracing. I've been traced twice, not through the official system, but people I've known have tested positive and they've contacted me to tell me they've tested positive. Is mine a unique experience, an unusual experience or is it reasonably common? The official tracking system still hasn't contacted me.

Dr Atherton.

Well, I don't know the details of how you manage your app or your personal contacts. I'm sure a lot of people have been contacted by friends, colleagues, or relatives who've said, 'Well, I've got coronavirus. I've been close to you'. I'm sure that that is not uncommon and that's perfectly reasonable. I don't know what the proportion of contacts is through that sort of route versus through the TTP programme, but that doesn't surprise me, particularly.

Dr Orford wanted to come in, I think, again.

Yes. I think that's fantastic if people are telling you that they've been exposed and they're positive. I think I would thank your friends. And more of those kind of personal protective behaviours and looking after others around them and the community, I think, really should be championed. So, I'm really pleased to hear that.

Shouldn't we be asking people to do it, rather than relying on the app? I go places without my phone—I know that that sounds unusual—for example, but wouldn't it be easier if we actually asked people to check, if they test positive, with the people they've been in contact with whether they have been traced? 

Again, I think it's really sensible. Let's do sensible, practical things. Previously, we've talked about the Swiss cheese defence where we do lots of things—hand washing, avoiding crowded places, telling people that you've got COVID. These are all sensible things that will protect you and others around you.

And something that is another one of these rumours on social media: how accurate are lateral flow tests? I have lots of people telling me that it's a waste of time and that if you keep on doing it, eventually it'll come out negative. 

Dr Orford.

Yes. All of these tests, as Frank said, have got a place and they have to have a purpose: what's the reason that you're using them? Now, lateral flow tests have a really good purpose—that's when prevalence is high and it gives you a really fast result, so when you're starting to get an infection. The PCR test is exquisitely sensitive and so it's a really good way of picking up samples and it's the platinum test that we support. If people come up positive with a lateral flow, then we encourage them to take a PCR test as well. So, as with any test, it has to have a purpose, it has to have a pathway and it has to have utility. So, at certain points, the lateral flow devices are less useful, but at the moment, when prevalence is high, they are useful and I think around about 3,000 positive tests were captured in the last 24 hours [Correction: in the last week]—I believe that that figure is correct, but I'll check that. So, a high number of them are being used and, clearly, they're picking up people earlier than they would've been picked up with PCR, because whilst PCR is exquisitely sensitive, there's a lag in the time it takes to get that test to the laboratory and the result onto your phone. So, they all have a place, they all have a purpose. Sequencing has a purpose, phenotyping has a purpose, point-of-care testing has a purpose, but it has to be deployed at the right time, at the right place, for the right reason. 

Thank you.

Thank you. I've made a note for the relevant committee to take up some of the points that Mike's raised in 100 years' time [Laughter.] It's noted in my file.

[Inaudible.] Chair—

Say that again, sorry, Mike.

Will you be Chair in 100 years' time?

I hope not [Laughter.] Well, that depends—that's perhaps a question for Dr Atherton, about life expectancy at that particular point.

The last set of questions is from Joyce Watson. We've got about 10 minutes. So, Joyce, you've got 10 minutes for the last block of questions. Joyce Watson.

Thank you, Chair. I'm going to wrap them up and not repeat. So, just top of the list is: how effectively do you feel that people are continuing to take the public health messages on board, and also to take responsibility for acting in line with those messages?

Fliss.

So, it's been so wonderful, especially in Wales, I think, to see quite how strongly the public have responded. We've got ways of assessing public behaviour—not just looking at the mobility data, through transport, though mobile phones, to see how little people moved when there was advice to stay at home, but the studies that are published regularly by the Office for National Statistics, the assessments that are done by Public Health Wales and by the Welsh Government, where we ask people in small focus groups, and in large groups, to talk about what their risk prevention methods are. Then, we find that a lot of people are still saying that they work from home where they can. A lot of people are still self-reporting as wearing face coverings when they go into indoor public areas. And a lot of people say that they are not likely to be changing significantly the way that they behave in public any time soon.

It's really, really important that we balance the understanding of what risk really is against not being so afraid that we can't live our lives. Finding that way to the new usual, where, as a nation, we start to work out what protective behaviours we are going to carry on using when there are periods of high risk from any dangerous infectious disease, is going to be one of the key challenges over the next six months.

So, I think that, from what we've seen from our studies, behaviour is still really good. Obviously, self-reported data have to be taken with a pinch of salt. A lot of people say that they do something that, perhaps, they don't always do. But, generally speaking, there is an intention, and there seems to be bearing out quite a lot of still protective behaviour by people in public places.

Unfortunately, in private places, which is where we are most likely to let our guard down, we know that there is a higher quantity of mixing. There are a lot of people reporting having been less protective of themselves, either in their households with other people, or in other people's households. So, one of the main likely routes of transmission at the moment is people socialising in their own and in other people's households, in very small amounts, but in places where they feel safe and so they let down those natural behaviours.

Finding a way to work with people to understand where their risk is actually highest, and to do what they feel is appropriate about that, is going to be one way in which we can start to sensibly cut down transmission, as the previous Member said, without needing to bring in TTP or national restrictions—but just getting into our own, underlying subconscious.

[Inaudible.] about behaviour. One of the behaviours that has been allowed to happen, but hasn't happened for some time, is international travel. Underlying that, of course, the big difference is that you don't have to take PCR tests. So, how concerned are you about the increased possibility of transmission, but particularly about new variants coming in? 

Thank you for that. It is an area that I do worry about. We have taken a different approach on international travel in Wales to the rest of the UK, and I think that that was appropriate. It still is guidance in Wales that people should travel internationally only for essential purposes.

There are two reasons, really, why we worry about international travel. One, of course, is the seeding of infection more generally. That's not such a big issue now that we have such high community rates here in Wales. But, the prospect and possibility of introducing new variants is a really concerning one. As Rob has said, while the delta variant is so widespread, it is hard to see anything that's likely to come in and outcompete it, but that won't always be the case. And as the current wave goes down, there is a significant possibility that a new variant could creep in. So, I think having surveillance to identify new variants, if they do come in, is really, really important, and I see particularly the day 2 PCR test after travellers return as a really important way of garnering information that will protect us for the future. So, that's kind of where I stand. I think Welsh Ministers are still to make a decision on that. I know, in the UK, English Ministers have moved away from it. I think Scottish Ministers are minded to retain it. But my advice has gone to Ministers and we'll see what they make of it.

Okay. Thank you. We're going to run out of—

Joyce, you've just gone quiet. So, we'll—

Have I? Can you hear me now?

I can hear you now. Go ahead. 

It's moving back in the chair, isn't it. Is it possible that TAC will advise regarding local lockdowns again? If there was a problem in certain areas—and I know that you just said that you really hope not to do that—and if it became obvious that that would help contain the spread, at what point would you advise—[Inaudible.]

Dr Orford.

My job is to advise, to look at the data, interpret the evidence and advise accordingly, and that's what I'll continue to do, as we have done throughout the pandemic. I think Ministers have been clear that it's not necessarily a one-way street here. I do think we need to be really clear that there are multiple harms that can occur not just from COVID; it's the indirect harms occurring in the NHS. There are harms associated with interventions themselves, like loneliness and isolation. There's a huge cost for population-level control measures. So, there are economic harms occurring. And then there are inequalities, both new and existing inequalities, that get exacerbated. So, these are really difficult decisions. 

Now, it's changed—we're not talking in terms of how many deaths are occurring, although there are significant deaths, but much less than before. But there is significant impact on an already burdened NHS. So, we do need to be exquisitely dialled in to what we're seeing in the data, and then asking what might come tomorrow and the day after that, and then advising Ministers accordingly, and Ministers are really receptive to those types of conversations. But I'm really clear in my role that science and evidence is one part of it, and there are lots of other considerations that need to go into these decisions. Thank you. 

And my final question is going to be: have you looked at the way other countries have managed their public health issues arising out of COVID, and their messaging, to try and keep people on board? Because what ultimately has been said so far is right; most people, most of the time, are actually on board with the messaging and following, and we're really thankful for that. But to keep that goodwill, have we looked at what other countries have done, if they've had successes that we might actually enjoy?

Thank you. Through the whole pandemic, we've tried to maintain a very careful watch on what's happening elsewhere, what's working elsewhere, in Europe of course, but also more widely. And I've had a number of calls with colleagues in different countries to try to understand what's going on in different places. There are some interventions in places that have succeeded in some ways, like, say, the Antipodes. New Zealand, Australia, of course, were able to pull up the drawbridge—that was their approach. It's left them with another set of problems down the road about how they now unlock when they don't have sufficient vaccination coverage.

There are other countries that have had a more authoritarian point of view. China, we talked about earlier, maybe has very low case rates, but it's a very authoritarian regime. I don't think that would be particularly applicable in the UK context or the Wales context. And, then, we've looked at the different application of the NPIs, the non-pharmaceutical interventions, in different countries across Europe and in the US, and there have always been some differences in those, but more similarities than differences probably. 

And so, taking that experience and the international experience into what we do in Wales has been an important part of our management of the pandemic, and will continue to be very important as we go forward. 

Fliss, you wanted to come in.

I just wanted to say that one of the things that works, regardless of the political or the social or the economic situation or the size of the country, is openness and transparency and clarity of message. If people understand what is being attempted, if people understand where the risks are, if people understand what the transmission is and what it is they need to do, then it is more likely that they will do it. The Welsh Government has issued a COVID code—there are some really simple things that everybody can do all the time to help, regardless of what alert level we're at: if you are positive with COVID, or if you are symptomatic and awaiting a test, self-isolate, don't mix; if you can work from home, do work from home; wash your hands regularly; try to make sure that you've got ventilation, open windows, or that you're meeting outside. And these are the things that lie underneath as we get better understanding about how good they are at helping to remove the risk of infection. Those are the things that work in every country. Thanks.

Thank you, and thanks, Joyce. This brings this particular session to an end. So, can I thank our witnesses very much for their time this morning again and for their evidence paper? The clerking team will send you a copy of the transcript of proceedings, so, if you think you need to add to anything that's been said, or correct anything, then there's an opportunity to do that.

We are going to take a 10-minute break, but can I just ask the witnesses just to hang on for a moment, until we go into the break session? So, if we can take a 10-minute break, and be back in just before 11 o'clock.

Welcome back to the Health and Social Care Committee. I move to item 3, and this session is in regards to general scrutiny with the Minister and Deputy Ministers for health and social services. I wonder if I could just start the session by asking the Ministers to introduce themselves and perhaps the officials then want to come in to introduce themselves as well after the Ministers.

I'll go first. I'm Eluned Morgan, Minister for Health and Social Services in the Welsh Government.

I'm Julie Morgan, Deputy Minister for Health and Social Services in the Welsh Government.

And I'm Lynne Neagle, Deputy Minister for Mental Health and Wellbeing, Welsh Government.

And then officials, in the order on my screen. Dr Goodall.

