National Assembly for Wales

Bore da. Croeso, bawb. Welcome to the Health and Social Care Committee this morning, and a happy new year to all Members and all our stakeholders watching in as well. First of all, can I say that this is a completely virtual meeting this morning, being undertaken by video-conference, and the Standing Orders remain in place as they normally are?

I move to item 1 this morning. We have no apologies and, therefore, there are no substitutions. If there are any declarations of interest, please say now. There are none.

In that case, I move to item 2. Item 2 is in regard to our first item this morning, which is a particularly long item—it's two and a quarter hours, so we will have a break during this particular item at some point. This is scrutiny of the Welsh Government's draft budget for 2022-23, with the Ministers, who I'm about to introduce: the Minister, Eluned Morgan, Minister for Health and Social Services; Julie Morgan, the Deputy Minister for Social Services; and Lynne Neagle, Deputy Minister for Mental Health and Well-being. And there's a whole range of officials on the call this morning, who I shall ask to introduce themselves as and when they speak during the meeting. But I should like to just say a quick word to Albert Heaney, who I know was awarded a CBE for services to social care in the new year honours list, so congratulations, Albert, on that.

Thank you, Chair.

Congratulations indeed.

Okay. Is there anything else I need to say? No, I don't think there is, so, there we are. I'd just thank Ministers, of course, for their written evidence ahead of the session this morning. If I can dive in with the first question, perhaps more of a general question, to the Minister. Obviously, when you do your budget, you consult, as you do every year, with relevant stakeholders and so forth. Is there anything within the consultation responses that you received, taking those into account, are there any priorities that were listed by stakeholders that have not been addressed in your budget, and if so, what are they, Minister?

Thanks very much, and thanks for the opportunity to update the committee on our priorities in relation to the budget. You'll be aware that the vast majority of funding in the health and social services portfolio is allocated to NHS Wales, and, obviously, there are very many well-established fora for discussion and engagement with NHS colleagues, which help to inform that policy development, which determine the prioritisations and, ultimately, the budget allocations. So, we listen to what they are requesting and then we make some determinations on the basis of what they are requesting. These are regular meetings. They take place with the director of the NHS in Wales, Judith Paget, who's with us today. Also, obviously, there's a finance directors forum, there are deputy finance directors monthly meetings, and the Welsh NHS Confederation is also represented at the chief executive meetings. So, what we have is an annual planning cycle, and I think that's now well embedded. So, we set out our broad expectations, and then the boards present us with integrated medium-term plans for every NHS organisation. And so, we're waiting for those plans to be given to us; we've actually postponed them for a month or so because of the omicron situation. But that, hopefully then, will be in line with the allocation that they have requested and set out. But we also have our priorities and we want them to follow those priorities. So, that's generally how the system works.

So, if I've got this understanding right, this is the draft budget, but then your draft can be amended following the input that you've just talked about from health boards.

It's about emphasis. So, we've set out what the priorities should be. We've already said that to them a couple of months ago, just to say, 'Right, when you're developing your plans, your integrated medium-term plans, then these are the priorities we expect you to put in place.' They present us with the plans and then I approve the plans before they start spending that money.

Okay. And going back to my original question, you've set out the process, but, to date, including all your stakeholders—that's beyond the health boards as well—what priorities may have been presented to you that you haven't been able to include within the budget or consider within the budget?

I guess where there's a slight frustration not just from them but certainly from us as well is the limited amount of money we have available in terms of capital. So, that will be an area that is probably not where we want to be. So, that's going to be, I think, a challenge for the NHS this year. I don't know if my colleagues would like to talk a little bit about the engagement that they've had with some of the stakeholders.

Okay. I can see Steve Elliot wants to come in. If you just introduce yourself, Steve, and the specific question is on considerations that have been presented to you that you've not been able to include within the budget, or where stakeholders would have a concern with. Steve Elliot.

Thank you. I'm the director of finance for health and social services within Welsh Government. Yes, obviously, as the Minister has outlined, we do have quite extensive engagement with the health service. In terms of areas that have been flagged up from the NHS that will be an issue, we're aware that energy costs in particular across both the UK and the world have been increasing significantly, and that's an area that will be a risk going forward into this financial year that we will need to manage in line with the service, as well as, obviously, the ongoing impact of the pandemic and how that will continue to pan out over the next financial year and beyond. Thank you.

Okay. And so, Minister, are there any other key priorities that you think—? I can see Julie Morgan wants to come in. So, talking about key priorities that haven't been included or addressed in the budget from stakeholders.

The point that I wanted to make, really, was how extensively wide the consultation is, and, certainly, with regard to social care, there are extensive meetings with the voluntary sector, for example, and I meet personally with groups of carers, for example. So, there is a wide engagement beyond the official bodies.

And with that, if I can ask the question to Julie Morgan: in regard to the consultation with the voluntary groups, are there any key priorities that haven't been addressed in the budget from their perspective?

I think we've been able to respond to most of the things that they've asked, but perhaps it hasn't always been as much as we would want to. Because, as the Minister has said, we are limited by the amount of budget money that we have got.

Okay. Thank you. And in regard to the health and social care budget, in terms of the agreement between the Welsh Government and Plaid Cymru—the co-operation agreement—are there any particular aspects of the allocation that are relevant to the co-operation agreement or have been included as a result of the co-operation agreement?

There's only one new commitment in relation to the Plaid Cymru agreement, and that relates the childcare and early years, so I'll ask Julie, if you don't mind, to make some comments on that.

Yes, as the Minister said, childcare and early years is a major commitment in the agreement, and the money for this is included in the additional £30 million up to 2024-25. This will include supporting more families who are in education and training, because, at the moment, the childcare offer does not extend to those people who are in education and training. So, we've given a commitment to do that in the co-operation agreement, and we estimate that will cost about £15-20 million over the next three years. We're committed to paying an increase in the hourly rate for a number of our early childhood education and care programmes, including the childcare offer, and it's anticipated that that could cost in the region of £10 million annually. We're also going to expand Flying Start to two-year-olds, and that will be planned in conjunction with the early years sector, so we'll be working together with the early years sector to make that happen. That funding will be announced in due course, and I'll make sure that you're aware of the plans. Those are the main areas that are in the co-operation agreement.

Okay, thank you.

It's probably worth just flagging up, as well, Russ, that we will continue to provide about £7 million towards meeting our commitment to establish a new medical school in north Wales. I know that was also a part of that agreement.

Okay, thank you. Lynne Neagle.

Thanks, Russell. Just to flag that, obviously, there is also a commitment in the co-operation agreement to pilot sanctuary provision for mental health for children and young people, but I'm sure we'll come on to that later.

Okay, thank you. Thanks, all, for those questions, there are a number of areas that I think Members will perhaps dig into later on in the session. Rhun ap Iorwerth.

Rhun, do you mind if Jack just comes in quickly before you move on? Jack Sargeant.

Diolch yn fawr, Gadeirydd. Weinidog, the Petitions Committee on Monday took a consideration of a petition calling for the increased funding of women’s health services specifically. Obviously, we didn’t have the detail of the budget on Monday. Can you confirm today whether there has been an increase in funding for women’s health services, or whether there will be? Obviously, that includes research, education, and the very important topic of public awareness.

Thanks very much, Jack. We don’t tend to silo money in that way within the health service. I know later on today we’ll be talking to the children’s committee, and they’ll be asking us here, 'Have you ring-fenced money for children?' It’s not the way we do things in the NHS. But what I can tell you, Jack, is that this is absolutely an area that I’m focused on. In fact, we were hoping, before Christmas, to announce the fact that we are developing a women’s health proposal, and hopefully that will be developed. But, obviously, omicron got in the way. So, we’ll be giving more information on that very shortly, and I know there’s a huge amount of interest in that. So, I can give you that commitment.

I'm very aware that I’m the first woman health Minister in a long time, so I really want to make sure that we’re putting our stamp and understanding that, actually, there are issues that we need to consider, and that lots of the research is done by men, for men. I’m very, very keen to step back to make sure that we are focusing our attention. For example, women’s heart disease—there’s fascinating information there in a space that I wasn’t aware of until recently. But I think we need to just put a real focus on some of these things. So, you’ve got my commitment that we’ll be doing that. But I’m not keen to do ring-fencing for women. Imagine how complicated that might be.

Diolch, Minister. Diolch, Rhun.

We might come back to that later in the session. Rhun ap Iorwerth.

Steve, I don't know if you'd like to add to that.

Thank you, Minister. I think it's worth saying that we've had quite a significant process of intervention over a number of years for those organisations that have been reporting deficits. We've undertaken financial governance reviews, and also, more recently, financial planning reviews. Two or three years ago we established a finance delivery unit to provide extra capacity for us within Welsh Government, and the NHS, to work more closely with organisations that are struggling. I think our approach now is much more a challenge and support process. We have very regular engagement with all organisations, because there are two that are continuing to report deficits, but every organisation, obviously, has its own financial challenges. As the Minister says, I think through the IMTP process we'll be particularly looking to Hywel Dda and Swansea Bay, and how we can work with them and support them to deliver a three-year plan that will bring them back into financial sustainability. Thank you.

I don't know if, Judith, you've got anything you'd like to add to that?

Thank you, Minister. Yes. I think they're important points. The formula that we use is revised every so often to ensure that it maintains fairness and equity in our approach. And, as the Minister has said, in particular in relation to Betsi Cadwaladr, we've provided additional funding for a period of, I think it was, three and a half years, and Hywel Dda has been given additional resources to support its baseline in recognition of that review. Clearly, we keep the situation under review, making sure that organisations feel appropriately supported but also challenged to improve their performance as well. So, I think we do try to keep that balanced approach and, as Steve has said, we'll keep close to the organisations now, all of the organisations in Wales, as they submit their plans for the next three years, to look at the impact of that, the impact on their own local populations and what we can do to encourage, support and challenge where necessary.  

Thank you. Good morning, everybody. I've been a Member of the Senedd now for near on 15 years, and it is the case that Hywel Dda have been in debt all of that time. We know it's historic, but we're here again, and obviously Betsi Cadwaladr as well. So, my obvious question is this: I've heard everything that you've said, so I'm not going to run through that again, but how likely is it that this situation is going to be resolved within this three-year window of financial management by Hywel Dda? And, adding to the question that Rhun highlighted for Betsi Cadwaladr, we are now seeing a rapid increase in the number of people who come to Pembrokeshire throughout the holiday season, and that in itself is expanding. I don't know whether there has been a reassessment more generally to make sure that that figure is realistic, because it just puts pressure on everybody, not just the people who are managing the budget, but the people who are trying to deliver those services as well. And that's not a good place for the staff, going forward. 

Thanks, Joyce. Well, what I know is that the health board is developing a road map for sustainability, which will underpin this three-year plan. And I think it's really important that we, and they, acknowledge that their deficit is largely driven by a service model where there is some duplication of some services, such as medical intakes across four sites, the number of beds compared to the average across Wales. It is more difficult. Obviously, you know the noise around this, if you were to say, 'Well, actually, proportionately, that's not a right balance but actually, geographically, it's difficult to cover those areas.' So, we do have to just bear that in mind, that there are political decisions that we've made here that we, as a Government, have determined.