Bore da—good morning. I'm Andrew Goodall. I'm NHS Wales chief executive and director general.

Tracey.

Bore da—good morning. I'm Tracey Breheny. I'm deputy director for mental health, substance misuse and vulnerable groups, Welsh Government.

And Albert.

Bore da—good morning. I'm Albert Heaney, the Chief Social Care Officer for Wales.

Thank you all for being with us this morning for what is our first substantial meeting of the Health and Social Care Committee. So, thank you all for your time with us this morning.

Perhaps it would be useful to start off by asking the Minister how you're going to divvy up your responsibilities between yourself and your deputies and how your working relationships are going to pan out.

So, we've set out, and it's set out on the Welsh Government website, exactly who's responsible for what in terms of the way we've divided our responsibilities. I will take overall responsibility for health and social care and look at the primary and secondary parts of the NHS. But of course the primary responsibility when it comes to social care will be with Julie Morgan, and, for mental health and public health, that will be Lynne Neagle. I'm sure they would like to go into a bit more detail about their particular roles, but just to say that we will be having regular meetings in order to ensure that, if there is any crossover, we're all singing from the same hymn sheet. 

So, just to give you an example: at the moment, as you'll be aware, there's huge pressure in our hospitals, but there is a direct relationship between what's happening in our hospitals and what's happening in our social care communities. So, obviously, we need to make sure that we're working together very closely on that. In the same way, in relation to public health, we want to take the opportunity, for example, with the roll-out of the vaccine, to give messages, public health messages, whilst that roll-out is happening, and so I'm working very closely with the Minister for public health on that.

Thank you, Minister. Perhaps, if the other Deputy Ministers want to say anything, perhaps they can respond when they get their first question, if they want to add to what you said, Minister.

If I can just dive into some questions in regards to COVID-19, I suppose the question on many minds and the committee's mind, especially after our first session this morning with the chief medical officer and other colleagues, was: what restrictions the Welsh Government would be prepared to reintroduce or introduce if the COVID situation got worse, but particularly—? I can imagine your answer on that, but I suppose the more important question is: what are the trigger points for perhaps reintroducing or introducing further restrictions?

Well, right from the beginning of this pandemic, as the Welsh Government, we have not ruled out any measures, but we are aware at the moment that the balance has shifted as a result of a very successful vaccination programme, which means that we mustn’t just be considering now issues relating to COVID, but we must be thinking about those wider harms that are occurring within our communities. Of course, we aim to keep our communities and our society open to maintain people’s freedom, and it is important that we understand that it was an exception for us to be in a situation where we had to have those lockdowns that were introduced. We will, of course, do everything we can to avoid that in future, but I think it is an option that we need to keep on the table. There aren’t any mechanistic triggers for when we would consider that situation, but, all the way along, we have been very aware that it is essential for us to ensure that the NHS is not overwhelmed. You will have heard in recent days that the pressures on the NHS are very, very significant at the moment, but we have to be careful, because there are always pressures on the NHS every winter, and we have to distinguish between the pressures that we’re having as a result of COVID and those pressures that we would see year in, year out. So, we’re aware of that; we’re aware of the five harms that we need to be balancing out.

What we will do, and you’ve heard in the prior session about the importance of us analysing the data, looking at international experiences—. We have set out what we hope to do in our coronavirus control plans and our regular updates and, of course, we revised our basket of indicators in August to reflect the fact that the delta variant takes us to a different place and means that we do have to respond slightly differently. So, we’ll keep the whole situation under constant review, as we have done throughout the pandemic and, of course, we need to be aware that, if we see a new variant being introduced, then that may change the whole situation.

Thank you, Minister. I should have said at the beginning as well, if other Ministers or officials want to come in at all, please just raise a hand or pen, and either myself or officials will see and bring you in appropriately as well. Thank you for that answer, Minister. Can I just ask about the priority given to keeping younger children and younger people in school and in education, in terms of further restrictions that you might consider?

Well, we’ve repeatedly said that we are very anxious to try and keep our children in school, and so they were the last to close and the first to open. So, we are determined to keep on with that situation. You’ll be aware that we are now rolling out the vaccination programme to 12 to 15-year-olds. That wasn't an easy decision—the Joint Committee on Vaccination and Immunisation came to a conclusion, but the CMOs really were very keen to make sure that they looked at the broader harms that could occur as a result of children missing more school, and so we are very aware of that situation. We’re aware of the lifetime effect on children, particularly from our poorer communities, if they miss school, and so we are determined, if we can, to keep children in school. That’s why we have invested significant sums now to introduce carbon dioxide monitors—spending £2.3 million on that—to make sure that we are monitoring ventilation rates, looking at how can keep those situations open, and, of course, we need to try and stop infections in schools. So, reinforcing those points with the general public, but also in our schools, that they really need to take hygiene, hand hygiene, very, very seriously, making sure that they are considering those ventilation issues, and making sure that, where appropriate and when they know they have COVID symptoms, that they take the appropriate steps.

Thank you, Minister. One issue I’ve observed, perhaps in recent weeks, is that some schools are closing or closing part of the school because of staff shortages, because perhaps a staff member is ill or self-isolating themselves. An issue that seems to be raised is that when, perhaps, a child does test positive, that it’s advised, but not compulsory, that perhaps a sibling or family member is also tested. So, there’s a concern then that that sibling or family member will go back into school and perhaps spread the virus or pass it on to a teacher, who then, of course, in turn has to self-isolate themselves, meaning that there's an impact for children's education. Is this something that you are aware of, that's been raised with you, and what considerations have you given to perhaps changing anything in that regard?

We're very aware of that situation, and our test, trace and protect teams are very experienced by now in terms of making sure they identify those people who have the closest connections to the person who has contracted the virus. Of course you're more likely to contract the virus if you're living under the same roof, but it's not definite that you will. I can't remember the precise percentage, but it's actually quite a low percentage chance that you will contract the virus if you take the right precautions. So, obviously we would be encouraging them to take the test, if they're living under the same roof, but, as I say, we are very keen to keep children in school as much as possible. And that's why we are still in the position at the moment where, if people have the test and they are negative, then of course they should be allowed to return to school.

I suppose the important part of your question there, that I would raise, is that you encourage the family member—or the parent is encouraged to test their child. But the suggestion, perhaps, by some teachers is that that's not enough—encouraging is not enough—and there should be a mandatory process of at least not being permitted back into the school until a positive test, or a negative test, rather, had been presented. And that's a suggestion perhaps by teachers who are concerned that this could help prevent the spread and keep schools effectively open due to staff not being away from having to self-isolate themselves. So, I suppose the question there is, really, about what considerations you've given to moving from encouraging parents to take tests for their siblings that may have been in contact with another sibling, who is positive, rather than just advise.

So, the education Minister has set out some very clear guidance on this, and I know he is concerned about the perhaps inconsistency that is currently being undertaken across Wales, where sometimes you see whole year groups again being sent home, which was not the idea. So, we are trying to make sure that that guidance is clear, that parents and teachers know exactly the situation. But, at the moment, we are not suggesting that siblings, if they are in the same household—necessarily—have to stay home if their other sibling has contracted the virus.

Okay, thank you, Minister. I'd appreciate it if that aspect could be kept under review with yourself and officials. Can you also perhaps give a wider update on the roll-out of the booster programme and in conjunction with the roll-out for the vaccination for those younger groups as well and how that also aligns with the flu vaccination programme? I'm just conscious that there are three programmes all coming relatively at the same time and how you're managing that.

Well, it is something we've been preparing for for a very long time. So, we were slightly frustrated that the JCVI took quite so much time to determine whether we should be rolling out a booster vaccination programme. So, we've been ready; that roll-out has already started. We will be prioritising the groups, as they were prioritised during the first roll-out of the vaccination, starting off with people in care homes and NHS staff and care staff. We are concerned about waning immunity, which is why this roll-out is important for us. Those booster invites will be sent out on 27 September, but, of course, we've already started offering that booster vaccine to people working and living in care homes and to front-line and health and social care staff. So, all of that is already being rolled out.

When it comes to children, you'll be aware that the chief medical officer has recommended that we should be offering this vaccine to children who hadn't already been offered the vaccine under JCVI advice. Those were perhaps clinically vulnerable children. So, letters inviting 12- to 15-year-olds will begin to be issued this week, and the vaccinations will start on 4 December. And the reason for that—and again, we've been preparing for this for a long time—is because we think it's important that children and parents have time to consider this information. The children's commissioner has been very clear with us that she thinks that this information has to be in a child-friendly way—that it is produced. And we hope to be able to offer the vaccine to everybody from 12- to 15-year-olds by 1 November. So, that's the end of the half term that that offer will be made. 

Jack Sargeant.

Thank you, Chair, and thank you for that, Minister. If I may just press on the flu vaccination programme. We heard from the Chief Medical Officer for Wales earlier that there's perhaps an expectation of an outbreak of flu, perhaps worse than we saw last year, for obvious reasons. He was confident that the vaccination programme will be a success. Do you share that confidence? Do we have the capability to deliver all these programmes alongside each other? And perhaps you could touch on the role of pharmacies and what you see their role is in being able to deliver it.

So, we've got a lot of experience in Wales rolling out the flu vaccination programme, although we're expecting that to be increased this year in terms of the number of people to whom that's offered, because of our concerns about the flu increase that we think we're likely to see, as has clearly been indicated to you by the chief medical officer. What we're hoping to do is to align, where we can, the flu vaccination programme with the COVID booster programme. So, we know that is already happening in terms of co-administration in places like Hywel Dda already, in particular with care home residents. So, we're going to see what we can do in that area. So, we're very keen to see that happen, and we are very confident, in terms of the roll-out of the flu vaccine, that we will be able to do that. And, as always, there will be a role for pharmacies when it comes to the flu vaccination programme; I think there's a real contribution that they can make in this space.

Gareth Davies.

Thank you very much, Chair. You touched on care homes just then, and in terms of care home visits, although the Government's advice has been to allow visits once more, individual care homes have, in some cases, been a bit more cautious, and we've seen media reports around the fact that there are still window visits. Bearing in mind that these are some of the most vulnerable people in society, with diseases such as dementia, Alzheimer’s in worse cases, then those protective factors in their lives have meant they've not been able to see their families, as such. So, is there any more targeted guidance that the Government may be looking at in terms of giving direct instructions to care homes, and giving them perhaps some more confidence in order that vulnerable people can see their families once more?

I'm going to ask the Deputy Minister to come in on this as well, but just to say that we have updated the guidance on this. We're constantly looking at this. But it is a really difficult balance, because those care home residents and the relatives of those care home residents will not thank us if we introduce COVID into those care homes. At the same time, of course, you're absolutely right that we've got to get this balance right that, actually, it is really difficult for people with dementia to understand why all of a sudden their loved ones stop visiting. So, we've got to get this balance right, but we have got to give—. That clinical call needs to be made, where possible, on a local basis, because the incidence of COVID within our communities is slightly different across Wales, and they need to take that into consideration. But we do think it is important that people have the opportunity to visit, even in situations where there is COVID in the home, because, actually, it is really important for some people to know that that care is available for them. Can I ask Julie to come in here?

Thank you, Minister. Julie Morgan.

Thank you very much. Making decisions about visits to care homes has been one of the most difficult things that the Government has had to do, because it is balancing the different elements, as the Minister has said. But I want to be quite clear, and I know, Gareth, that you know this, that right from the beginning we have not banned visits to care homes. There has always been the opportunity for relatives to visit their loved ones, particularly if the situation is an end-of-life situation or any other exceptional circumstances. So, right throughout the pandemic, there has always been the possibility for relatives to visit.

We have updated our guidance continuously. We do draw our partners into these decisions, because care home visiting is a standing item at the national residential care homes group, which the Welsh Government chairs, and our partners are there and the environmental health officers are there, and they're able to feed back to us to identify when there are homes that are anxious, or when visiting does not seem to be taking place in the way that we would wish, and, of course, we do get feed in from relatives and from the older persons' commissioner as well. If that happens, we get in touch with CIW—Care Inspectorate Wales, and Care Inspectorate Wales will arrange to speak to the people who run the care homes and will often explain things more and, often, a resolution can be made and they will be able to enable visits to take place. But the most up-to-date guidance that we're preparing now is guidance for the residents of care homes themselves, directly aimed at them, explaining what the current guidance says.

Gareth.

Thanks again, Chair, and thank you to the Minister and Deputy Minister for your answers. I have to take certain issue with the start of the answer from Julie Morgan, in that care home visits were never banned. At the height of the pandemic, in March, April and May 2020, people weren't able to even go out of their homes, so I'm not sure how it can be said that the Welsh Government haven't banned care home visits, because it was the case across the country, across the whole of the UK. People could only go for one piece of exercise, so I can't see how care home visits would have been permitted under those circumstances. Now, I know things are better, but in terms of that part of the answer, I have to take issue with that one.

I mentioned in Plenary yesterday about insurance difficulties for care homes and possibly looking at indemnities for further protections for care homes, as this has been allowed for the NHS and, I think, a couple of music festivals across Wales in the summertime. So, I was wondering why those can't be permitted, as such, to people who are caring for our most vulnerable people. Will the Welsh Government be looking at a public liability indemnity similar to the one that I think has been in England, in place since around September now?

Deputy Minister.

Thank you. Just to go back to your first comment, in all our guidance throughout the pandemic, we have always said that there are exceptional circumstances where visitors can go in and see their loved ones, and that has been the situation for the whole of the period, and if you look at the guidance, you'll see it, because, obviously, there were circumstances—end-of-life circumstances and other very exceptional circumstances where our guidance said people could go in.

And then, to go on to the insurance difficulties, we are very aware of the rising premiums and the fact that many care providers find it difficult to obtain public liability cover for COVID-19. Now, this is a UK-wide issue, and we're working closely with the Department of Health and Social Care, and we're working with the other devolved administrations to try to find a solution. But the Association of British Insurers and the British Insurance Brokers' Association have this week published guidance for the care sector, setting out the steps providers can take to put themselves in the best position for renewal or for a new quotation. Obviously, this won't resolve all of the insurance issues providers are facing; it will be a useful resource and one that care providers across the UK can return to as they prepare for future insurance renewals. We will be making sure that all our care providers get a copy of this published guidance, which, as I say, has only appeared this week, and we will continue to keep the sector updated. In relation to the restriction of visits in relation to the insurance issue, we are quite clear that the risk assessments that should be made for visits should be focused on the health and the well-being of the individuals at the home. 

Thank you. Joyce Watson. 

Thank you, and good morning, everyone. The Minister's paper provides an update on support for people with long COVID, and that includes the establishment of a recovery programme and guidance for the management of long COVID. My question is: how will that work be assessed in terms of people's ability to access support and the outcomes? And how is the patient experience being captured?

Diolch, Joyce. As you'll be aware, we have launched the Adferiad programme. I indicated when we launched that that we would be revising it on a six-monthly basis, partly because we're still learning about long COVID. We still are not clear what this looks like, what it will look like in future months. So, we will be updating that in January. In order to do that, we'll be including an input from the health boards, who have all been provided with a template in order to identify the data that we expect to see as a part of that response. And that will include data that we want to see in terms of demand, the quality of experiences, which is what you're talking about—how do we know how people will respond to it—and obviously the recovery outcomes, which is really what matters. We are going to focus on that patient experience, and we are talking to the directors of therapies and health science in the health boards to make sure that we are looking at outcomes, because that is the thing that really matters here. The other thing we've done is we've asked for case studies. There are some health boards that are doing this better than others, and I think it's really important that we learn from best practice and share that out. But what's clear is there's not one, single, specific treatment when it comes to long COVID, and it is going to be a moving feast. 

My next question is linked to exactly the same. Of course, long COVID could have an impact, and may have an impact, on staffing levels, particularly in social care services. Is there any evidence that that is the case? And, if there is evidence that that is the case, what sort of actions are being taken?

Because this relates to social care, if you don't mind, I'll ask Julie to come in on this. 

Long COVID is obviously bound to have an effect on the social care service, and it's going to create more demand for the ongoing services. There will be more demand for domiciliary care, which we know is already under great pressure, and also reablement and, potentially, the need for independent living equipment for longer periods. So, at the moment, the regional partnership boards are doing their five-year population needs assessment, which will help them understand the healthcare and the well-being needs of key population groups, and that would include older people, children with complicated needs, people with a learning disability. Obviously, the impact of COVID and the impact of long COVID is one of these groups that will also have to be considered in the population needs assessments. So, these assessments of need will also explore the range and level of services available to meet population need and will plan any action that's needed to address gaps in service delivery. And they set that out in their five-year strategic area plan. So, that's how it will be planned in relation to social care services at the RPBs when they do their five-year population needs assessments.

If I can just have a follow-through on that. Clearly, if people have got long COVID, there will be differentials in need, like there is with everything. And potentially, there's a differential in equipping people to go home, to make sure that they're going to stay as independent as possible. How high up the agenda are the needs of those individuals—and there may not be many, and they may be varied—being assessed and delivered rather promptly in the local health board areas? You may not have the answer now; I don't expect you to, but if we could have a response to that, it might be useful.

Yes, certainly. As I say, I've said where the longer term plans will be made, in the RPBs, but we can certainly come back to you about the plans in the health boards. But, obviously, long COVID is a high priority.

I think it's probably worth just adding that there are lots of different levels of this. So, someone who's been on a ventilator may need more reconditioning after that experience, compared to someone who has not been hospitalised, perhaps, but also just suffers from real exhaustion. So, there are really different needs that we need to consider here. But, if you need a bit more detail on that, Joyce, I'm sure we'd be happy to provide that.

I think Mr Heaney wanted to come in at this point. Mr Heaney.

Thank you, Chair. I just wanted to add really that a great deal of work across health and social care is focused on recovery planning, and in that recovery planning, of course, one of the really important aspects is long COVID. So, in relation to social care, Ministers have only recently announced £48 million additional funding to support recovery, and long COVID is one of the key areas within recovery work and recovery planning. Diolch yn fawr.

Joyce, do you have any further questions at this point?

Not on this, no.

 No. Gareth Davies.

I wanted to cover quite simply this coming winter and how plans are going to prepare for the winter months. We're all too aware of the stresses on the ambulance service, and the health and social care sector in general. So, what steps are the Welsh Government taking so far in preparation for the winter months?

We always prepare for winter. We've been preparing for winter earlier this year than ever. You're aware of the massive pressures on almost every aspect of the health service at the moment. I'm going to ask Andrew Goodall to come in in just a second to talk through the mechanics of how we're making sure that the health boards are on track with their planning, but just to say that we've already announced £140 million to allocate to health boards to get through—the recovery fund to deliver those services for the remainder of the year. We know it's going to be very, very difficult. We know there are lots of things to consider; not just COVID, but also the backlog of patients. And, of course, you heard just now from Albert about the £48 million has been allocated to social care. So, today, we've announced an extra £25 million specifically for PET scanners to try and address that issue of the backlog as well. But if I could ask Andrew to come in, just in terms of how we're making sure that the health boards really stick to the plans that we've asked them to put forward and produce. 

Diolch, Weinidog. We've been reporting to the committee throughout the pandemic response and the different phases of our actions, and of course, we've had to take many exceptional actions over these recent numbers of months, including as we were experiencing the first wave. But I think the current status of the NHS in overall terms feels like it's at its most challenging position, because it's trying to balance a number of things. I would just like to say to Senedd Members that we are, from a hospital and NHS system, at our fullest in terms of our capacity than we have seen throughout the whole of the pandemic response. But we have a combined set of factors that are impacting on that.

Firstly, whilst our numbers of corona cases coming into a hospital environment are much reduced, as the Minister was reflecting earlier, because of the success of the vaccination programme, nevertheless, even yesterday afternoon we had 650 COVID-related patients across Wales, and that is still a significant number of beds taken up that would be used for other purposes. We're seeing a return to our highest levels of emergency care coming into our system, whether that is in respect of calls or the ambulance service, right into the front door of A&E departments. Primary care is reporting that it's busier than ever before as the public continue to look to access services, and of course having launched our recovery framework back in March this year, what the NHS is also trying to do, and wishes to do this because of our responsibility for patients, is actually to restore activity for patients who have been waiting to access services, and who have been supporting all of the range of actions that we have taken.

So, I think it's an incredibly difficult point and the language that we're using within the NHS at the moment is that this is already a winter pressure in respect of the balance of those different areas. There are other factors kicking in at this stage in respect of staff, who are the same staff, still coming in and being very committed to provide that support for patients through a very long period of time through all of these phases, and recognising that they are very tired despite all of their ongoing commitment to support the people of Wales and their needs at this stage. So, it's a challenging period. Having said that, as the Minister said, we would always be approaching the winter anyway, because we know it will always be the most challenging period of time, and there are actions that we put in place normally.

There are a number of things that the Government has already agreed through the NHS that will help us, I think, to manage our resilience—so, the booster programme, for example, is a really important way in which we keep a focus on avoiding patients coming in for COVID-related reasons within the system. But organisations have given us plans to support the money that the Minister has announced, both during the end of the last Government tenure into the new Government term, but also, as the Minister said, a recent material investment recognising that we need extra things to be happening in the system. It's not about putting even more pressure on our existing staff in there. So, we have plans from all health boards. We're having to challenge some of those plans. I think there is a need also to ensure that organisations work across their boundaries more so, that they work alongside each other to deliver the services that are necessary, and in fact we are setting expectations for some of those things to happen.

But on the winter side, just to bring together the range of different activities and the particular context at this stage, we will be ensuring that there is a very clear winter plan that is visible, that connects all of these things together, during October. That's not to say that there aren't existing actions taking place. There is an improvement plan in place for the ambulance service, individual health boards are tackling their local pressures, and they are using some of the permissions that we already have across Wales with the local choices framework, which is endorsed by us nationally. We have to allow the systems to take account of their local context and circumstances, because they will change over time, and even change day to day and week to week. But just bringing it together in a single framework, as we would normally do in a year, I think will be really important to spell out some of the choices and difficult challenges ahead, but continue to focus on the resilience of the system.