I think the other issue to bear in mind is workforce challenges, and they're looking to address that through the 'A Healthier Mid and West Wales' strategy. And I think it's part of the solution, maybe, to address that service duplication through a new hospital for west Wales. But we're waiting, again, to hear formally and officially from the health board on that.  

Steve wanted to come in. 

Yes, if I could just add, around the issue that Members have raised around summer visitors to both Hywel Dda and Betsi Cadwaladr areas, just to confirm that there are financial mechanisms in place for health boards to recover costs if tourists become ill while they're in that area and need treatment in their hospitals. So, those costs would be picked up in addition to the funding that comes from Welsh Government. Thank you.

Thank you. Rhun, back to you. 

Thank you, Rhun. Mike, you wanted to come in. Mike Hedges.

Lots of other organisations outside health have made substantial reductions in their fixed costs—things like LED lighting, things like reducing the cost of agency staff. I know that nursing agency staff is a huge cost in the NHS, and I also know that different health boards are more efficient in different areas than others. Though I haven't got the numbers in front of me, if every health board in each area was as efficient as the best, we'd have huge savings. The 1.5 per cent would be a very small saving, which could be done. How are you going to ensure that every health board in each area does as well as the best are doing?

Thanks very much, Mike. This is something that I'm very keen to do a lot more of, and that is to get health boards to benchmark against each other. I'm really keen to see a lot more of that going on. Part of the issue there is to make sure that we're measuring apples and apples, rather than apples and pears. So, we've got to get the data right first, otherwise they all complain at the end, 'Well, we weren't measuring the same things.' So, we just need to make sure we've got the baseline in place, but that is definitely a direction that I've made it clear that I'm very keen to go down, particularly when it comes to waiting lists. How is it that some consultants managed to get through eight cataracts a day and some managed to get through three? I think we do need to be doing a lot more of that benchmarking in terms of efficiency and ensuring that we're getting the very best and very most out of people.

Can I just say I agree entirely? If you read a Nuffield report from 2010, it shows a huge reduction across the health service in England and Wales, but especially in Wales, in the number of people dealt with per consultant.

Thank you, Mike. Jack Sargeant.

Thank you, Chair. Minister, if we could look at the issue of addressing waiting times, if we may, obviously, the pre-pandemic level of waiting times was in a situation that was already struggling. Clearly, because of the pandemic, that has significantly grown and the struggle is real now. Your evidence to the committee, in written evidence, says the budget contains £170 million of revenue funding recurrently from 2022-23 onwards to tackle this issue. Can I just ask what impact you think that investment will have and are you confident it will deliver what is needed to reduce this backlog?

Jack, I'm very aware that, once this pandemic intensity that we're going through at the moment is over, the focus is going to shift very, very quickly onto clearing those backlogs. So, I have made it clear, and I know Judith has made it clear on my behalf to the service, that, 'You need to start getting ready to really tackle this in a very comprehensive way'. I think we've got to be realistic in terms of what the constraints are going to be, and the constraints are usually staff and infrastructure, and what you can't do is to switch those on, which is why we made that announcement before Christmas in terms of, 'Right, this is what we're planning in terms of getting the right people in the right place.' So, we've identified where the gaps are. We're training people up for those gaps.

I think what we're looking at is recurring investment here. This is what's great about this. We've got an interesting spending profile, where we've got this additional funding this year, but, actually, that becomes the baseline for next year. So, people can invest knowing that they've got that ongoing commitment. The difficulty for health boards is when they're given a whole load of money towards the end of the year, but there's no recurring funding, so they can't employ people. So, the other thing I've emphasised to them is that I would like them to consider whether we can deliver some of this in a regional context, in particular things like orthopaedics, cataracts, endoscopy and diagnostics generally. And, again, what I hope we'll see as a result of that is a reduction in the variation and inequalities in terms of who does what efficiently and things. So, if people work better cross-regionally, I think that will be helpful.

What I am planning to do, Jack, is to publish a recovery plan in April to set out very clearly, 'Right. This is where we're heading here', and part of that will include the transformation and redesign, making sure that we've got that whole-system approach, but also looking at where, actually, we sometimes do things now that we don't need to be doing. We call people back in for consultations when we actually don't need to be doing that. And all of those add to the waiting lists. And we count everything in Wales. We count things very differently from England. So, we have got to be very careful in terms of comparing England and Wales waiting lists as well. 

Thanks for that, Minister. The budget also—as well as the £170 million, it also includes £20 million a year, and I quote, to support:

'a value-based approach to recovery over the medium term, with a focus on improving outcomes that matter to patients'.

Do you want to tell us a little bit about that now, and will that be included in the April recovery plan that's going to be published?

So, I think what's really key here is to focus on what matters to patients. So, there may be some clinically really good reasons to do things, but, actually, that's not what patients want. And I'm thinking in particular of maybe end of life. Sometimes, people want to spend their last months, last weeks, at home being cared for at home rather than being hooked up to a whole load of machines in hospital. So, I just think we've got to be aware of what matters to patients, and one of the things we'll be doing is a lot more measuring of what happens to patients, and making sure that those evidence-based best practice clinical pathways are being followed. And all of that then embeds that value-based approach to services. I don't know, Judith, if you've got something else to add to that.

Do you want to just introduce yourself, Judith?

Oh, sorry, yes. Judith Paget, chief executive of NHS Wales, director general of health and social services group. Thank you. Sorry, Chair. 

Yes, thank you, Minister. I think your comments about the NHS needing time to build capacity around staff and infrastructure are really important. I think, just to pick up some of the other comments that have been made, it's very much about how we just don't go back to doing what we did pre-COVID, and actually take the opportunity to do things differently, moving forward—so, how we manage referrals, how we manage follow-ups, how we use technology-enabled care to do things differently; yes, improving efficiency, but, more importantly, improving outcomes for patients, and value-based approaches are very much in that arena of talking to patients about what's important to them, talking to their families as well, and actually tailoring our services so that we actually support what people want, as opposed to sometimes what the standardised offer is across the NHS.

So, I think value-based healthcare is an important feature of our recovery work. It definitely will feature in the April plan that the Minister has referred to. And I have to say, in Wales, we've done a huge amount of work developing our approaches to value-based care, and have been leading on some of this work, definitely across the UK, but also internationally as well. So, I think we've got a really good baseline to build on. Thank you, Chair. 

Joyce Watson wants to come in. Do you mind, Jack? Is that all right?

Yes, of course. That's all I had, Chair.

Okay. Thank you. Joyce Watson.

Just a small question. When you talk about value-based care, one of the big issues that has really come to the fore is that the mental health of people suffered through isolation. And that drives them, then, to their GP—sometimes just to simply have a chat, because they expected that individual to listen to them. So, how is your thinking in terms of joining up the accessibility for large numbers of the population—perhaps mostly the elderly—with a provision that might sit outside the NHS? It might rest with the voluntary sector or local government, for example.

I'm happy to take that, but I'm sure Lynne has got more to say on this than me.

Lynne.

Thank you, Chair. Yes, thanks, Joyce, that's a really important question, because we do know that loneliness and isolation has a very significant impact on mental health. So, one of the things we're doing is developing a national framework for social prescribing in Wales. You'll be aware that it was a programme for government commitment, and work is continuing apace with that, and we are looking to fund that after we've completed our consultation with stakeholders. But what we're also being really mindful to do is that we know that, in some areas, they've got really well-developed social prescribing provision, and we don't want to reinvent the wheel, really, we want to spread that good practice where we know it exists. But, absolutely, we're very committed to ensuring that we do tackle loneliness and isolation. And also our whole approach to mental health is based on the fact that we shouldn't be medicalising distress, and that's why we're focusing so much on early intervention and providing low-level support across the board, really, so that problems don't escalate and so that people aren't seeking medical help for problems that can be tackled in another way.

Julie Morgan wants to come in. Julie. You're just on mute, Julie. Oh, you're unmuted—go ahead.

Following on from what Lynne has just said, it's very important, as she says, that we don't medicalise this issue. And we do have a loneliness and isolation strategy, which has a fund, where we give grants to small community groups who work with, perhaps, elderly people in an area, to make connections. And the theme of our loneliness and isolation strategy is that making connections between different areas, and I think it's really important that we are able to reach people in that sort of way.

Thank you, Minister. Gareth Davies.

Thank you very much, Chair, and good morning, Ministers and officials. I want to just take a healthcare workforce tack, really. In the budget documentation, you mention in very broad-brush terms about investment in the workforce, including £260 million in education and training, and over £300 million for Health Education and Improvement Wales, which all sounds fantastic. But what are the Welsh Government's key spending priorities within this funding in terms of specifics, and what are you hoping that will achieve during this period? Thanks.

Thanks, Gareth. This is the eighth consecutive year where we have increased professional training and education funding in Wales. So, before Christmas, I announced that £262 million is going to be invested in 2022-23; that's a 15 per cent increase on last year. And as I say, this is so important to remember—getting the right people into the NHS—. It's about people. You know this, Gareth—you were one of them. It's really important for us, I think, to understand that that training is crucial. So, where is that training going? Well, there's a 9.5 per cent increase for medical training places, there's a 30 per cent increase to support core GP training numbers, and there's a 29 per cent increase for pharmacy training across Wales. So, we're hoping that all of those things will take the pressure off some of the GPs, for example, and also the accident and emergency services.

I think it's really important also to stress that we've increased again the number of training places for nurses. So, for the last six years—and I think these numbers are really quite significant—nurse training places have increased by 69 per cent in six years; midwifery training places by 97 per cent. Health visiting training places increased by 30 per cent. Physiotherapists—I think you were a physiotherapist, were you, Gareth?

Yes, until May, yes.

There we go. That's an increase by 30 per cent. And radiographer training has increased by 18 per cent. So, there are some of those specifics that I know you're interested in.

Thank you for that, and I think it does go a long way to addressing some of the longstanding issues in recruiting front-line workers and indeed ensuring that they're adequately trained, which is most important to ensure that patients receive the best care possible. 

How will the budget balance the need to meet existing workforce pressures though, and people who may be considered maybe well developed in their careers, who've had a tough time during COVID-19, and the exacerbation of a lot of longstanding problems? So, will that be achievable to tackle some of the longstanding issues and some of the workforce pressures whilst still reducing that money being spent on agency staff? Because I'm still aware that there's still a lot of money going into agency staff and they cost a fortune, don't they?

Yes, they do. They cost more than—. Obviously, we're very keen to get people working directly for the NHS, rather than in agencies, but what we have done—and we're very aware of the kind of pressure people have been under for two years now—we have been boosting workforce numbers. So, we've now got historical levels. We've got 103,000 individuals working in the NHS today in Wales, which is a significant number. And that's about 4,000 more than at the same time last year, and about 7,000 more than before the pandemic. So, those are significant increases.

And what we've also seen is an increase in the temporary workforce and also we're benefiting from a significant number of volunteers, for example, the British Red Cross and Macmillan Cancer Support. So, I think—. Also, we've tried to get people back who've retired. So, we've had about 635 NHS Wales staff who retired and have come back to help us out. So that's been very welcome.

And I think the other thing to point out is that, actually, we've done things differently—we've got new models of care. So, I certainly know that the way GPs work now is very different from the way that they worked pre-pandemic. So, I think it is important for us to understand that it's not just about doing the same thing—it's about doing things differently. And I'm very pleased to push on the digital side of things as well, for example, and make sure we make more use of remote consultations as a way of maybe saving a lot of time in future and using those experts in the best way possible.

Thanks for that answer, Minister. And just finally, if I may, can I just refer you to the Cancer Research UK's response to the Finance Committee's consultation on growing and supporting the cancer workforce specifically? And I'm just looking for a Welsh Government response to that, really.

Well, as it happens, I met with the cancer charities yesterday and gave them a detailed response to exactly where within the cancer field we'll be increasing the numbers. I'm afraid I haven't got that to hand at the moment. I don't know if anybody on the call can recall that information. It is very detailed and, Gareth, I'd be very happy to send that to you, if you don't mind. I can probably get it to you by the end of the meeting, if you'd like.

Yes, that would be more than helpful; thank you very much. And that's all from me at the moment.

Thank you. Were they happy with your response, Minister?

I think they were. I think they seemed pretty happy. I'm really clear that of all the things that we need to tackle, cancer is the one thing that we absolutely cannot let go of. There are things that we can postpone. Cancer is not one of those things we can postpone. So, absolutely. Cancer is right up there, top of the agenda.

Okay. So, you believe, following that meeting yesterday, that you addressed their concerns, as they had detailed in the letter, from your perspective.

I think so, yes, and I am certainly happy to send you more detail on that, if you'd like.

No, thank you. I think you agreed to share with Gareth, but if you're happy to share with the committee, that would be useful for us, so thank you, Minister.

Two sets of questions. Joyce wants to come in. Then I'll come to Mike, and then we'll go for a break. Joyce.

Thank you for your answer on the workforce. Lots of people mentioned agency nurses, and that they're expensive. Well, there are two things, and this is my question to you in terms of budget. I think there's probably some work going on and it would be useful for us to know why it is that people choose to go and work for an agency rather than the NHS, because you need that information before you can address the problem, and whether that's around flexibility and patterns of work that people are choosing because it doesn't suit their lifestyle. So, you may not have that information in the here and now. But the other side of working for an agency, of course, is the individual, then, more or less, becomes self-employed. They don't have access to the same terms and conditions as the NHS staff as well. So, whilst I've sort of put this out there, and you might not be expecting it—well, you wouldn't be expecting it—I would like some information about that, because you can't tackle the issue unless you know what the issue is, and then it has budgetary consequences for us all. In all aspects of health and social care, agency will be prevalent. 

In terms of the increase in the nurse training, I really welcome that. Everybody welcomes that. And I'm assuming that that new training, whether it's for nurses, physiotherapists, or anybody, is meeting the development of the new type of healthcare provision, because clearly we're moving into a different space, using technology more et cetera. So, it might be useful to understand that. And I'm going to link two things here—

We're just a little short of time, Joyce.

My final one. We see the increase in nurse training, but we know that people are leaving, whether that's because of Brexit or whether it's because of some of the stresses that I've already highlighted. So, to understand the fit between the increase in training and the numbers leaving and the budgetary implications of that would be useful to us as well. Thank you.

Thanks, Joyce. There are lots of questions there. It is an area that we're obviously quite focused on. Generally, I think we're looking at, in terms of nurses, people who are looking for more flexibility. What we've been trying to do, in particular with locums, for example, is to get a better central data system so that at least we don't have locums taking advantage of different pay awards in different places and things. So, there are mechanisms that are being developed centrally now to make sure that we can at least understand who's paying for what where, so that the taxpayer is absolutely getting the best value. I don't know, Judith, if you've got anything to add on this. You must be an expert on it.

Thank you, Minister. I'm not sure about the 'expert', and I know we're short of time, but, yes, just to say, from my previous roles, I'm always interested in why people might leave NHS employment to go and work in an agency. Clearly, pay is one of those, but the maximum flexibility the agency offers to individuals about where they work and when they work is also raised, but pay is mostly the issue. Clearly, from an NHS perspective, we do have contracts with agencies—those who provide care and support into the NHS—and they are negotiated and renegotiated on a regular basis.

In relation to training, yes, the training requirements of nurses, and indeed all staff, changes as the needs of the NHS changes, but not only for new staff, obviously, but, clearly, Health Education and Improvement Wales and other organisations are really interested in making sure that existing staff get skills updates and development as well. So, a huge focus on both of those: the training of new, but also the training and updating of existing staff as well, so that everybody can keep up with the changing requirements of the NHS and changing needs of patients. Thank you.

Thank you, Judith. We'll take a couple of blocks of questions from Mike Hedges, and then we'll have a break, if that's okay. Mike Hedges.

Diolch, Cadeirydd. Financially, primary care has lost out following the merger of primary and secondary care in the health boards. How will the budget use targeted investment to improve primary care provision and stop people having to use A&E for their primary care needs because they cannot get appointments with their GPs?

Thanks very much, Mike. I've made it clear to health boards that I am expecting to see a shift from secondary to primary care, and in terms of the general medical services contract that has just been announced on 1 December, what we are hoping to see is a better focus on cluster delivery models, so that we can see improved services for people using them, and that will see significant changes to the way that patients access their GP practice through an access commitment. So, that access commitment, and we've put an extra £5.2 million on the table to help with that—we hope to see an end to that 8 a.m. bottleneck that so frustrates so many of our patients.

I mean, that is where we're at in terms of GMS, but, obviously, there are other areas in primary care that we need to consider. One of them is dentistry, and I've been trying to really focus on dentistry. It's really quite difficult at the moment, because we're still in a system where we're on kind of an amber signal, which means that, due to the pandemic, it's actually difficult for us to get back to normal, but we have a new contract starting from April, and that will mean that we're introducing a new way of measuring activity and volumes, which will be different from the way we're doing it, and that's going to be an extra £2 million in recurrent funding. And we are setting some measures in place with that new contract in terms of the application of fluoride varnish, taking new patients on and appropriate recall intervals. So, we often go for little check-ups that are not necessary, so we just need to make sure that we're focusing the attention on where it needs to be. And also the same thing on optometry: very keen to see far more optometry work being done within our communities rather than people going directly to secondary care.

If I move on to something that we discussed in some detail yesterday, so I'm not going to repeat everything I said yesterday, on prevention and health inequalities, Chair. You'll know my view on health inequalities after yesterday. But can I ask how much of this budget is being spent on preventative action, and how does the budgeting tool for health then enable longer, healthier lives?

I'll come in first, then I'm going to invite Lynne, if you don't mind, to also comment on it. For me, one of the key things is to not lose focus on the fact that, actually, there's £8 billion there and we've got to get that £8 billion working better, so it's not about focusing just on the £800 million. So, how do we get people to shift? So, I've been very clear that I'm expecting to see a shift towards prevention, but I think it's really important that we understand, and that debate yesterday was really interesting, I thought, and really touched on the fact that it's not all about health—it's about housing, it's about poverty, it's about failure to be able to eat properly, all of those things that are much broader than direct health issues. So, prevention is absolutely clear, and what I'm hoping to do is to really start looking at the specific measures in certain areas, so tobacco use, or a healthier weight, for example, and that the health boards will have to account for those—so, a lot better monitoring and accountability mechanism. I don't know if Lynne wants to add to that.

Thanks, Eluned. Like Eluned, I'm also very keen to see health boards proactively investing in prevention—so, I very much support action in that area—but also recognising that prevention is a cross-Government effort that involves all departments. But we are also taking targeted action to support prevention. Just to give you a few examples, we've reprioritised the £7.2 million annual prevention and early years funding from April, and that's going to be used by directors of public health across all LHBs to support interventions in the obesity and tobacco policy areas, in line with the work that we're taking forward there. We're making significant investments in an in-patient hospital smoking cessation service across Wales. As part of our tobacco control plan, we're also undertaking specific engagement with groups with higher smoking prevalence, such as those in our most deprived communities. We're funding things like the Bump Start programme in Cwm Taf Morgannwg to support healthy weight gain in pregnancy and healthy family lifestyles. Our new regional investment fund, which is over £144 million, will, for the first time, have a pillar that concentrates on prevention as a key priority, and we're encouraging regional partnership boards to work collaboratively within that framework to make sure that they deliver preventative activity. All activity funded by the RIF must directly support development and delivery of the six national models of integrated care, one of which is community-based care prevention and community co-ordination. And I'm happy to give further examples, if the committee would like me to.

Finally from me, Chair: I think that we've seen one really good example in Designed to Smile, which has really reduced the number of children having fillings. When you go to a poor area of social deprivation and an 11-year-old girl asks you what a filling is, that's a success. What I really want to ask is: how are you working with the education Minister to ensure that the free school meals that we're going to bring in for primary schools can actually be used to try and reduce obesity? An obese four-year-old is almost certainly going to become an obese adult, and they're probably going to end up with diabetes at the end of it—type 2 diabetes at the end of it. How can we use some of the other levers outside health in order to improve health outcomes?

Irfon wants to come in there.

Irfon Rees, do you want to introduce yourself as well? Thank you.

Will do. Irfon Rees, director of population health in Welsh Government. Thank you, and thanks for that question. The health Minister absolutely identified this as an area where we need to work closely with education colleagues. There is an existing strategic partnership called Building a Healthier Wales, which brings together local government, Public Health Wales and a number of other partners. Within that group, they have some very specific public health expertise, and we've commissioned that group to support that commitment around free school meals, to undertake a health impact assessment and to think about how do we maximise the opportunity of that commitment to deliver improved nutritional standards, for precisely the reason you say: so that it can have maximum impact at a universal level. So, I welcome the question and it's an area we're keen to prioritise.

And on top of that, it's not just about the food aspect of it, what I've asked them to do is to think about the economic aspect. Let's make sure that the food comes locally and that we can help support the local economy and that that produces more jobs—all of that helps health. So, it's using that significant additional investment to do just much wider good than what was initially envisaged.

Lynne, did you want to come in on that as well?

Yes, I did. Thank you. Mike quite rightly highlights the importance of cross-Government working. Just to add to what's been said, we are investing a very significant sum of money in our 'Healthy Weight, Healthy Wales' strategy—£6.63 million a year. And as well as the very targeted actions as part of that strategy, which includes £600,000 for a children and families pilot that we're running in three areas—Cardiff, Merthyr and Anglesey—we're also looking at how we can work across Government and link in to the free school meals work to make sure that we're delivering across the board to reduce obesity. Because we also recognise that the challenges we had before the pandemic have actually been exacerbated by the pandemic, so this is absolutely an area of priority for us, which we're supporting with a very large sum of funding.

Thank you, Minister. If there are no other questions from Mike or other Members, we'll pause at that point, and can I suggest that we just take—I'm hoping a five-minute break is okay, but, Minister, you're working the hardest, is five minutes okay?

Yes, that's fine.

Thank you very much. So, we'll be back just after 10:50—10:51, 10:52. Thank you.

Welcome back to the Health and Social Care Committee. This is currently our item in regards to budget scrutiny with the Ministers, and I next come to Jack Sargeant. Jack.

Diolch, Chair. If we could focus on mental health and well-being for a short while, Deputy Minister, can I focus my question to you? Obviously, the pandemic has had an enormous impact on all of our mental health and well-being, and including the services as well, but you'll know I've fought for a long time—. Pre-pandemic, I believe we were in a crisis state with regard to mental health then. I do welcome the specific allocation of the £50 million in the budget, and, of course, I recognise that will be increased to £90 million in 2024. It's worth saying that Mind Cymru have too accepted and welcomed the allocation of the budget from the Welsh Government, but they would like to know how the funding would be used. So, Minister, will you be able to tell us a little bit more about that? I also note—and I'm conscious of the committee's time today—that the Children, Young People, and Education Committee will be looking at this specifically for children, so perhaps you could set out the other priorities for your portfolio.