I think the Minister also made the point earlier that it's really important to recognise that in the coronavirus context, while much improved, there is a difference in distinguishing things that are directly related to COVID as opposed to those normal pressures within the system, and I think that's a really important thing for us to recognise at the moment. Having said that, though, for example, if you have 50 patients in critical care or if you have 650 patients in hospital beds who are there for coronavirus reasons, that is a lot of patients that could act as triggering additional concerns and additional contingencies in the system. It's the equivalent, for example, of having two of our medium-sized district general hospitals across Wales simply not available.

Thank you for that comprehensive answer, Dr Goodall. My next question was on that last point you made, about the typical cases that we dealt with pre pandemic and how are we going to deal with this backlog that we've got now. Because even before coronavirus was around, one in five were on a waiting list. How are we going to deal with waits for diagnosis, cancer treatments, referrals and the everyday things, if you like, that we're used to dealing with, which has essentially been exacerbated by COVID? What steps are going to be taken to deal with this big case load, if you like, that we've got on our hands? 

Dr Goodall or the Minister, who wants to come in on that? 

I'll just give you a broad figure, and that is that, actually, we are trying to get up to the pre-pandemic levels. We're not there yet. We're managing to see about 70 per cent of what we were seeing pre COVID in terms of elective activity. When it comes to out-patient activity, we're up to about 80 per cent. You've got to remember that the funnel keeps on filling up. Those numbers still are constantly increasing. So, it is very, very difficult for us to get on top of this, but the first thing to do is to get up to 100 per cent and then to start digging into that backlog.  

Do you have any timelines, Minister, in terms of getting up to the 100 per cent? Do you have any projections about when you might get to that position? 

It's really difficult because a lot of it depends on what happens in relation to COVID. So, if we see increasing numbers coming into our hospitals, if we are still unable to get people out of our hospitals because of the issues in relation to domiciliary care, then obviously that's going to impact on the number of beds that are available for us to carry out these operations. I'm sure Dr Goodall could express that much better than I can. 

Chair, just to give a sense of the scale and what staff have done, firstly, if I could just say again, I think our staff have been fantastic through the whole of the pandemic response, and they are absolutely committed to focus on the needs of people, including access to services that would not have been available throughout the pandemic response. But in respect of the scale of how we're seeing things change, we were looking at the first few months of this financial year compared with the same period last year, and that was at the outset of the pandemic response. We're approaching almost three times more elective in-patients and day cases coming into the system than then. So, the local plans have been stepping up activities. There are plans in place.

I think it's really important to hold on to changes that have been occurring anyway that have to accommodate for some of the difficulties of bringing patients, particularly vulnerable patients, into these environments. So, the way in which services have transformed themselves and that people have thought in a very different way, we cannot revert to the NHS fully as it was before. We have to make sure that we continue to think differently, learn about things that work that are supporting patients to access the different services, although some of that, as the Minister was saying, will include us needing to invest nationally in new services and, indeed, new facilities, and I would say particularly so in respect of diagnostics. 

In August, for example, on our operational data, we were able to see a return to almost 80 per cent of our elective activity, so that would have been one of the highest proportions when we compare the same month with last year. But I think a really limiting factor for us at the moment, even if we're trying to put additional capacity into the system and additional staffing, where possible, is the mechanics for how the NHS has to safely manage patients coming into our system and accessing the facilities. So, the environmental measures that are in place, and the actions and the risk assessments that you put in place when the levels of community prevalence are below 25 per 100,000 are very different from the measures that need to be in place, whereas in our current system we have levels that are over 500 per 100,000 population, which is almost the highest level that we would have seen in respect of community cases during the pandemic response. 

So, all health boards in respect of individual services and environments and sites will always be doing risk assessments, and shifting services around. You'll have heard of the concepts of red and green areas, for example. But it's very difficult to restore fully the 100 per cent activity if you're having to slow down and protect both staff and patients who are moving through our system. And I think we do need to support the health boards to have the right actions, but that's why the plans that we have in place are about investing in the longer term, having the current plans in place, and ensuring ultimately that we can actually ensure that it is absolutely a safe environment, while we still have coronavirus very prevalent across our communities and in our services.  

Thanks again for the answers. I just wanted to pick up about regional variations as well because, obviously, the issues in north and mid Wales are different to what's happening in west or central south Wales. So, a one-size-fits-all approach is probably not applicable in some cases, because you've got Betsi Cadwaladr University Health Board that covers 700,000 people, and then Cardiff and Vale, which you'd think would be more, is actually less. Are we actually looking at giving these areas—different health boards—the autonomy they need in order to cater for the local needs, rather than it coming directly from Cardiff and saying that Betsi has to do it the same as Hywel Dda, or anywhere else, for that matter?

Every health board has come up with a plan for themselves in terms of how they would like to tackle this issue, and Betsi have come up with some very innovative ideas that we're exploring very actively at the moment. Of course, every one of them will respond differently to the needs of their own communities, but what I will say is that we are encouraging them to think beyond their natural footprints. So, we are encouraging them in some instances to think about maybe a regional solution; you've heard me talk in the Chamber this week about cataracts, for example, and the need, perhaps, to develop cataract centres perhaps on more of a regional footing, rather than have one in each health board. So, there are opportunities here to do things differently, and we've got to be careful when we're developing these new approaches that we don't create white elephants for the long term. But we are also aware that there are long-term challenges in terms of an ageing population that we need to consider as well. So, all of those things are being considered in the mix. I can see Andrew is anxious to come in again.

The Member's point is absolutely right. So, again, as we've gone through different phases of this pandemic, the nature of the national guidance and decisions will have changed depending on the prevalence level that is available, and clearly the nature of the decisions that needed to be taken during the first wave was really a need to ensure that the NHS, for example, was able to step away and prepare for the potential numbers that we were going to see coming into our system, and that was a national, consistent approach that was in place.

I think one of the real advantages for us in Wales about how we have responded collectively, for the NHS and also for public services more broadly, is that it's a very close environment. Having 12 chief executives reporting to me and 12 organisations that are reporting to the Minister allows us to have those collective discussions very easily and very regularly—a pattern that can move very easily from weekly to daily in respect of those pressures. But in respect of how organisations are currently responding, and it reinforces the Minister's point on those local plans, we have to allow the discretion for organisations to adapt to where they are, both in respect of their plans and their particular context, but recognising that the level of COVID prevalence will differ at different stages. In this last third wave, we've seen Betsi Cadwaladr, for example, having higher numbers of cases earlier than it would have experienced in the first and second phases at this stage. So, the local choices framework that I've referenced is a clear, consistent framework that we have signed off but that does allow for that risk assessment and discretion and local actions that are appropriate to the circumstances, as the Member describes. And I think it's really important that we allow ourselves to maintain that.

Thank you, Gareth. Can I just ask, Minister—? In regard to your answer in regard to when we might get back to 100 per cent capacity, or that's the position you're working to, I understand fully that this is obviously subject to where we're heading in terms of the pandemic, but earlier on we heard from Dr Atherton about various modelling exercises that have been carried out, and I wonder if, when you're talking about heading towards 100 per cent capacity, whether any work has been done in terms of assessing that against the modelling in terms of the pandemic that's being carried out, in order that you can make an assessment of when you might get to the 100 per cent capacity. 

So, we can set it against the modelling of what the COVID situation looks like, but it's not just about COVID now. You've got to bear in mind that, actually, at the moment it's very difficult to get people out of hospital. So, we've got 1,000 people in hospital beds at the moment who are ready for discharge, and there is no capacity within the care system to absorb them. And so it's not just about COVID. It's not just about the incidence. It's about fixing that problem, which is why we're having weekly meetings on that issue. It's not straightforward to say, 'We're going to crack that one' and to tell you exactly when we're going to be hitting the 100 per cent, because all of these things impact on each other.

Thank you, Minister. Joyce Watson.

Diolch. I'm going to ask questions around the sustainability of the health and care workforce, which, really, is at the heart of everything, and there are three areas that I'm going to explore. The first one is the investment in education and training of healthcare workers, and you're hoping to deliver 12,000 more clinical staff by 2024-25, as stated in your paper. So, what action is the Welsh Government taking to support the existing health and care workforce in the immediate term, because that's obviously where we need to be? And then, moving on from that, addressing the staff shortages that we've said and also, to try and retain the staff, of course, that we already have, where there is evidence suggesting that they are leaving.

I'm going to ask Lynne Neagle to help out here in terms of the support we're giving to our staff, because, obviously, they have been under the cosh for a very long time now. But just, first of all, I think it's worth putting on record my admiration and respect for the incredible work that has been undertaken by our health and social care workforce over the course of this pandemic. Staff well-being is absolutely crucial as far as we're concerned, and we have been providing additional funding to support them. So, I'm going to ask Lynne to come in on that.

But just in terms of the training, Health Education and Improvement Wales has produced and submitted an education and commissioning training plan and that is currently being commissioned by officials, so that is moving on with that process of training up those 12,000 people you talked about. Of course, the other thing is that we've announced that we're going to be establishing a new independent medical school in north Wales and I was very pleased to visit that a couple of weeks ago and things are moving on there. We've got our 'Train. Work. Live.' campaign, which managed to recruit an additional 200 new GPs in 2020, and, of course, there's the ethical overseas nurses recruitment that we're still undertaking. And of course, we've ploughed in an additional £48 million for the social care recovery programme, so, hopefully, that will help us to get through the winter in terms of some of the pressures relating to social care. Can I ask Lynne to come in here, if you don't mind?

Absolutely.

I'm not on mute, am I?

No, we can hear you, Deputy Minister.

Thank you, Eluned. Yes, I think it's really important that we recognise the huge toll that the pandemic has taken on our staff in health and social care, many of whom have encountered extremely traumatic experiences. There are a range of measures in place to support NHS staff. The Welsh Government has funded Samaritans to provide a helpline service to NHS and social care staff. There's also Health for Health Professionals Wales that the Welsh Government has established and we are currently looking at expanding that to social care staff. I know, too, that a Welsh health circular was issued reminding all health boards to put in place measures to support NHS staff throughout the pandemic and, of course, NHS social care and, indeed, third sector staff can also access the tier 0 provisions that we have in place, including the call helpline for Wales and also SilverCloud, our online open-access cognitive behavioural therapy provision for Wales, too. So, we are extremely mindful of the need to provide support for all of our staff, but we're not in any way complacent and always looking at what more we can do. Thank you.

Thank you for that. Of course, lots of local health boards have their own specialist services where they have supported their staff, and I know that Hywel Dda particularly have done really well in this space and I want to pay tribute to those.

But moving on, and this is the nut we all have to crack so there's no easy answer, and it's the staff shortage issue in social care. We know—it's been rehearsed many times—that they are now at a critical level, and that there are large numbers of vacancies. So, without doubt, the Government recognises the urgency of that situation, and you've talked a little bit about some of the actions that you're taking. Is there anything else that you would like to add to it that you haven't already said today?