Thank you very much, Jack, and thank you for recognising that it is a very substantial additional investment in mental health services in the budget that we're considering today. From the additional £50 million, what we're planning to do is to use around £25 million to directly support mental health services, with the remainder of the funding then being utilised to support key areas that impact on mental health, so that would include substance misuse, employability and prevention. And I should draw the committee's attention to employability. We've got a number of employability projects that were previously funded by European funding, so, because we haven't had that replacement money from the UK Government, we have had to find the money to continue those very important programmes that help keep people in work or get people into work, which we know is so vital to people's mental health.

Some of the funding is going to be used for COVID recovery, because, obviously, the pandemic has had an impact on waiting times, but I'd also like to assure the committee that we are going to use the funding to continue with the reforms that we're taking forward through the 'Together for Mental Health' delivery plan and also the commitments that we've made in committee reports, the 'Mind over matter' report and this committee's 'Everybody's Business' report.

In terms of priority areas, we are planning to invest significantly in increased service improvement funding. This year, we've invested an additional £7 million, and we will be increasing that again in the coming year, and our priorities there will include child and adolescent mental health services, perinatal mental health, early intervention in psychosis and crisis services. As you know, we're developing the 24/7 mental health support through the 111 number, and we're also going to be implementing the recommendations of the delivery unit's review of crisis care services.

In terms of other priorities within next year's budget, there'll be further support for all-age eating disorder services to ensure that we implement the recommendations of the 2018 eating disorder review. There'll be support for primary care liaison and additional support for tier 0 and tier 1 services, and that will include both national commissioning and regional allocations through health boards, and, as you know, we've been very keen to increase the lower level support available, especially in light of the pandemic and the worries that we know people have had.

We'll also be funding alternatives to crisis admission, and that reflects the agreement that we've made with Plaid Cymru to pilot new models to prevent admission for children and young people in crisis. We will be implementing the recommendations from the national collaborative unit's secure services review, and that's going to be published shortly. Also, I'm very pleased to say that there's going to be additional funding for national commissioning to support the suicide and self-harm programme, including a postvention pathway, which was, again, a recommendation that came from the predecessor committee to this one. But I should say as well that we are acutely aware that the workforce pressures we were facing in mental health before the pandemic have been made worse by the pandemic, and we know that some of the investment we put in last year hasn't been able to be utilised by health boards because of those recruitment difficulties. So, before we release funds for 2022-23, we are undertaking an exercise with health boards to identify any legacy posts and grades that they haven't yet recruited to. So, by working with health boards then, we should be able to get a much clearer picture of what the needs are and how we can best use the substantial extra money that we've got available to us.

The other point that I wanted to make, which is in relation to the previous discussion around outcomes, is I am very, very keen as Deputy Minister that we are really focused on outcomes. So, for any money that health boards access, they will have to submit a plan to show how they're going to use that money to reach the outcomes that we've set out as priorities, so that we can make sure that we deliver, and I will of course be holding them to account on that.

Thanks, Deputy Minister, for that very detailed answer. Just very quickly, you mentioned towards the end of the answer the review with the health boards. When is that review likely to take place and when will we hear the outcome of that?

Well, the review is starting now and I'll bring Tracey in to talk about the precise timescale, but we want to make sure it's done with pace because obviously we need to sort out exactly how much money each health board will be getting. Tracey, did you want to come in?

Yes, please. Thank you, Minister. Yes, it's immediate in terms of reviewing with the health boards. We have very regular interactions with the teams anyway, but as the Minister said, the important thing for us to understand in allocating the funding for next year is that we don't disrupt the workforce in any way, and really to understand how they're utilising new models. So, assistant psychology posts would be an example of where, through their planning, they're using new models in the mental health workforce to be able to utilise the money in the way that the Deputy Minister has described.

Diolch, Chair. Thank you, Tracey.

Thank you, Jack. Joyce Watson.

I want to talk about capital spending. You've already said, Minister, that it might be an area where there could be some risk because it's £53 million less than the revised final budget for this year, and capital investment, according to the Welsh NHS Confederation, could put at risk some of tackling the backlog, transforming services, supporting digital and delivering safe care. They share your disappointment, I think it's fair to say, about that reduction, especially in delivering transformation and improved facilities. And running, of course, alongside that is the reduced capital allocation and the likely impact that it will have on the ability to decarbonise as well. So, I'd like you to speak to that and tell us what impact that might have and how you might move forward with priorities, considering that that is so reduced.

Well, thanks very much, Joyce. This is definitely the most challenging part of the budget as far as I'm concerned because obviously we have big ambitions to be transformative and it's difficult, there may be some instances where we would like to go further. Regional centres, for example, we're keen to move forward on them. There will need to be some capital allocation for those kinds of things, but actually the amount of money we have in place is very restricted. And a lot of that money that is earmarked for capital, some of it has already been committed, because it’s ongoing capital expenditure, and some of it is money that we have to spend in order to keep the show on the road. So, some of the areas, for example, are to do with fire hazards, and you have to spend money on those or you have to shut a hospital. So, there are lots of those things that, actually, are money we just absolutely have to spend, and then the amount that’s left over is fairly limited. So, if there is an area where there’s slight frustration on my part, then it’s definitely in this space.

One of the positives is that we are going to have £50 million capital expenditure for social care and, as you know, it was a key part of our manifesto commitment that we would really focus on social care. So, 50 local community hubs over the course of this Senedd, the integration of health and social care, and the rebalancing of the residential care estate. So, there’s £50 million for that.

Obviously, there will still be COVID recovery investments that we need to focus on, so we are hoping to see a regional treatment centre, such as those being considered by Betsi at the moment. And there will also continue to be a focus on key primary and community care schemes. So, places like Tredegar, Bridgend and Machynlleth. You will be aware of the one in Machynlleth, of course.

The other thing, of course, is the Velindre cancer centre. So, there’s enablement work that needs to be done there. And also genomics. So, what we know is that the way through a lot of future pandemics—. The fact that we’ve all been able to be boosted and all of that development is because of genomics, so we are continuing to invest significant money in that—about £12 million.

Then the other thing that I’m really keen to keep driving on is digital transformation and investment, making sure that we’ve got a 111 system that is available for people, and I’m really keen to see us drive forward with e-prescribing. The limitation with e-prescribing is quite often about personnel and staff and the expertise in the digital space, because, obviously, the people who work in that space are at a premium. But you still need a lot of capital to make all of that work. So, that money is also going in.

Thank you, Minister. There's a lot in there and because we’re short of time, it might be that we can pick up some points in written form as well, but thank you for your answer, Minister. Gareth Davies.

Thank you very much, Chair. I want to talk now about general social care spending. The Welsh NHS Confederation has called for ring-fenced local authority allocations for social care to tackle the social care problems and to have more of a direct, local influence on how those budgets are spent. The Welsh Government says it is directing an amount through the social care formula, but there aren’t any plans to specifically monitor any element of the local authority spend in relation to the funding. So, with that in mind, how can you ensure that the funds deliver on those objectives for social care if you can’t actually monitor what local authorities are actually spending?

Thank you very much. Thank you, Gareth, and obviously this draft budget is very good news for local authorities and for social care. We all know the huge pressure there’s been on social care services and local government has asked for an increase in resource, and this budget does move towards that.

But we do respect local democracy. Local government is there with its own elected people, and we won’t require specific monitoring of local authority spending on social care in relation to this additional money funded through the settlement. But we do continue to collect extensive data, and we publish data on local authority budgeted and actual expenditure, by service area, through our standard data collection processes. We’ve given local authorities the best opportunity to use this funding in the way that will fulfil their own aims with their knowledge of the local area.

We do retain a detailed overview of the sector because, on a fortnightly basis, we have data submitted by the local authority social services departments to provide a social care checkpoint—and this is shared with Welsh Government officials, directors of social services and external stakeholders—which describes exactly what's happening in the social care field. And we get that every fortnight. And on an annual basis, the local authorities' social services are reported on via the performance and improvement framework, and that provides us with a lot of data. So, we get data from wide sources, and of course local authorities are monitored and assessed via the Care Inspectorate Wales inspection plan. So, there are lots of areas where we're able to get information about what's actually going on. But, as I said at the beginning, we do respect local democracy and the local members elected, and so we don't monitor this expenditure in the way that you asked about in the question.

No, I quite agree with that point, and I appreciate that well-informed answer there. Could you possibly provide further information on this new £50 million capital fund for social care? I know we're going to expand a bit further on in the session about the integration, but just to cover for now how that's going to happen and more information specifically on this £50 million and what it will do to strengthen those arrangements. Because from what I've seen, the fund seems to be a bit of a middleman between what you want to achieve and the sector feeling what there is to be achieved by the £50 million. So, how are you going to break those barriers down to ensure that the sector is benefiting from the £50 million and it can be felt on the shop floor, if you like, as well?

Yes, we're very pleased that there is this new capital fund, and the aim is to support the development of integrated health and social care hubs across Wales and the rebalancing of social care through investing in the social care estate, which of course, as you know, is very varied. So, the new capital fund amounts to £50 million in year 1, £60 million in year 2, and £70 million in year 3. And we'll work through the regional partnership boards to ensure that there's an integrated response and to absolutely maximise the alignment of resources across health, social care and housing, because obviously there may be an element of developing some specific housing provision.

So, RPBs will develop investment plans for this new capital fund alongside their plans for the new regional integration fund, which is £144.6 million, in order to maximise the impact, so that the capital and the revenue will be aligned and integrated models of care and delivery can be developed and operationalised. And this is very much being done in partnership, to go back to what you said at the beginning, to be sure that it will reach the places that it should reach. So, we will see those examples coming forward, those proposals, from the regional partnership boards, and we'd be very pleased to keep the committee in touch with the development as it goes along.

Thanks, Deputy Minister. Just finally, what was lacking in terms of clarity in the evidence paper was how those allocations will ensure the stability of social care services in terms of residential and domiciliary care. I'm just wondering if you're in a position to expand a bit more on those areas.

Yes, because obviously this has been a matter of huge concern to us all, and I know you've asked questions about it in the Chamber on a regular basis, and we're all very concerned about the stability of residential and domiciliary care and getting through this really difficult period that we've been in so far. And the funding uplift does recognise this, and obviously we hope that local authorities will be boosting their social care sector in their own budget settings. 

Now, the allocations in our draft budget reflect our clear choice to invest in the social care workforce. We know how hard the social care workers have worked, and we know what a terrible time they've been through, so we really want to help stabilise that care provision and to better support, then, those people with care needs. The allocation of £43.2 million to social care, including £36.5 million in the local government settlement, and £6.7 million to the NHS in the draft budget, is to enable the real living wage to be offered to social care workers in the public and the private sector. I think that is a critical move for the workforce, and I hope that will help provide sustainability and will enable providers to be more competitive in the labour market. It's absolutely essential, as I know you'll agree, that we have a strong social care sector, and I see this budget as a major step forward on the way towards getting a strong and more sustainable sector.

But just to talk generally about the sector—

I'm ever so sorry, Minister. It's not your fault, it's just timings, but just ever so briefly. 

I just wanted to say, basically, that we don't want things to stay the same, we want things to change, and we are planning a national care service which, perhaps, we will discuss at another time. 

Thank you. Albert Heaney, I think I saw your—. If you can be ever so brief, because we've got more questions than we've got time for left. Albert. 

Diolch, Chair. Albert Heaney, chief social care officer. I just wanted to add to the question, really, and the wealth of the answer in terms of the shift around closer partnership working across health, social care and partners, across primary community services to really support people living independently in their own homes for longer. We see that the funding opportunity that's presented here, both in terms of the settlement for local government, but also this new change funding around the regional integration fund, is a real opportunity to have enabling reablement approaches that will help improve independence and, significantly, hopefully, over time, reduce the burden on our health and social care services. I'll pause there because of time, Chair. Thank you. Diolch.

Thank you, and sorry for interrupting on that. Just to give some perspective of time, we've got 15 minutes left and there are three subject areas that we really must cover. Joyce is going to cover some areas around social care workforce, Jack's got questions about unpaid carers, and to finish with, Mike's got questions around the integration of health and social care. We've got about five minutes for each section, so, Minister, I hope you don't mind if Members politely interrupt you if you're not quite getting to the point. I hope that's okay. So, Joyce Watson. Thank you. 

I'm going to ask about the social care workforce. You started by talking about the minimum living wage, but we need to address the immediate urgent need of the severe shortages across the social care workforce, and beyond that living wage. The Trades Union Congress talks about terms and conditions. For example, one of those is sick pay and the other, quite clearly, was the support needed for mental health, which is now in situ, but the sick pay is due to finish. In terms of keeping people interested in working in the social care workforce and those who have dedicated their lives already within it, how are you going to address those needs? And I'm going to add in career progression as well.   

Thank you very much. There's obviously an awful lot in those questions. Just to say that we know that the real living wage by itself will not be enough to support, retain and attract workers to social care, and that we must give urgent attention to terms and conditions beyond this. We have set up the social care fair work forum, who advised us on the living wage, and they are now looking at improving terms and conditions, looking at career progression, and looking at all those other elements that will enable us to attract and sustain the workforce. We believe it's very important that we work in partnership with the fair work forum, which consists of the unions, the employers and Social Care Wales and other interested bodies, so that we can come out with proposals that are acceptable to the workforce as a whole. So, we're using that forum. We're waiting for their recommendations now about terms and conditions and career progression, so that's how we're going to move forward on those other areas. And then of course, on the statutory sick pay, we have helped with that during the pandemic, but that would be coming to the end in March 2022, so I've asked officials to look at what we can do to see if that can be continued, and we'll be able to report back to the committee about that. 

Can I very quickly ask you to look at what Hywel Dda are doing in terms of recruiting some additional social care workers, and the learning from that? They haven't poached the local government employees. There must be some learning from that pilot that they've done, so it might have some value in this area.

Yes, absolutely. I know about what Hywel Dda has done and I know there have been quite a lot of experiments on ways of working and trying to deal with the extreme shortage that we've had. It's meant really close working together. But whatever happens, as you say, we don't want to poach from one area to another. We need new schemes that will bring new people in, and I know that's what is happening in some places.

Lynne Neagle, did you want to come in?

Thanks, Chair. Just very briefly, just to pick up on Joyce's point about mental health. Obviously, we recognise the importance of supporting our health and social care staff with their mental health, and there has been a range of support in place throughout the pandemic to support both health and social care staff. In December, a decision was taken to reaward the contract to Health for Health Professionals Wales, and that, from April, is going to provide support for all health and social care staff. So, just to give you that assurance, Joyce, that we are taking the need to meet people's mental health support needs very seriously in the Welsh Government.

Thank you, Lynne. Jack Sargeant.

Diolch, Cadeirydd. If we can look at unpaid carers, please, and the access to respite and the well-deserved breaks from caring duties, the Welsh Government's budget allocates £3 million for 2022-23. That is the same as this year. It is out there that access to respite has been historically poor. Are the Welsh Government confident that this £3 million is enough to meet the need for access to respite and breaks from care? Perhaps I can ask you how this is going to be achieved as well.

Thank you very much. Absolutely, in the Government, we recognise the huge pressure that there's been on unpaid carers across Wales. We work very closely with carers and with their representatives, with Carers Trust Wales and Carers Wales and the forum of parents and unpaid carers, because it's really important that anything we do is developed in conjunction with the sector.

An additional £10 million from this budget has been allocated to provide a range of support to unpaid carers, and this figure includes the £3 million allocated to local authorities to meet the urgent demand for respite for unpaid carers. I'm very glad that we were able to move ahead and allocate that. A mid-year report of that £3 million shows that a range of new and innovative options are being developed, such as a rapid response respite at home service, day trips, vouchers for young carers, gym membership and the purchase of exercise equipment and outdoor furniture or tablets. They're just some examples of the way the funding has been used, and that is to support more traditional residential and daycare respite services.

The indicative funding of the £3 million is intended to build on this work. A lot of the work has been done about indicating what are the sort of things that will help to give respite. We'll deliver, of course, our programme for government commitment to fund a short break respite scheme. I've got a ministerial advisory forum that advises me about the best way to achieve the best outcomes for unpaid carers. We'll also be informed by the report that I commissioned from Carers Trust Wales, which sets out a new vision for respite and short breaks in Wales.

I hope we will be able to transform respite provision in Wales, because it's so important that we provide opportunities for carers to take a break. But, of course, it's not the only funding that will be available for this. This is specific extra work. Local authorities receive substantial financial support from the Welsh Government through the local government settlement, and this, as we've discussed earlier, is hypothecated funding, which offers flexibility to the authorities to prioritise their services locally in line with their local communities, which, of course, includes unpaid carers. 

In addition—and finally, Chair—regional partnership boards will be expected to invest a minimum of 5 per cent overall of the regional integration fund, which is over £4 million over three years. So, this £3 million is very welcomed and very important, but, of course, it's only a small bit of what we are able to give to carers as a whole. 

Thank you for that very detailed answer, Deputy Minister. I was going to delve into some of the financial assessments behind those decisions in the budget allocation. I don't think we've got too much time for that. Perhaps we can have sight of those in written form if that's available. 

Yes, of course. We'll let you have those if they are available. 

Diolch. Thanks, Chair. 

Thank you, Jack. Thank you, Minister. Mike Hedges. 

I want to talk about the integration of health and social care. I think of them as a continuum rather than cut-off points. Can the Minister tell us the exact figure to be allocated to the new social care regional integration fund? How will schemes be integrated into the main stream in future years, and how will it be scrutinised?

Shall I take that, Julie, and you can add some bits? Is that okay? The total amount is £144.6 million, and, of course, what we've done is we've taken the previous funding pot for the integrated care fund, the transformation fund, but also the dementia action plan fund and the emotional health and well-being fund. We've amalgamated them all and we've put them all into that new integration fund. Obviously, I agree with you; I think it's a continuum, but what we've got to do is to create the facilities and the opportunities and the ways of working, and I think the regional partnership boards are a real opportunity to do that. 

There is a major difference in terms of the way we've done things in the past, because there'll be a focus now on embedding six national models of care. Also, one of the things that we were a bit concerned about before is that, actually, there was a lack of continuity and a lack of ownership by the health boards and the local authorities. So, this time, we are saying that you have to match fund here in order to mainstream services that we know work well. There's also going to be dedicated support for the regional partnership board infrastructure costs, but also, a clear exit strategy, because what we find is that they'll say, 'This is fantastic, we love this. It's really working well; just keep on spending, just keep on giving us this new money.' What we're trying to do is to change the way they do things at the moment, so they need to be shifting their ways of working, but we just need to give them a leg up on that journey. 

And just in terms of the governance and scrutiny and things, we are very keen to make sure that we've introduced a work programme. It's got some key work streams, including governance, including scrutiny, including planning and performance, including citizen engagement. So, all of those things are there and in place. I don't know, Julie, if you've got anything to add to that.

I think you've mainly covered it, but I think the important thing is that we want to strengthen the RPBs and make sure that integration really works. We have got a lot of experience now of the previous projects, so that we have learnt from the two different funds that we had operating before, and that the new integrated care and transformation fund will produce models where we've learnt from what's happened in the past.

Thank you, Julie. Mike, do you have any further questions?

No. Thank you.

Rhun ap Iorwerth.

Just a very straightforward question from me, relating to the voluntary hospices funding review. I understand that discussions have been pretty positive from the point of view of, certainly, the children's hospice sector, but they haven't yet seen anything on record about additional funding that could or hopefully will be made available. Are you able to shine some light on that today?

If you don't mind, Rhun, I'll be making an announcement on this imminently. So if you can hold on, and there will be some positive news, I hope, very shortly.

Wonderful. We'll claim credit as a committee for encouraging that statement to take place soon.

That's right. When will you be likely to make that statement, Minister?

I'm hoping in the next week.

Okay. Thank you.

You have to now. [Laughter.]

I will.

When next week? What day?

Oh, God. Russell. [Laughter.]

No, I'm joking. [Laughter.]

Right. Okay. Thank you, Minister, thank you for that. You've kindly agreed to just 10, 15 minutes on anything that Members may have on the current COVID pandemic and the current situation, so, grateful for that, Minister. Can I just ask—? From my perspective, the pressure obviously at the moment, and the concern, is the pressure on the NHS with higher levels of staff sickness or being away from work. Now, I just want to clarify, in your statement on Tuesday, you said that 8 per cent of NHS staff were self-isolating from COVID-19. That seems to be the overall sickness absence rate, as I understand. Can I just confirm what the percentage of NHS staff is that are currently self-isolating, are sick with COVID-19 or absent for other reasons? And I can see Judith wants to come in as well. Minister.

Yes, sorry, that was the overall figure. So, it's about 8 per cent and that reflects about 10,000 staff off. But that does include other sicknesses as well. I know Judith can give a bit more detail on the breakdown of where exactly—who's off with COVID, who's off with other things.

Thank you for clarifying that, Minister—grateful. Judith.

Thank you, Minister. Thank you, Chair. So, the overall NHS absence rate at the moment is 8.3 per cent. That is broken down as follows: COVID sickness is 2.3 per cent; self-isolation is 1.4 per cent; and other sickness is 4.6 per cent. Those figures came into Welsh Government on Tuesday, and relate to the previous seven days. Just to say, that rate is reasonably stable from the week before, so that's positive. What the average does mask, of course, is that there are some organisations with much higher and some with lower, and I'm still waiting for the breakdown by individual organisations. But I know, having regular contact with health boards particularly, and trusts, that they are struggling with staffing in some areas.

How does this rate, Judith, compare to 12 months ago and perhaps two years ago, if I can ask that, if that's possible—before the pandemic?

I haven't got the actual data in front of me—

I appreciate that.

—so it probably would be wrong for me to try and give you any accurate information. But in terms of a year ago, it's probably there or thereabouts in line with what it was like in January of last year. In terms of January 2020, which was pre-pandemic, usual staff sickness absence in January is usually around 5.5 per cent, maybe 6 per cent. But of course, there is variation in that as well, so I'd give that caveat around that.

No, I appreciate that. Thank you, Judith. Any further questions from Members? Joyce Watson, I think you had a question. You're off mute; go ahead, Joyce.