Can I ask Julie to answer this?

Yes. Thank you very much, Joyce, for that very important topical question. I'm sure that you probably heard on the news this morning about the letter that the sector in England have sent to the health Secretary there about the concern of the shortage of staff. It is something that is affecting the whole of the UK, and it is a matter of great concern.

I think that it's important to remember that social care staffing has always been precarious. It has always been difficult to maintain social care workers in their jobs, and it's really much more difficult now. We've noticed in the last couple of months that there has been real pressure on keeping social care staff and recruiting, and I think that that has linked up with the opening up of hospitality and the lack of European workers who, because of Brexit, went back to Europe, and most of them haven't come back. Also, the retail sector. So, all of these things have competed to mean that there is a real problem in social care. But, I think that it's important to remember that there is a long-standing issue there that we need to tackle on a longer term basis.

So, we are doing a number of things that we haven't mentioned yet to try to deal with the pandemic and the shortage of social care staff. As an immediate response, we ran a three-week advertising and social media campaign, and that started on 23 August, and that was to drive recruitment up in the sector. Early indications are that this has been successful and there has been an increase of almost a third in applications for social care jobs. That's on the national WeCare Wales jobs portal. So, we are considering continuing to do that.

We've also increased the resources that Social Care Wales has to provide free introductory online training for social care to people across Wales and to other targeted recruitment activity. Then, of course, the other issues that we have to tackle include the low pay of care workers, and we have committed as a Government to introduce the real living wage for social care workers in this Senedd term. We realise that, in order to attract and keep staff, we need to have better pay levels. We have also set up the social care fair work forum, which is looking at levels of pay and also looking at conditions for social care workers. They will be reporting back to us this autumn.

So, we are taking a number of actions, and to actually cope during the actual period, everyone has been very innovative. Local authorities have helped other local authorities. The third sector has helped, health has helped social care. So, there has been a lot of working together to try to keep the show on the road.

Do you have any further questions, Joyce?

Thank you. You anticipated my last question, which was on low pay. So, thank you.

There we are. Thank you. I'll take the last block of questions, and then we'll have a break before we come back. So, we'll have a break in about 10 minutes. So, the next subject area, Jack Sargeant. 

Thank you, Chair, and I will stick with carers, if I may, but particularly unpaid carers. Obviously, the Deputy Minister has mentioned the potential reduction in social care, so it's evermore important that we support our unpaid carers. Some local authorities are currently reducing care and support packages, and they are asking family and unpaid carers to take on even more duties. Of course, it's been a difficult period, as it has for many people, but an extremely difficult period for unpaid carers, and they are, I imagine, exhausted. So, I just want to know what the Welsh Government's response is to the local authorities who are reducing those support packages and placing this additional burden onto unpaid carers.

Thank you, Jack, very much. Unpaid carers are a very important part of our caring service, and we want to do as a Government all we possibly can to support them. Local authorities and health boards are working together to consider new ways of working and mutual support to try to maximise the staffing that they've got, because as we said in answers to earlier questions, there is a shortage of social care staff, and that means that they aren't there in order for the care packages to continue or to be started. So, there is huge pressure on unpaid carers. 

As I mentioned in the previous question, we have had this advertising and social media campaign to attract more people into the sector and increased the resources of Social Care Wales to try to get more people to work in social care. And then, to recognise our unpaid carers, we've allocated £3 million in this financial year to increase the availability of respite services across Wales, and also, following a commitment we made in our programme for government, an addition of £1 million to continue the carers support fund in 2021-22, because, in the last financial year, we had a support fund for carers, which was very much appreciated and very well used. So, we have continued that this year, and we are considering if there is any more we can do to try to help unpaid carers and to recognise the work that they're doing.

Thank you, Deputy Minister, for that answer. Care Inspectorate Wales's annual report actually said that for most local authorities that they visited support for carers remained an area of improvement, so I'm pleased that you're taking that seriously. Can I just ask you then: Carers Wales have suggested that you need to find creative solutions, and you've talked about innovative approaches to support unpaid carers. Is this something that you would consider? Will you consider, for example, a fast-tracked direct payment system for carers, in lieu of the support provided by paid care workers, so that they can go on to arrange support separately? Is that something you would consider and work with Carers Wales on?

We're very happy to consider any proposals that will help carers, and we are actually in dialogue with the local authorities, and with the health boards, to look at all options that can possibly help unpaid carers. The Minister said how we are in weekly meetings with the local authorities and the health boards, and unpaid carers are featuring in those discussions. So, we're certainly prepared to consider any proposals that come forward, and I'm really happy for stakeholders to explore all avenues with my officials to seek to secure improvements. So, I'm very happy to discuss any of these proposals.

Obviously, it will all have to be looked at very carefully because the urgent needs for help is what we're looking at at the moment, and the longer, sustained, planned-out help that is needed may be something quite different. But, in terms of direct payments, it is possible to employ family members or friends to provide care and support for their loved ones, and that is very good because it enables continuity of care and gives the recognition of personal choice and early intervention. And during the pandemic, obviously there's been an increased role for family members, and we have developed and published guidance with carers about the flexible use of direct payments. 

So, certainly, we are prepared to discuss any proposals that come forward because we recognise the huge strain that there has been on carers, unpaid carers, and what a huge contribution they've made, and I think we can't really commend them more highly for what they've done in this very difficult period. 

I appreciate that answer, Minister, and I'll certainly join you in your last comments there. That's all from me, Chair. 

Thank you, Jack. At that point, I suggest we take a 10-minute break, so if we can be back at 12:15.

Welcome back to Health and Social Care Committee. And I move to Mike Hedges to ask the next set of questions.

I'm going to talk about service transformation, and that's something that is going to have to occur—the service will fall down if it doesn't transform itself. I want to start with GPs. I think that the first thing is that we've had a lot of GPs doing online and telephone consultations, which many people have liked and other people have hated, but the continuation of that. How are you going to reduce the number of people going to GP surgeries or trying to contact GPs, often with minor ailments? How are you going to triage them so that 10 per cent, 20 per cent, of GPs' time is not taken up by people who've got colds and flu?

Thanks very much, Mike. I know you've got very strong feelings about this, and I heard you very clearly in the Senedd yesterday, speaking very eloquently on this issue. I think the first thing to say is that the way GPs see patients has changed during the pandemic, and some of that change will be retained. I think it's really important for people to understand that we will not be going back to life as it was pre-pandemic, and there will be some changes. And one of those things, of course, is the fact that we've done a lot more video consultations, a lost more telephone consultations. So, if you think pre-pandemic, about 8 per cent of planned care activity was undertaken virtually. At the height of the pandemic, this rose to about 54 per cent; now, it's about 24 per cent. Video consultations have taken place in more than 0.25 million cases since March 2020. And what our research finds is that, actually, generally, it's well liked by patients and clinicians. I know, because I live with a GP, that they are under incredible strain at the moment. The pressures on them are intense, but they are seeing more patients than ever. It's just that they're seeing them in a different way. And what we do know is that a lot of people like that.

But you're quite right: part of what we need to do is better triage when people come into GP surgeries, whether that be in person or virtually, and it is important that that triage is done in an effective and efficient way. And what we'd like to see is that the public trust the clinical judgment of our skilled professionals in the primary care team and that they trust that they're the best people to determine whether or not a face-to-face appointment is necessary as a part of that clinical investigation. Now, I know you have very strong feelings about receptionists making those judgment calls and I think you're right—I think there are a lot of patients who are uncomfortable about receptionists, who are not necessarily clinically trained, making those judgement calls.

We're making sure that we continue those discussions with GPs. And one of the things we've done is we've set out in our letter to GPs the need for good communication with patients, the offering of digital services and the effective offering of triage services. But on top of that, we've got to take the pressure off them as much as we can. And that's why we've introduced this 'Help Us, Help You' campaign, trying to divert people away from GP services, if they can use alternatives. You'll know that we've got lots of pharmacies that can deliver a very efficient and effective service as well as the 111 service.

Okay. Can I move on to the other big, big one in your inbox, which is—I call it A&E, but urgent and emergency care? That's the other big hold-up within the system. You've talked about, in your paper today, a national, '111 First' model, urgent primary care centres and same-day emergency care—will that take some of the pressure off?

If only people with urgent problems or an emergency went to A&E departments, there would not be a problem. People are using it as a secondary GP service because they can't gain access. Because, actually, people just want to see a doctor; if I can go and wait eight hours to see a doctor in Morriston Hospital A&E or I can have four or five days of phoning between 8.00 a.m. and 8.20 a.m. to try and get in to my local GP, it's hardly surprising that people are taking the option of going to A&E, clogging it up and causing all the other problems that follow on from it. So, what progress is being made on these urgent primary care centres and same-day emergency care to make urgent and emergency care—I will keep on calling it A&E, I'm afraid—to take the pressure off them so that they actually deal with what they're there for?

You'll be aware, Mike, that we've already committed £25 million to addressing this issue. And you're absolutely right: emergency departments are not the most appropriate places for a significant number of those patients who attend, and you're quite right that some of them are attending because they can't get access to a GP. 

So, what we're trying to do is develop those alternative pathways. And I'm really pleased to say now that the 111 service is now live in all health boards except here at Cardiff and Vale University Health Board. And I have been trying to put pressure on Cardiff and Vale to roll out their system, although they do have an alternative, quite effective, system, but I would like to see an all-Wales system for 111, just so that it's easier for patients across Wales to understand. And the idea is that that will become a 24/7 urgent care model and that then you'll be triaged from that point.

You talked about the urgent primary care centres and that's absolutely right. So, there are pathfinder urgent primary care centres across all health boards now. Powys has one already. So, we are hoping to see that that work will now change and that that will become part of the learning as part of the development of the 24/7 urgent care model. 

And then the next thing also is, of course, to remember that we have made funding available for that same-day emergency care. And I think it’s probably worth pointing out that this is not just about physical care. I know Lynne Neagle, for example, is very interested in making sure that that mental health urgent care is also there, but, ideally, of course, we don’t want to see things build up—we need to tackle things much, much earlier on, which is why we’re going to be putting a lot more effort into public health in the next few years.

On your innovation programme, are we going to see a lot more day surgery? And are we going to see specific hospitals, like Port Talbot hospital, which is aiming to become, in the near future, if you accept their proposals—and I’m not asking you to make a decision on that now—a centre where they deal with things like knees, like ankles, like hips, like backs? They deal with all those sorts of orthopaedic actions rather than having them in the same queue for service as you get at the big general hospitals where you’ve got people coming in with heart attacks and strokes.

Thanks, Mike, and this is certainly something that I’m very interested in looking at. We have had some proposals from health boards and, as I said before, we’re trying to encourage them to work collaboratively outside of their areas, because we won’t be able to establish specialist centres in every single health board. So, they will need to work together.