Right. Okay.

Mike as well.

I don't have another question.

Oh, sorry. If it comes back to you, Joyce, that's fine. Mike Hedges wanted to come in. Mike Hedges.

Thank you, Chair. I was talking about COVID variants. We've had thousands of them, which is inevitable with a virus. We've had 12 of them that have been serious enough to be named. Does anybody know where we are with variants that are in existence in other parts of the world now, and if any of them are as infectious as omicron or are as deadly as delta?

We keep an eye on this, Mike, and we get regular reports in relation to new variants. You will have seen that there was a variant of concern, or I don't think it was officially stated as a variant of concern, in France recently—there was a little concentration there. But we've looked into that and it does look like omicron, and even delta before that was outcompeting it. So, that was something where—. We just keep prodding a lot of these things.

I think we had about 15 cases in Wales of a variant of concern that wasn't delta, from India, but, again, there was no further transmissibility and omicron seems to be outcompeting everything at the moment. And that's not to say that there won't be a new variant of some sort somewhere in the world, but omicron at the moment seems to be outcompeting everything. So, we've seen lambda in South America, that's been something we were concerned about and kept an eye on.

But the key thing is: does the variant we have now, can it outcompete those? And that seems to be the pattern at the moment. It's going faster and faster, as you can see. The issue then is: is it possible—? If you see changes to the protein spike, that's the time to start getting worried, so that's why I was a little bit concerned about the variant in France, because there were lots of changes to that one, but nobody seems to be concerned about it.

Thank you, Minister. Gareth Davies.

Am I muted? I think so.

You're free to go.

Thank you. I'm just wondering if the Minister's got a response to a specific area around in-patient mental health and some of the COVID restrictions for in-patients specifically. Because I've been contacted recently by a constituent whose relative is currently an in-patient in a mental health setting and some of the detriments that self-isolation has to mental health patients who are recovering in hospital, because a large part of their programme for rehabilitation is social interaction, is getting out, it's engaging with social groups and adding some degree of normality to their day and their schedule. And that's been a little bit undermined by the pandemic recently, to say the least. I'm just wondering: is there any scope to review this at some point in order to allow acutely unwell mental health patients to effectively recover from their illnesses?

Is that Lynne, or does the Minister want to come in on this? Lynne Neagle.

Thanks, Chair. Yes, just to say that, obviously, the deteriorating situation we were facing has had an impact on people in in-patient mental health hospitals in terms of visiting and in terms of access to outdoor visits, et cetera. But I understand that we did issue guidance this week to the NHS to try and help with this situation and I'll just bring Tracey in to add some more details to that very important issue.

Thank you. Thank you, Minister. Yes, you're absolutely right, this was an area that all of the health boards were looking at because they absolutely recognise the importance of leave to, obviously, recovery and treatment. So, as the Minister said, guidance issued yesterday, so we can make sure that the committee has sight of that guidance, and that's intended for there to be a national approach to leave and group work, and also then that it's aligned with things like care homes' visiting guidance and so on. So, that's what we tried to do there. But we'll share that with the committee, with your permission, Minister and Chair.

Thank you. Joyce Watson.

Sorry, Chair. My question is: there's a big focus on omicron, and quite rightly so, because of the infection rate, but delta is still around. Do we have—if you don't have it now—any indication of the numbers of people who are in hospital with delta, as against the numbers of people who are in hospital with omicron? Because we all know that, from every evidence so far, delta seemed to affect people more severely if they had underlying health conditions than it appears that omicron does.

My other question in this area is: the PCR testing has disappeared because the UK Government have decided that people who are entering the country no longer have to take a PCR test, and how we're going to be aware of—and it follows through the previous question—any variants that might enter the UK, thereby Wales. Are we now depending on other countries to notify us that they have a new variant, and have we sort of passed the buck, or have the UK Government passed the buck to other countries to do the job that, in my opinion, we should be doing? And if that is the case, how concerned are you?

Thanks, Joyce. I'm going to ask Judith to come in on the omicron and delta hospitalisations. But just on the PCR side of things, we've been really clear, right from the beginning, with the UK Government that we thought it was a mistake to dismantle PCR testing when people returned from abroad. Unless you do the genomic sequencing, you can't tell what's coming in. So, we thought it was a mistake. It's unlikely to stop things from coming in, but what we could do is to slow things down, and that makes a big difference. If you're able to vaccinate people, as we were able to give the booster, that extra couple of weeks really allows you to protect the public and the population, and we're starting to see some very interesting statistics now in terms of hospitalisations and things, as a result of that booster programme. Our booster programme in Wales was phenomenally successful—more successful than anywhere else in the United Kingdom in terms of speed of roll-out. What's happening now—. We had to agree this reluctantly, as you know, because we've got this border situation that we can't—. People fly into the United Kingdom generally. What happens now is that you take a lateral flow test on day 2. If that is positive, then you automatically go for a PCR test. So, you will have to do a PCR test, but all of this is based on trust, and it's based on people doing the right things, and what it does do is to delay the process by a couple of days. And the real tragedy here is that the United Kingdom is really, really good at genomic sequencing. We're one of the best in the world. South Africa took about 21 days to do the genomic sequencing, by which time it had gone all around the world. Even Hong Kong took about nine days. Had we had this protection in place, we could have seen it earlier—I've got no doubt about that.

Thank you, Minister. Sorry, I don't have any assessment of the absolute breakdown of omicron versus delta or other in hospitals. What we are paying close attention to is the number of patients in hospital who are there because of their COVID-19 symptoms and conditions and those who are in hospital for other reasons who just happen to have COVID-19. So, that data is available.

In relation to omicron itself, the committee will be aware that just before Christmas it was by far the dominant strain in Wales. The genome sequencing being undertaken was detecting it. The estimates were that about 80 per cent of the cases in the community were omicron. So, from that point of view, I think that will certainly translate into hospital admissions, because some of those patients who are attending for other reasons who have got COVID-19 will most definitely be omicron COVID as opposed to anything else. So—

Can I, Chair—? You say 'most definitely', but we don't know, and I'm just wondering: why is it we don't know? Are we going to find out the difference between delta and omicron? According to everything we're reading and being told by the experts, the likelihood if you have delta affecting you as an individual—should you already have any underlying conditions or age as a factor, it could present a potential greater risk of harm to you as an individual.

Thank you, Joyce. Just briefly, Judith. I think we're a little over time.

I was going to say, with the Chair's agreement, if I can check that out with colleagues in Public Health Wales and come back to the committee on that specific point, I'd be happy to do so.

Thank you ever so much, Judith. Appreciate that. Any more Members got—? I've got Rhun waiting. Anybody else? I've got one question myself. No. So, Rhun, and then myself, and then we'll end the session. Rhun ap Iorwerth.

Thank you, Minister. Just one final question from me: during the scrutiny of the First Minister session last month, in December, the First Minister said that some modelling was showing that, in January, half the UK population could be ill with COVID. Do we have an update on the latest modelling in that regard?

I know that, in London, about 10 per cent of the population are ill with COVID, and in Wales it's about 6 per cent. So, that's a significant difference. And, obviously, we're hoping that we're coming to the peak now, and if we arrive at a peak of 6 per cent and they're at 10 per cent, then actually there is real cause to celebrate. So, that is a snapshot that you can look at. We are clearly keeping a very close eye on the data at the moment, but there are some very positive signs, I'm pleased to say, in terms of us possibly turning the corner, which would be a huge, huge relief.

Thank you, Minister. Any officials got anything to add in terms of the modelling at all? No. Okay. Thank you very much. Well, diolch yn fawr iawn. Can I thank the Ministers and officials for your attendance this morning? I greatly appreciate it. We've got a couple of areas to pick up in written form that we'll clarify, but thank you ever so much for your attendance and time this morning. We're going to move on to our next item. You're welcome to stay, but feel welcome to disappear as well. Thank you very much. Thank you, all.

Moving to item 3, we have a vast amount of papers to note. We're clearly a very popular committee. I'm not going to read them all out, because it will take too much time, but they are in the public pack. Some of them we're discussing later on in our meeting in any case, but are Members content to note the papers in the public agenda pack? Thank you. Diolch yn fawr.

I'm happy to note, Chair, but would like to make sure that we have a discussion at some point around the letter from the First Minister on 14 December regarding the COVID inquiry.

Yes, absolutely. I think we've got some time scheduled for that later in our meeting, so we'll absolutely do just that. Thank you, Rhun.

Okay. I move to item 4, and I propose, under Standing Order 17.42, that the committee resolves to exclude the public from items 5, 6, 7 and 9 of today's meeting. And if Members are content with that, it will just mean that we come back into public session at 1 o'clock for our evidence session on waiting for diagnosis or treatment. That will be between 1 p.m. and 2 p.m., which will be a public session. But are Members content with the other items? Diolch yn fawr. Thank you very much. In that case, we'll go into private session, please.

Good afternoon and welcome back to the Health and Social Care Committee. I move to item 8. This is a session in regard to our work on the impact of the waiting times backlog on people who are waiting for diagnosis or treatment. We have an evidence session this afternoon and I'd be grateful if our witnesses could introduce themselves for the public record.

Good afternoon, thank you. Hi, my name is Sue Hill. I'm a consultant vascular surgeon. I work at the University Hospital of Wales and I also represent the Royal College of Surgeons, having been their previous vice-president. Thank you.

Good afternoon. Thank you, Chair. My name is Jonathon Holmes. I'm a policy adviser at the King's Fund. We are an independent health and care think tank, based in London, and our work focuses on England.

Good afternoon. I'm Danielle Jefferies, an analyst also at the King's Fund, and I work with Jonathon on analysis of the elective backlog in England.

Thank you ever so much for your time with us this afternoon, we greatly appreciate it. So, Members have got a series of questions and the first set of questions is from Rhun ap Iorwerth.

Sorry, just to check, Sue, are you okay? Can you hear the Welsh translation?

I'm not getting—. I got it earlier. Let me just try again.

If you go to the globe at the bottom and you click on to 'English', you should be able to hear.

Done it.

Lovely. Stop Rhun if you can't hear it. If he doesn't see you shouting and waving, he'll assume you can hear.

Fantastic. Thank you.

Thank you. They certainly support the concept and, as you'll be aware, they have actually put money aside in order to help the Welsh health service get through the COVID pandemic, but not specifically on that point—as far as I'm aware, in any event.

Okay, so let's try to drill down into what is not being done, still. So, what measures, at this point in time, are not in place to support people waiting for treatment across Wales?

Be aware that I work in Cardiff, and things in Cardiff are different to what they are in other health boards around Wales. So, a lot of the information I get from the other health boards has come through our members. So, to some extent, it’s anecdotal because the data’s not there.

If one is waiting a long time—longer than one expected—to have what we describe as routine elective surgery, it doesn’t necessarily mean that you’re not in a hell of a lot of pain and your day-to-day living is not entirely different to the way that you’d like it to be. So, in Cardiff, we’re able to contact patients and talk to them and reassure them that they are actually on the waiting list. In other parts of the country, I’m not sure that’s happening. But that needs input and it needs people, and one of the points that perhaps I can move on towards is that one of the issues in the NHS in Wales, even before the COVID pandemic, has been related to workforce. And that's workforce not just within the NHS and the hospitals—the doctors and nurses—but also in social care. We have a chronic workforce issue here in Wales. We have a lot of vacancies, and that, actually, has been made worse now by the pandemic with issues around self-isolation and having to take time off work, which obviously makes a difference to the number of people one can put on the ground, but also to the fact that we’re trying to separate COVID-free zones from zones where a patient might be a risk of COVID. We’re stretching a very small workforce.