The great news, in relation to COVID, is we have seen much better collaboration, and what we’re really keen to do now is to lock in that innovation that we’ve seen arise as a result. We’re going to have these intensive learning academies that are going to help support our recovery, of course. But those regional hubs that you’re talking about—I am very interested in seeing those progress, and to separate them out. We’ve got to be careful—there are red and green zones—because if you had somebody, for example, with an orthopaedic problem, a hip operation, but they also had a heart problem, you’ve got to make sure, just in case something goes wrong, that you’ve got the right physicians on the same site. So, in complicated areas, you won’t be able to do everything on those sites. So, it will only be certain conditions that you will be able to deal with that don’t have those additional complications. So, I’m very keen, and I have listened very carefully to clinicians on that point.

Of course, cataracts is another one that we’ve talked about, because you and I and lots of other people have talked about actually having cataract centres rather than having cataract queues.

I want to move on to the integration of health and social care, which I think is very important. Can we step back a stage though to the integration of primary and secondary care? Putting everything under the same health board, if you talk to any primary care practitioner, they'll tell you it hasn’t made it any easier for dealing with secondary care. So, I think, yes, we want primary care and secondary care to work together, but there’s a lot more to be done—not having one director and then move down to a deputy director for each of those areas, and they work separately. I think primary and secondary care need greater integration and greater collaboration. Can I just welcome the fact that you’re talking about them actually sending emails and IT information to each other, rather than bits of paper? Sometimes I think some parts of the health service still think we’re in 1960.

I have been quite surprised at how delayed the digital transformation in the NHS has been, but I can assure you that we’re on that now, that there are some really great innovations that are happening, and you’ll be aware, in Swansea, that the e-prescribing model is already being rolled out within the secondary care system. But, of course, we need that to speak to, then, the systems within primary care. So, you’re quite right, we need much better integration between them both.

Secondary care keep on telling us, ‘Look, the issue here is that, if you want to reduce demand, we do need to look at prevention’. Prevention is what you’ve got to do in primary care. Actually, not even primary care—you’ve got to get it out to specialist services that sometimes do it even better than the NHS. So, I’m very keen to make sure that we focus a lot more on public health in order to avoid those situations from developing.

But you'll be aware that we've got the regional partnership boards, and that we're very keen to make sure that we're integrating other aspects of health, understanding that there's a relationship between housing, between education and all of these other things when it comes to health as well. And you'll also be aware that we've put significant funding into trying to transform things. We've had the transformation fund of £50 million, the ICF, the integrated care fund—almost £90 million there. And they love it—organisations love this. What they're not doing brilliantly yet is integrating it into the mainstream, and that's the next nut that we absolutely need to crack. So, I'm going to be focused on that.

If Jenny Rathbone was here now she'd have told you about diet, as well, being important. I won't myself be doing that. My final question is about quality statements. They've been published for cancer and heart conditions; there are lots of others. I understand the pressure your department's under and I understand the pressure all your senior staff are under. I'm not saying they need to produce all these as a matter of urgency, but why can't we just roll forward the current delivery plan until such time that we're in a position to create new ones?

Well, in 'A Healthier Wales', we've set out that we're going to have these national clinical frameworks, and within that, we're going to have these quality statements. I think we've got to understand that when it comes to delivery, the delivery is done by the health boards, and so what our job to do is, from the centre, to remind them what we think good looks like, and set out much clearer expectations for the system. But there are some very ambitious requirements within the models that we're requesting and that quality statement. If you think about organising and making sure the workforce is planned, making sure that we recover the pre-pandemic waiting list, we reconfigure the fragile services—all of those were in the quality statement, and they're not trivial ambitions. So, there's plenty of work to do within the quality statement that has been set out.

I agree with you entirely. I was just thinking of those areas where the quality statements have not been produced yet. I've been told—you can tell me if I'm wrong—the stroke quality statement has not been produced, for example, and just carrying on where we were before rather having a hiatus.

Well, I'm glad to say that the stroke quality statement, I certainly approved it yesterday, I don't know if it's gone public yet, but that should be coming out today or tomorrow. So, I'm pleased to say that that, as you say, is a very important statement. So, you know, there's work to do here, but it's important that we set, if we can, a common standard that we expect all health boards to meet.

I don't disagree with that.

Thank you, Mike. Minister, can I just ask on the issue of face-to-face GP appointments versus physical appointments? My question is not at all about the merits or not of appointments and how they're carried out, it's about the data that you hold. Do you hold data, or what data do you hold in regard to the extent that GP surgeries are carrying out face-to-face surgeries, and any variants between practices across Wales?

Well, we do have a requirement, and what happens is we've got a General Medical Council contract that we've negotiated with them, and they're, effectively, paid a bonus if they reach the contract requirements. So, we, obviously, do clock that, and it is published. I'm quite happy for Andrew to come in and give a bit more detail on this if he's able to.

Yes, the information is available nationally, but really the focus is with the individual practices themselves and the way in which they report to the health boards. We've been able to facilitate some of that at the cluster level across Wales—that's when practices are working with each other—and the Minister is right to say that it's something that is a negotiated part of our approach. Variation is something that is taken up by the local teams, and where we have particular concerns, we have that opportunity to talk to both the British Medical Association and the General Practitioners Committee directly, but we also have a chance, of course, to talk to the health boards across Wales. It is an area for improvement, and I think the Minister has already been clear about her expectations that she wants to continue to support patient access in this area.

And from the information you've obtained to date, are there widespread differences between GP practices to the extent they're using face-to-face versus virtual meetings?

There are variations across Wales, and I think also we need to ensure that when we talk about remote consultations—virtual consultations—that it isn't only about video use, for example. I know, for a lot of practices, just being able to speak to patients, to respond very quickly, has been part of that. Every individual GP practice, because they are independent contractors, is responsible for the system that they have in place, but we do think that we can change those as well. Yes, there is variation, but the variation shows that there is really some excellent practice across Wales, and, of course, as you would expect, it will show us that there are some areas that need targeted support or, indeed, may need to change their system. In providing advice to the Minister, what we would like to ensure is that if there are areas that we can support or assist, whether they are infrastructure issues or telephony, we would rather be involved in those kinds of changes, because, obviously, we have an opportunity to improve the overall facilities and the technical things that are in place across Wales as well.

It would be useful if you could send to the committee the data that you do hold in terms of—because it would be interesting to understand the data that is held and the variance between GP practices and GP practices reporting to their health boards in terms of the percentage split, to understand why. Perhaps that's something the committee can dive into to understand why some GP practices are undertaking more face-to-face appointments than others. If that information is publicly available, it would be useful to receive that.

Yes, Chair, we're very happy to do that and we'll, with your agreement, work with the health boards who've got the closer oversight on that detail as well. I think also, as the Minister was saying in her earlier comments, what we would really like to emphasise is what we're always trying to do is to ensure that, based on patient need, any patient is directed to the right healthcare professional in primary care to support their needs as well. So, irrespective of what we're assessing with GPs only, I would just want to make sure that we're able to give that rounded position, which is that it's about going to the appropriate available practitioner within their services.

Thank you very much, Dr Goodall. Jack Sargeant.

Diolch, Chair. Just before I move on to a different section, if I could just pick up on comments that were pre-empted by our colleague Mike Hedges's questions with regard to digital transformation. I'm pleased the Minister—that one of her priorities in this brief is digital transformation. I think that is really welcome, but I think it's a question for the committee as well to have a look in the future at actually what is innovation, or perhaps what is my expectation of where we should be. So, I think it's a key area of interest and perhaps we could pick this up at a later date.

But if I could direct my questions to the Deputy Minister for Mental Health and Well-being, if I may, and then firstly ask the Deputy Minister to provide an update on people accessing mental health services, for example the recent trends in number of referrals to both primary and specialist mental health services, and if you could include the numbers for children and young people and adults, and also include waiting times for assessment and therapeutic intervention, please.

Thank you very much, Jack. I'll try and provide an overview for the committee, but what you're are asking for is quite detailed information, so if it's okay, I'll write following the meeting with some more detail around what you're asking.

Just to start by saying that mental health services were positioned as essential services throughout the pandemic and, therefore, remained accessible throughout the pandemic. So, services haven't built up the kind of waiting lists that we've seen in other parts of the NHS, where they had to stop seeing patients. But similar to other essential services, we did see a drop-off in people contacting mental health services during the pandemic. At the same time, health boards were reporting that those people who were coming forward had more complex needs, the level of acuity was higher, which meant more time spent with patients and, therefore, despite the drop-off in referrals, services were still under pressure.

We did see a significant increase in demand for the tier 0 support that we put in place during the pandemic in order to address the increased anxiety and other problems that we were anticipating. We launched an online CBT provision called SilverCloud, which has received 12,000 sign-ups since it started. We also strengthened our 24-hour provision of the CALL helpline, and at peak that helpline was receiving over 100 calls a day.

We've definitely seen some spikes in certain areas. We've seen fluctuations in the average waiting times for children and young people to access specialist child and adolescent mental health services, and we did see a significant increase in referrals between October 2020 and January 2021, which has added to the pressures in that service. But the data over the last 12 months shows that the average wait in Wales to receive a first appointment for specialist CAMHS is 4.4 weeks and ranges amongst health boards from three to six weeks. We will write to the committee with the detail on individual health boards, because there is quite a variation. In terms of our mental health measure, at an all-Wales level, referrals have now returned to the normal levels of pre-pandemic. If I can just mention Veterans' NHS Wales, again their referrals have remained lower than pre-pandemic levels, although the latest data suggests that that is now returning more to a normal pattern.

A particular area of concern during the pandemic has been in eating disorder services. While the latest data suggests the pressures are stabilising, we did see a very significant increase, a 22 per cent increase, during the pandemic, of people, especially children and young people, contacting eating disorder services. What we also saw was a significant increase in the acuity of the young people who were presenting. And just to say, of course, that in recognition of all the pressures that we've had, Welsh Government has made a very significant additional investment in mental health services in this year; £42 million extra has been provided across the system to try and address the range of pressures. Thank you.

I appreciate that answer to quite a large question, and I do welcome the commitment as well for you writing to the committee. That's very much appreciated. You talked about increased demand, of course; I mean, we've had this discussion before, Minister, where actually, before COVID, I did think, in mental health, we were in a state of crisis, but certainly, post pandemic, I think we're entering a pandemic in its own right with mental health services. I know that's something we share.

Of course, I welcome all the interventions that you've mentioned and the additional funding to the CALL helpline and the SilverCloud online platform, but can you just tell us your understanding and the Government's understanding of the likely level of the need of services going forward, and what type of support is needed? I'm particularly conscious of the communities and people who won't pick up the phone through no fault of their own, or won't access that SilverCloud app or web platform. Is there a remit for the Government to look into how we can actually break it down at community level to help these individuals cope with whatever they're dealing with?