Yes, it is something you have been incredibly consistent on throughout this pandemic. So, if we look at the measures that need to be put in place, and it’s clear you don’t believe they are in place, most of those could be addressed if there were more people there to do it. The crux of the problem is the workforce and weaknesses in the workforce.

Yes, I think that’s correct, because what the Royal College of Surgeons have been calling for, primarily, at the present time, has been what we call 'surgical hubs'. So, we want pathways through which patients who have been tested and are COVID free can come into a COVID-free system, get their surgery done by COVID-free staff and get out the other side, so that we have a protected, safe surgical pathway. And we can do that. We can do that in Wales. We’re doing it at the moment in Cardiff. We have what we call a 'hospital within a hospital' in Cardiff, which is a COVID-free area and is allowing us to do pretty complicated surgery—highly technical surgery, cancer surgery and so forth—and also we have other less-complex facilities where we can do the high-volume, low-technical aspect surgery. But, in order to have these COVID-free zones we need, almost, to have a second workforce compared with what we started off with. So, how do we put that right in the short term? It’s incredibly difficult to put it right in the short term because doctors take five to 10 years to train and nurses take three years. What I think we need to do in Wales is to have co-operation across the health boards. We need to have regional solutions rather than individual-health-board solutions.

Maybe that speaks to the problem that we’re facing here. You’re talking about making sure that we have a workforce that is able to do all this work of clearing the backlog, and having that workforce almost work side by side with the workforce dealing with COVID. What we’re looking at in this inquiry, I guess, is the other workforce needed to look after the people that are waiting. We all want to get to that point where they get treatment as quickly as possible, but, unfortunately, it’s taking a heck of a long time, currently. We need people actually looking after the patients as they wait, don’t we? Psychological support, pain support and so on.

We certainly do, and that workforce is not really there. We’re reliant on charities. We’re reliant on a lot of charities to give patients the psychological support and help in and around their homes. We do not have a workforce within the NHS at the moment to be freed up to help people psychologically, or perhaps with their day-to-day activities. It's not there, I'm afraid.

That's really useful. Shall we just compare quickly at a high level with the situation in England, then, Jonathon or Danielle? What is being done in England in general terms? What steps have been put in place to make sure that there is care for those people whilst they are waiting, be it with pain management or psychological support or whatever?

Good question. A lot of the issues that Sue was referencing there, some of the limiting factors around workforce capacity and infection control, are absolutely ones that I would recognise and echo. I think in terms of looking at the ancillary support, the psychological support for people on waiting lists, that is something again that, because of all of those issues around that 'stretch the workforce point', that kind of fraying around the edges of the resource, often isn't there. There are lots of examples where integrated care systems or hospitals have developed really great relationships with the voluntary sector organisations or the NHS using volunteers themselves to bridge some of those gaps, but there's an awful lot of variation in how that happens. It's something where there are plenty of examples out there, there are places where it is being done really, really effectively, but there are an awful lot more where it isn't, and that's having all those implications again, like Sue talked about—people living in pain, with the anxiety that comes from a persistent or a long wait, the impact on their ability to work, the impact on mental health, and that backlog just growing and growing as a result of it.

Is it an issue that is being addressed enough, or is it a side issue, as appears to be the case in Wales, where the main act is actually concentrating on getting people into treatment? Is there a piece of work that's been done nationally in England to look after people whilst they are waiting?

Not that I am aware of. I don't know if Danielle has any insight on that.

Not that I'm aware of, either. I think it's the same issue of workforce capacity. At the moment the workforce are dealing with so many different things at once—so, the usual winter pressures, now there's COVID, and now the elective backlog as well. There's just not enough staff to stretch to all of those demands.

Thank you. I know Members will have more detailed questions, but that's very useful to start us off. Thank you. 

Thank you, Rhun. Can I just pick up Sue Hill's point on the regional surgical hubs? It's Welsh Government's position to support regional surgical hubs, but there seems to be some delay in moving forward with this. Why is that, and what should the Government do?

The college of surgeons talked about this to the Government, and the Government in England as well, at the beginning of the pandemic, and in general it's a no-brainer. Most politicians would of course look at that and think it must be a good idea to put in place a COVID-safe situation where patients can be moved through to get the waiting times down and keep them down. One of the problems I perceive is that these things are not mandated—they are suggested as a good idea. If you go to Cardiff and Vale, we have a big infrastructure, we've got a big hospital, and we also are luckier in south-east Wales than in other parts of Wales because there are some small private providers. There are more small private hospitals around the Cardiff area than other parts of Wales. But we also have a big tertiary referral centre, so we've been able to do two things in Cardiff. The first thing we've been able to do is build what we call a hospital within a hospital, which essentially means that we've got an area of the main university hospital that is shut off and kept clean with respect to COVID infections. And that means that we're able to do what we call the priority 2 patients, the life and death stuff. So, in Cardiff, we can keep going with the colonic cancer resections, the really big, serious, life-threatening surgery that I wouldn't be happy doing in a small private hospital or a small clinic to the side of the hospital. Because, with the hospital within a hospital, we have the facility to get intensive care doctors down, we have the facility to get the physicians seeing patients, so we can deal with the complicated unwell patients. 

Similarly in Cardiff, we've been able to utilise parts of the day surgery unit to run through what I would describe as high-volume, low-complexity surgery, such as gall bladders and inguinal hernias. So, those can be done fairly safely. Many of the other health boards around the country do not have the facility to do that. To some extent, Swansea is in a good position, because they have multiple relatively large hospitals, and they have tried to set up a surgical hub in Neath Port Talbot. But they're running into problems there because they don't have the facilities to look after the complicated medical patients who have a surgical condition. But in other parts of the country, there isn't the facility to do it. I know Betsi Cadwaladr haven't been able to do anything like this at all. And, more importantly, we can't do some of the cases that need an in-patient stay unless we have a good bed base. So, why isn't it happening in Wales? It isn't happening in Wales in various parts of the country because it hasn't been mandated. I think, with respect to politicians, they have said it's a great idea and then they haven't pushed it. The other problem—

So what does the Welsh Government need to do?

I would suggest that what the Welsh Government needs to do is to get the chief executives of all the health boards in the same room and explain that we can't do this just on a health board basis, we have to have a bigger regional solution. So, Cardiff and Vale can help Cwm Taf, Swansea can help Hywel Dda. We need to have cross-health board solutions for this, and we're very much at the moment concentrating on doing our own thing in our own health board, which is not fair for the patients, because if you're a patient living in Cardiff, you have a greater opportunity to get through the system because we have the infrastructure there. If you're living in the middle of Powys, it's a different matter, I'm afraid. I hate to say 'postcode lottery', but there is an element of postcode lottery in this. 

Jack, you wanted to come in, I think, on this. 

I did, Chair, but my question has already been answered following that, so it's fine. 

Thank you, Jack. I think, Sue, what you're suggesting is that this is mandated from the Minister rather than the Minister relaying the message or asking health boards to bring forward their own solutions. Have I got that right?

Yes. I've spoken to health Ministers in Wales for a long time now, maybe 10 or 15 years, and I get the same answer all the time, which is: 'We set the policy and then we leave it to the health boards to enact the policy.' I'm afraid that sounds good but, in this situation, it doesn't work. You need to call the chief executives in and mandate that they do this cross-border collaboration. 

Joyce, you wanted to come in. 

Good afternoon, Sue. Whilst I don't disagree with anything that you've said, there is another element to this, and that's the public. If you say that, for example, you're going to have a regional health board and all people who have a certain procedure have to travel—and I live in Pembrokeshire, just to give you an idea of where I am; it's 30 miles to get out of here before I go anywhere else. The first thing that would happen if you were to say to people, 'Well, you can't have this here now, you need to go 40 miles away', which is not unrealistic where I live, and I cover Mid and West Wales—then you get the pressure that is put on by those individuals who don't want to travel, those individuals who can't travel, which is a realistic part of what we're talking about. I'm putting it back to where it belongs on the ground, and the reactions that I've seen repeatedly. So, it's about managing expectation. That's really what I'm saying. 

These are all valid points by Joyce. I'm just conscious that mine was a supplementary to Rhun's, and yours is a supplementary to my supplementary, so we don't want to—. I'm just keen not to go too much off track. But Joyce's points, of course, are valid. Do you want to comment on Joyce's comments there? 

If I may. I've heard that argument many, many times, and not just in Wales but in more rural areas of England, and it's a valid argument. However, firstly, with education, you can talk to members of the public and explain to them that there are better outcomes from units where one performs the highly complicated surgery in volume. I'm a vascular surgeon, and the evidence is absolutely clear that if you have a vascular surgical condition, your outcomes—the chances of keeping your leg or staying alive—will be far greater if you are prepared to travel to a high-volume centre. And that's why, in your corner of Wales, most of the arterial interventions are performed in Swansea, whereas when I first came here 20, 25 years ago, vascular procedures were being performed in Aberystwyth and out into Carmarthenshire. The results were just not good enough. So, that's the first thing.  

In my notes, I have something from our college office. We actually did a poll, carried out by Savanta ComRes, about whether Welsh patients would be prepared to travel, and we got about 66 per cent of adults in Wales saying that they would be prepared to travel if they thought they were going to get a safe operation in a COVID-free environment. I know there is that desire to stay local and to have a local hospital that gives you a good service—of course there is, who wouldn't want that—but the fact is the outcomes from surgical procedures are better, when they're complicated surgical procedures, in a higher-volume centre.  

Thanks, Sue. My next question is to any of the panel members. I just want to understand a bit more about the research behind waiting lists, and to understand the extent of how much surgical activity was affected by the pandemic, but also the extent of any hidden groups that we don't know about as a result of the pandemic in relation to waiting lists as well. I'm looking to any of the panel members to address that point. Jonathon.  

I'd be happy to come in on that point, Chair, and Danielle might want to follow up, I don't know. But just to reflect on some of the research that Danielle and I undertook, we looked specifically at the elective waiting list in England, looking at how it had grown over the course of the pandemic, taking a reference period of April 2020 up to July 2021, because of the limitations of the data. Unsurprisingly, as was well reported at the time, the waiting list had grown rapidly. It's now approaching approximately 6 million in England. That's a growth of around about 50 per cent over the course of the pandemic. Danielle and I were interested in looking at how inequalities may exist within that. We first of all looked at how growth in the waiting list had varied by socioeconomic status of local areas, so looking at the measure of the index of multiple deprivation, and we found that in the more deprived areas, waiting lists grew far, far more quickly. In the least deprived areas, they grew but at a far, far slower rate. 

Now, part of that is something that you wouldn't be too surprised by. But when we looked at length of wait, that's where the concern, and some of our worries, start to come in—that people were far more likely to wait over one year in a more deprived area. So, you are approximately twice as likely to wait over one year for an elective treatment in one of the poorest parts of England, compared to the wealthiest parts.