Thank you, Jack. Predicting level of demand for mental health services is of course a complex area, and while the evidence suggests an increase in anxiety during the pandemic, it is difficult to know how this will affect demand for NHS services. We've been using a range of measures to try and identify what the need will be. So, we've looked at population surveys, NHS benchmarking data, health board data, and also, of course, regular meetings with services, including the third sector, to understand operational pressures. And one of the reasons the ministerial oversight board was set up by my predecessor, Eluned Morgan, was to try and strengthen the links with academia. Knowledge and analytical services from Welsh Government are very much a key part of that board, to keep us updated on what the likely trends are.

Our current planning is based on the modelling earlier in the pandemic, which anticipates a potential increase in referrals of between 20 to 40 per cent in primary care, and around 20 per cent in secondary care. So, a very significant potential increase. But what I would say as well is—and I know this is something that the committee has discussed in the previous Senedd—it is really important that we don't overmedicalise people's distress. We've all been through a really terrible period with the pandemic. It's had an impact on all our mental health. So our response to the pandemic is a natural one to something very, very difficult that's happened to all of us. I think it's very important, as we frame our response to the increasing mental health pressures, that we recognise that, and also that our focus is on intervening as early as we possibly can. The challenge for me as Minister is to try and reform our services focused on prevention and early intervention at the same time as meeting the increased pressures within the service that we're seeing. 

Just to say as well, just to add, Jack, that there are work streams ongoing as well to identify groups of people who are less likely to easily access mental health services. If I can just mention the work that we're doing around people from the BAME community, we've got a specific task-and-finish group that is looking at the challenges people from those communities have accessing services, and that also then ties in with the action that we're taking through the Welsh Government race equality plan. 

Thank you for that. I'm pleased that work is ongoing. You mentioned something at the end that I very much agree with. I sometimes find it hard, when we talk about 1 in 4 people having mental health problems—I don't agree with that actual fact, if you like. I think the fact, and the reality on the ground, is that some days we just have worse days than others and vice versa, and I think that's the message we should be all putting out there.

Minister, you did mention the oversight board that was set up by Eluned Morgan in her previous role. Is that something that's been taken into account, the work that they're doing? Do all Ministers across all Government portfolios look into the work by the oversight board when making their decisions? Is that something you're confident in confirming?

Thank you, Jack. I'm continuing to chair the ministerial oversight board that was set up by my predecessor, and I see it as a key mechanism for driving change across the whole mental health system. We've got all work streams from our mental health system across Wales reporting into that oversight board. That does include our 'Together for Mental Health' delivery plan, and cross-Government working is a central tenet of that work. Generally speaking, I'm absolutely committed to driving the cross-Government working on mental health. I've been very clear that I see mental health as everybody's business across Government. I've had very positive discussions with Cabinet colleagues around the contribution everybody can make around the Cabinet table to not just preventing mental ill health, but supporting people when they do have problems. Those arrangements are also then reflected in the discussions that officials have on a very regular basis across Government. So, I'm actually very pleased with the amount of cross-government working that is happening around mental health, and that's extended now as far as the budget preparations this year, where I'm working with Cabinet colleagues to identify, in line with our programme for government commitment, how we can further invest in mental health services, but also to make sure that when Government colleagues are making decisions, decisions aren't taken that disadvantage people with mental health problems or mental health services. So, I'm feeling very positive about this area of work, and it is absolutely a priority. Mental health can't just sit with me; this is everybody's business, just as it is in wider society. 

Again, I'm grateful for that, and I would tend to agree with you. I'm pleased that there is a positive message and it's something that we'll be looking at closely.

You mentioned the budget; I've got my own view on what the answer should be on this, but I have to ask: how will the outcomes be measured in terms of the impact of spend on mental health? How will value for money be assessed?

Thank you, Jack. I think there are a number of things here. Obviously, we need to make sure that our services are operating sustainably and that we're meeting the need that's out there. So, that is a key thing that we need to be doing, and you can see that through the performance data that we're monitoring very closely. I meet vice-chairs regularly of all the health boards to try and make sure that I drive the performance that we need to see, and similarly with regional partnership boards. But I think it's very important, just as I did before I came into Government, and I'm very keen to move to a system where we are more effectively monitoring the outcomes people are getting from mental health services, rather than just the numbers of people who are going through them and how long they're waiting. And that is something that I'm working with officials on, and which we can provide an update in future on. It's very important, I think, that we look at the quality of services that people are getting, how that is making a difference to people's lives and how they are either recovering or moving on from having their mental health problems.

Thank you, Minister. I think that would be welcomed by the committee as well. Thanks, Chair. 

Thank you, Jack. Mike Hedges. 

Thank you, Chair. The first question is about the financial position of the NHS in Wales. The Auditor General for Wales assessed that the financial position of the NHS remains extremely challenging. Does the Minister agree with that, and what are the health boards doing in order to drive down fixed costs, and trying to drive down, say, the cost of things like lighting by putting LEDs in? There are things that can be done and far too often in my opinion—and you can tell me if I'm wrong—health boards are just sort of, 'Well, we spend that on that, so we'll just write that in', without giving thought to, 'How can we reduce that cost?' 

Thanks very much, Mike. I think, first of all, it's probably worth noting that I don't fully agree with the auditor general's assessment that the financial position is extremely challenging. Of course, it's challenging—it's always challenging—but I think even he acknowledges in the press release that he issued, when he suggested that that situation is challenging, that there's been an in-year reduction in terms of the in-year deficits that we've seen, and we've seen cumulative deficit fall by £119 million.

So, we're now in a situation where only two health boards are in deficit, compared to four, which was the case about three years ago. And I think you're right that we've got to keep on looking for efficiencies within the system. I'm intensely aware of the fact that our department eats up over half of the Welsh budget, and we've got a responsibility to make sure we drive efficiencies. Now, it's hard during a pandemic to drive efficiencies but, certainly, if you're talking about things like efficiencies in relation to energy and things like that, that would be a part of our climate change agenda. That is a very coherent programme that the NHS is undertaking as well. So, that funding is there and we are driving those efficiencies as much as possible. 

[Inaudible]—to come in. Dr Goodall. 

Just again to report in to Members and support the Minister, what I would like to just describe is the way in which we tried to ensure that there was real clarity of the available funding for the NHS through the pandemic response. And on top of all our normal expectations for working within the finances and resources that are made available, actually, for the last six months of last year, despite how exceptional the pandemic pressures were, we had, through Ministers, put funding out into the system that ensured that the financial resilience of the system was there, that decisions could be made by the system, particularly about supporting the pressures that were coming out through the second wave. So, we were able to ensure that the NHS was able, in overall terms, to manage within its budget, and that obviously allowed the ministerial budget to happen. 

Clearly, there remain lots of unpredictable things that could still happen within the COVID-19 outlook at this stage, and I think one of our concerns is that, whilst we're always very hopeful that we can take away some aspects and, over time, that vaccinations would be less needed, and even Test, Trace, Protect, as we continue to see these high levels of prevalence occurring in our communities, and also looking at the international trends, we'll have to still put in some of this exceptional funding. 

The Member was just asking about approaches to how financial savings are made, and just to say that in supporting, again, choices that are made by the NHS, even where organisations are in deficit, it's always really important that the focus of their savings is not something that is about compromising care and treatment, that we have to act from a national perspective to ensure that the quality of services is maintained. And in fact, with a couple of the health boards that have been under pressure, we could have just insisted that they break even, but we knew that they would have had to have made more difficult decisions.

But on the points on savings programmes generally, we've tried to switch the NHS to look a bit more roundly, almost, at how it can improve the way it uses resources by looking at patient outcomes. But, on the basics, I think that is absolutely true, and certainly with concerns about climate change, our approach to the carbon footprint, we recognise that the NHS has got a really big contribution to make to those areas. And sometimes, it is about just focusing on some of those basics, so invest-to-save schemes have been open to the NHS over recent years to focus on that.

My final comment, Chair, is just that, clearly, whilst we would always expect the NHS to demonstrate itself being more efficient, making appropriate savings, and doing more with the funding that is available, it's been particularly difficult through the pandemic response, because the clear focus of the leadership teams and the clinicians has, of course, been on making sure that there's been a resilient response, and we've been dealing with the immediate care needs of the Welsh population. So, we have allowed for, in the pandemic response, just seeing that there would have been a lower level of savings being done in the normal way, but, as we look forward, we would expect those to revert in the normal way.  

Do you have any further—?

If I move on to savings. Following on from what you've just said on invest-to-save, I think: why, if an invest-to-save scheme works well, in, say, Swansea Bay University Health Board, on something like travel claims, isn't it rolled out to all the other health boards in Wales? We know (1) that that has worked, and we know (2) it hasn't been rolled out.

Well, lots of health boards have innovative projects, and that, I think, is part of the challenge for us—making sure that that good practice is rolled out. I guess it's quite difficult to roll that out when, frankly, they have been firefighting for the past year and a half. So, it is important that we try and roll out that best practice, which is something that we have been doing, for example, with the 111 service. So, there are examples where that is working well. But I do think it's important that you allow each health board to do things that work for them and their particular areas. So, in relation to travel, what's right for Swansea is going to be very different from what would work in Hywel Dda, which has far, far greater geographical areas to cover. 

Sorry, I won't press this too far, but it's about the system that exists for making the claims, and it doesn't matter if you're travelling 1,000 miles or 10 miles, the claims system. And it worked in Swansea Bay University Health Board; it hasn't been rolled out to the other parts of Wales. And it's probably aimed more at Andrew Goodall than you, but can you try and push the health boards, when something has worked well, to actually do it in their own health board as well?  

But, moving on, the £48 million social care fund—is that into the base budget or is it a one-off? 

I'll just say very, very briefly, that that's part of the Government COVID reserves. So that would be just a one-off payment for this year. And it's very important, of course, because we are in a position where we're firefighting; we need to get through the winter. 

Thank you for that. And one last question: I know Care Forum Wales are concerned that the funding is going to local authorities without guidelines. Is there any local authority in Wales spending less than its standard spending assessment amount on social care? 

I don't have the detail on that. I don't know if Julie, or maybe Albert, could help with this. 

I think maybe Albert could help us with that. 

Yes, of course, Ministers. We meet regularly with local authority leaders and directors, and clearly their financial spend at the moment on social care is running extremely hot. So, they're spending within their allocated budgets, but, in addition to that, they have needed substantial funding from Welsh Government during the pandemic. So, for example, the hardship fund scheme, that you'll all be aware of as Members of the Senedd, has been in place since the beginning of the pandemic, and, to date, over £185 million has been provided through local government funding and, of course, assisting in local health boards around their nursing care responsibilities. And that's been significant funding to assist with the pandemic response cost and to help with the additional pressures from underfunded voids in sustaining residential care placements, and that support has gone directly from those organisations, the health boards, the local authorities, to supporting, then, providers right across Wales.  

That was a very interesting answer, but it had nothing much to do with the question I asked. I asked: does any authority spend less than its standard spending assessment on social care? Now, 'yes' or 'no', and if the answer's 'yes', you'll name some authorities, and if the answer's 'no', then we know local government is supporting social care. 

Well, we will certainly come back with that detailed answer to confirm that to committee, of course, and I was just merely assisting committee with some of the substantial knowledge that we get from local authorities in terms of their spends and responding, and we are seeing local authorities clearly responding to care costs in social care.

And my final question is: is there anything more you can tell us about the reform of the paying for care system in Wales and the timescale the inter-ministerial group will be working towards? 

And if the Minister could just be more brief in replying to this, so we can get through our final questions. Minister.  

Yes. Just to say that the inter-ministerial group on paying for social care will be meeting on 7 October, you'll be pleased to hear, Mike. Obviously this group did a lot of work in the previous term, and we'll be looking at how we take that forward in the light of the UK Government announcement. 

Thank you, Deputy Minister, and Mike Hedges. We've got limited time, and I want to allow enough time for Rhun ap Iorwerth, who's joined us, to ask his questions. So, we've got a couple of supplementaries—if they could just be brief, with brief replies, please. Jack Sargeant.    

Thank you, Chair. Minister, just very quickly, I wonder if you could provide an update to the committee on discussions regarding NHS pay and any discussions your officials may have had with our trade union colleagues. 

I did meet with some trade union representatives yesterday. Obviously we are keeping an eye very closely on the situation. They've gone out to consultation; we've had the response from the RCN; the GMB also, I think we're just awaiting for that response; Unite, we're expecting next week. So, obviously, we're keeping an eye on the situation. Unison as well. We're obviously concerned that we want to do everything we can to avoid industrial action. We have suggested that there may be some options, but I'm afraid, at the moment, because of the restrictions that we have in terms of our finance, unless we're given more money by the UK Government, it's going to be very, very difficult for us to meet certainly any significant additional pay awards, but there may be some other options that we could offer around the edges. And obviously the trade unions have gone away now to think about some of those options and if they would be interested in picking up on any of those offers.

That's great. Thanks, Minister. 

Joyce Watson. 

Diolch. In May 2018, the Welsh Government did give £27 million in additional recurrent funding for Hywel Dda University Health Board, and the Minister at the time then said it would place it on a fair funding basis with other health boards, and yet it seems that that particular health board is still struggling with its finances. 

Thanks, Joyce. Well, you and I are aware, and we keep a very close eye on the situation in Hywel Dda. I think it is important that people understand that there are issues around the demographics of the population in Hywel Dda that are slightly different from other areas, and the scale of the provision, which means that there are excess costs that have been recognised by an accountancy firm that went in and really looked at the structural situation there. I'm pleased to say that they have managed to reduce their deficit from £35 million in 2018 to £25 million in the last financial year. But I'm very happy for Andrew, perhaps, to come in on this issue as well, because I'm aware that I'm quite close to the situation, and I need to be sensitive. 

I described earlier that for organisations generally this last year would have meant that some of the normal approaches to savings, including Hywel Dda trying to make some of the changes that we had been expecting with them—the environment just hasn't allowed them to do that. In a normal year, they probably would have been planning, through last year, for about £18 million-worth of savings. They were unable to deliver that, because they were responding to the pandemic. So, perhaps some of the progress that we would have expected even further. I would give them credit, though, for them improving their position. There was a time with Hywel Dda where, actually, it was a deteriorating financial position. They’ve shown that they’ve stabilised it, they’ve showed that they’re improving, and we are continuing our conversations through our monthly monitoring and conversations just to see whether there are other areas that the organisation can decide, or whether there is support that we can offer in a different way.

I think positively for all organisations, and it’s particularly so for those that have deficits, we have a financial delivery unit that has a lot of technical detail, and it does actually allow the kind of issues that the Member was saying earlier—Mr Hedges—that organisations do have a list of all of the things that have worked elsewhere in other organisations in Wales, and to look for it to be more consistently implemented. So, that is available to Hywel Dda alongside others. I think there is progress, but we also want them to make sure they make the right decisions on behalf of the population. So, it’s a balance between those two aspects.

Thank you, Dr Goodall. We've got nine minutes left of the meeting. Rhun ap Iorwerth has joined us, so, Rhun, you've got nine minutes to cover the areas that you want to raise with the Ministers.

Thanks for that question, Rhun, and I know this was a long-standing concern in the previous committee. Just to say that the NHS collaborative has reviewed face-to-face support for mental health provision vis-à-vis online provision, and how that worked during the pandemic. Local health boards have all been providing assurances to us that face-to-face provision is being offered when it’s necessary, and that’s being done on a risk-assessed basis. I agree, if people are vulnerable and they need to see somebody face to face, then, clearly, that’s something that needs to happen, and the assurance that we are getting from health boards is that that is indeed the case.

Thank you, Rhun. Well, as you’re aware, although the board was taken out of special measures, they remain in targeted intervention due to issues with their mental health performance, so I would just like to assure you that that situation continues to be monitored very closely. There is a maturity matrix that’s being used on an ongoing basis to monitor the progress made by the health board on their journey to come out of targeted intervention. I’ve been up to north Wales to meet with the chief executive of the health board and with other key officers, and I’ve emphasised to them the priority that I place on them ensuring that they tackle the problems that they face.

Now, in terms of the events on the Hergest ward that you just referred to, I know that Dr Goodall has hosted a meeting this week with key people on that. So, if it’s okay, I'll ask Dr Goodall to provide an update on that.

Yes, Minister, and your point on mental health and the targeted intervention status of the organisation is really important, because it does set ongoing expectations for services to be improved, and, obviously, the issues locally to be addressed. And just as part of our assurance process, and also checking in on the point that you were making, which is: how do we continue to support staff and the organisation to make the progress that all of us would expect and patients accessing the services are?

So, I chaired a round-table event that had been agreed as part of the escalation process. That brought the health board together, alongside Welsh Government colleagues that support us in our oversight in Wales, but also Healthcare Inspectorate Wales and Audit Wales. It was an opportunity, very directly and genuinely, to listen to the experiences of the health board, the learning that's happened, and the focus that they have on the priorities that the Minister has outlined in that way. So, it was a very constructive and open discussion. There are changes that there was evidence of, very explicitly and clearly within that context, but I think it's going to be important for us to reflect on that to just see whether there is more that can be done.

Just as part of the support, though, when funding was provided to the health board, I just want to advise Members that funding was directed towards mental health services in north Wales. So, from a resource perspective, we have also tried to make sure that that doesn't just remain as a normal budget decision within the organisation. But the round-table yesterday, I think, was a significant event and was part of the reflections that were taken within the escalation process as well.

That's probably a question not for Mr Heaney, but for the Minister, I suspect.

Absolutely.

Yes, thank you very much, Rhun. First of all, I just want to say that this role, the chief social care officer role, and the appointment itself have been very well received by the sector—welcomed both in terms of the role, because many people had asked us to bring in this role, and the appointment of the particular individual to this post, given his long history and experience in social services. And it is a programme for government commitment. It's an important high-profile role and it's a statement of intent for social care and care sector professional leadership, supporting the Welsh system. So, I think it's a great thing to have done.

Now, we introduced the role as an enhancement to the existing director of social services role, as many of the core responsibilities were already contained in the role. We never intended to have competing roles in providing advice both to Ministers and to the system, and the enhancement and nature of the role were reviewed through Welsh Government remuneration committee arrangements, in the normal way for senior civil servant appointments. Of course, any successor arrangements would obviously be subject to open competition at the point they arise. The post is operating consistently with the chief medical officer and the chief nursing officer arrangement. Those roles provide professional advice to Ministers as well as discharge internal director roles within the Welsh Government. And so, obviously that applies in the same way to the chief social care office. So, the key issue is that it is an enhancement of a role that already existed.

I'm sure that Rhun will be pleased to hear that we had an event on 13 July with citizen, carer and third sector representatives who were on the regional partnership boards, and that was in response to concerns that the board members weren't being properly supported or enabled to make a really effective contribution. So, we did recognise that this concern was there, and we held this event where they were able to talk in the presence of the chairs about how they felt. Obviously, it is quite a difficult role if you're a citizen representative or an unpaid carer or a representative of the third sector coming into the group where there are established local authority people and health people. So, we do recognise that that is very difficult, but this was a great occasion. I attended it, and I laid out very strongly that it's really important that we want the RPBs to be inclusive of everybody, and it's so important that we get the third sector voice, the citizen's voice, there. These lay members can help RPBs determine what their strategic priorities are.

So, it was a very good meeting. As a result of that, we set up a task-and-finish group to develop a charter to clarify the roles and expectations as well as other tools that could used by RPBs in supporting those members. So, that issue has been addressed—is being addressed, shall we say—about how people actually feel on the board. The 'Rebalancing care and support' White Paper proposed that RPBs should be strengthened, and that was one of the things that we're getting round to addressing now, in light of the announcement by the UK Government about their plans about paying for care. So, I don't know whether you were in the room, but we're reconvening on 7 October the inter-ministerial group on paying for care, and so we hope to be able to announce what direction we're going in as soon as we can.

Diolch, Rhun. Gareth, you have a very quick question.

Yes, thank you, Chair. I just wanted to briefly go back to the question around the chief social care officer, and I'd like to congratulate Mr Heaney on his appointment. I just want to ask: is this a step in the right direction in the integration of health and social care? In time, will this be reflected in our day-to-day services across Wales?

Deputy Minister, just a quick response if possible.

I think it's absolutely the right step. It's so important that social care workers and the work of the social care sector is acknowledged, and by having this post—it's something that the sector asked for. We were asked by so many people, 'Why don't you have a chief social care officer in the same way as you have a chief medical officer, a chief nursing officer?' And so we've certainly responded to those asks, and I see social care there working very closely with the health service, recognising how they are so intertwined. One depends on the other.

Thank you, Deputy Minister. Can I thank the Ministers for their time with us today? I think I should put on record as well, on behalf of the committee, I think we are greatly indebted to our health service and our social care workforce and health professionals, particularly at this time with the ongoing challenges. So, I think I should put that on record.

As a committee, we're yet to discuss our wider priorities, but from my perspective as Chair, Minister and Deputy Minister, I hope that our committee can be influential and persuade you with recommendations over the course of the next five years. We can do that, I hope, and work constructively with you alongside appropriate scrutiny as well. We thank you for being with us this morning.

Thank you.

Diolch.

There we are. Thank you. Sorry, I wasn't sure—do you want to make any comment, Minister, as we conclude? No. The Minister's waving. Thank you, Ministers, and diolch yn fawr.

In that case, I move to item 4. There are a large number of papers to note, so I'm not going to go through them. We've had a large number of papers over the summer period, so there's various correspondence in regard to the previous committee's work, and there are some responses from the Welsh Government in that regard, and also there is some correspondence with the Business Committee about the business timetable and other correspondence as well, but they are all there in the public agenda packs. So, could I just ask Members if they're happy to note those papers? Thank you, Jack. Diolch yn fawr.

In that case, I move to item 5, and I propose in accordance with Standing Order 17.42 that the committee resolves to exclude the public from the remainder of this meeting and from the meeting also on 7 October. Are Members content? Thank you. Diolch yn fawr. In that case, I draw this public meeting to an end, and we'll now go into private session.