Now, a lot of the focus in England on tackling the backlog has looked at doing it in an inclusive way, so trying to focus in on groups that are experiencing the worst health outcomes. Now, at the centre, national bodies aren't taking an approach of saying, 'It is specifically these groups', but are leaving it up to local areas to identify in their populations the groups that are most exposed to inequalities and worse outcomes as a result of waiting longer for care, which, very broadly—and I'd be happy to go into more discussion about this—seems like the right approach to me. 

Thanks, Jonathon. You threw up lots of questions there, but I'm just conscious of time, actually. Mike Hedges.

Thank you, Russell. You talked there about the longer waiting lists in England of people in the more deprived communities. Do you see any reason why that would not be replicated in Wales?

I would anticipate that the patterns you would see in Wales would be similar. I say that on the grounds that what we know about inequalities and health more broadly would be things that, of course, would translate to Wales. So, I think there would be a lot of the same underlying factors driving it, yes.

I'm glad that you said that because I agree entirely with that. It was just over 50 years ago when the late Julian Tudor-Hart produced his seminal paper for The Lancet on the inverse care law. We've spent 51 years not making a huge amount of progress in that area. I won't ask you to comment on that because that would be getting vaguely political.

What I would say is: is some of the reason why people are waiting longer in poorer communities not just because of the way that the health service is run, but the fact that it is relatively cheap for people living in middle-class areas to pay £3,000 or £5,000 for a cataract, and so they are prepared to go private, whereas for some people, that £3,000 to £5,000 would be a third of their take-home wage for the year?

So, I would stress that in the analysis that Danielle and I undertook, we didn't look specifically at this point, but we do know that there is a correlation between levels of deprivation and private sector capacity. So, there is more space, and you did refer to the idea of there being an inverse care law, which tends to mean that there is greater capacity in the areas where, actually, it's needed less. So, I think that all of that is kind of playing in here. Again, it's beyond the confines of the analysis that we did, but I would think it would stand to reason that the wealthier you are, the more affordable in real terms private treatment is. I think that's sort of a logical truism, almost. 

I represent Swansea East, which in English terms could quite happily be east Newcastle or central Stoke or Coventry South East or any of those areas. What has to be done to ensure that those from the most deprived communities get equal treatment, i.e. they wait the same length of time as those in the more affluent areas?

So, that is the million dollar question, really, and I think that's where a lot of the policy focus, at a national level in England, has been, as attention has started to turn to tackling the backlog that COVID has—as many of its legacy effects, thrown a really, really stark light on the issue of inequalities in health. And so, as we're looking at hopefully returning to a period of recovery, how that's done inclusively and in a way that minimises the inequalities that we're talking about has been a focus.

I was saying that NHS England have deferred a lot of the practicalities and the specifics for how that works to local areas, to integrated care boards, which gives them the latitude to identify the population groups most in need in their area. The national policy initiative is called Core20PLUS5, and so that sets a very loose framework for integrated care systems to go ahead and look at. So, the 'Core20' would be the most deprived 20 per cent, then the 'PLUS' would be other groups exposed to health inequalities above and beyond the prevailing trend, and then the 'PLUS5' would be on the core clinical areas. So, they would be on neonatal, on cancer care, on cardiovascular, and mental health as well, I think. So, that's broadly the approach.

Thank you. Sorry, Danielle wants to speak.

Yes, I'd just like to add to Jonathon's point about how we can tackle some of these inequalities in the backlog. So, what we found in our analysis is that there is a trend between deprivation and longer waiting lists, but we also found that it wasn't the case for all trusts. So, there were some clinical commissioning groups in more deprived areas that were managing their waiting lists well, and from speaking to those trusts, we found that some of the way they are doing that is, back to what Sue was saying, about collaborating across providers and across systems, so sharing resources, sharing capacity, and that's one of the ways that they're managing their waiting lists, despite being in more deprived areas.

Thank you. That was very helpful. And it might be in some of the papers I've read—I've read so many papers for today—but you talk about 'more likely to wait longer in deprived areas' of 1.8 times. Have you got a range for that, as in, it's an average of 1.8. Does it vary between 1 and 2.83, or is it all very close around the mean?

So, our analysis split the CCGs into quintiles, so, 20 per cent. So, that 1.8 times per cent is the difference between the most deprived and the least deprived 20 per cent. So, the most deprived 7 per cent of people were waiting over a year, compared to the least deprived, where 4 per cent were waiting over a year.

Sorry, I didn't express myself very well. I was talking about the fact that—. I know what you're looking at there. You said some areas are doing better, and the 1.8 is the mean, yes? I was just wondering what the range was. I suppose you've got a standard deviation for it as well somewhere.

I think that might be beyond my recall specifically, but it's certainly something we could get to you. But we did publish alongside that data on how much the waiting list had grown, and there was a vast variation in that from some areas, growing by 10 per cent up to 90 per cent at the other end. But in terms of the inequalities issue and the quintiles, it was very much a systemic relationship. So, while we broke them into quintiles, you can see that as a clear relationship between each group. But I can return to the spreadsheets and get back to you with some additional numbers, if you wish.

I would like that. Sorry, Chair, one question I've got to ask you, as a former researcher: why do you use quintiles rather than deciles?

That's a good question. So, we looked at quintiles because the number of CCG areas that we had to exclude because of various border changes over the course of it, and how the data was recorded and mergers within some trusts, meant that outlier data points confounded it. So, it was a data issue, and a presentational issue as well.

Thank you very much.

Thanks, Mike. Did your research only look at deprivation, or did it look at other factors, such as whether older people or women are waiting for longer periods of time?

No, we didn't look at that. So, at a national level, the main way to break down the elective backlog is by deprivation levels, so you can link an index of multiple deprivation with CCG, so that's the way we've broken it down. It's more difficult to link things like gender or age to an individual CCG, so we've just done it on the index of multiple deprivation for a CCG.

Thanks, Danielle. Gareth Davies.

Thank you, Chair, and good afternoon to the panel. We've already touched, really, a lot on the independent sector and private hospitals, and I won't repeat what's already been said for the sake of it. In terms of those who do not have the option to pay private and those who have received private care, but probably funded it through means such as life savings or getting into debt, and perhaps it dictates an alternative lifestyle to what they'd initially hoped for—I think they can be probably considered to be in a similar bracket, because I've seen cases of people who are elderly people, and they might think, 'Hey, I've only got another 10 years left in this life, and I want to live those days in comfort, so I'm going to take this decision to go private and to jump the queue', if you like.

So, in terms of a question of where the sectors can work together, the NHS and the private sector—because, more often than not, the recipient of the private healthcare and the NHS are probably seeing the same doctor, it's just a case of how quickly this person is seen and dealt with. So, what do you think can be done across health boards in Wales to ensure that people receive NHS treatment in the private sector, or there's a little bit of joined-up thinking and they can meet each other halfway, slightly? Do you think there's any way that that could be achieved in tackling these problems long term, and certainly post COVID as well?

Is that addressed to me? Before I answer that question, can I just make one quick point related to the last question? And that is: if you look at the scale of the problem that we've got now with waiting lists in Wales, compared with the scale of the problem in England, it's an entirely different ball game. In Wales, in October, there were about 680,000 people waiting for hospital treatment, surgical treatment. That's out of a population of around about 3.5 million. So, that equates to almost one in five people in the Welsh population waiting for some sort of surgical in-patient treatment. You go to England, and even though in the news today they've been saying that in England there are now 2 million people on the waiting list, that only equates to about one in 25. So, we have a massive problem in Wales compared with England. That's the first thing.

And then, in answer to Gareth's question, yes, in Cardiff, over many years, when we're coming towards the end of the financial year, when people are looking at how many people are on waiting lists, we have used the private sector as a sort of emergency fire stop and we have thrown money at the system, particularly with respect to orthopaedic patients. So, always at the end of the year, all the while I've been working in the Welsh health service, we have done that. We have spent hundreds of thousands of pounds on getting the long-waiting knees and the long-waiting hips done, paying consultants over the odds for doing it in the private sector, and I've said to the last three health Ministers that I think that is the wrong way of doing it. I mean, I love to be paid. Great, pay me extra money for coming in Saturday morning and operating on these long-waiters. What we should be doing is building capacity in the NHS.

And again, on that issue, of course it's very tempting to say, 'No, these patients must be done, let's do them in the private sector', but we haven't got a big enough private facility in Wales compared with England to do meaningful volumes of work to use it as an overflow. And when we do things—. For example, as I said earlier, I have been doing lists for the NHS in St Joseph's Hospital. We're paying top dollar for those lists. St Joseph's Hospital are not giving us those lists for charity. We're paying over and above the odds. The only way to deal with this is to build capacity into the national health service, in my opinion.

Thanks for that answer. I do agree with what you say in terms of building on NHS capacity and, no, I'm not suggesting for one minute that we go the other way. I'm just trying to open the question up to—

I wasn't trying to beat you down or anything, I'm just trying to explain.

Yes, of course. I just didn't want there being any confusion as to what I meant there.

You did touch briefly there on the cross-border working. I'm a Member in north-east Wales, as is Jack Sargeant as well, so I've seen constituents of mine go over the border to receive private healthcare in places like Chester and Cheshire and Merseyside and wherever else to receive those treatments. So, we've not been able to capture those people in Wales, so obviously something's going dreadfully wrong here, isn't it, in that people feel that the care that they need isn't available a few miles down the road in Glan Clwyd or Wrexham or Bangor or wherever?

The private system is great. So, if I have a lot of spare money in my bank account and I would like to sit in a private room and have nicer meals rather than go on my Spanish holiday, it's fine. It's a lifestyle choice if I choose to have my hip replacement in the private sector. But I shouldn't be forced to spend money I don't have and get a bank loan out when the NHS is here and it's supposed to provide people with care—necessary care. So, I think we should be able to provide people with this care in the NHS and save private facilities for lifestyle choice. I don't object to people going privately, but I don't think that they should have to.

I think it's personal choice, isn't it, if somebody feels that they've got the spare money to do that and that's what they want to do then that's fine, but—

I'm just conscious of the time. Any more questions, Gareth, at all?

No, I was just responding.

Absolutely, no problem at all. Thank you, Gareth. Jack, did you want to come in at all on this point?

Just very briefly. Going back to the point on the one in five in Wales and the one in 25 in England and your first point on workforce, does that match with the workforce in Wales to England? Is there a significant number of more people employed in NHS England compared—if you do the figures that way?

I can't put my hand on my heart and tell you the precise ratio of figures. I don't think they have got five times more staff in England than we have, but I will say that proportionately a lot more job vacancies are left open in Wales than in England. I could find you the proper figures. I don't know the exact figures and I don't want to get into trouble by giving you wrong figures. So, there are more job vacancies in Wales, even for consultant posts. So, jobs stay vacant in Wales, and the vacancies within the social care sector are similarly higher in Wales than they are in England, which makes a huge difference to us because we can't decant our patients into a safe environment and have to keep them in hospital.

Of course. Thanks for that.

I'll look for the figures for you, if you'd like them. 

That would be great, in due course. Thank you. 

Thank you, Sue; appreciate that. I know Mike Hedges, one of our members, his internet connection is unstable, but he is here listening in; he's just not able to get a picture at the moment on the screen. Joyce Watson. 

I'm going to talk about the workforce, so that was a good point for me to come in. And what we've clearly heard, and we would all understand, from the Royal College of Nursing, is that you can't tackle a backlog by adding in overtime for the existing staff. That's pretty obvious, I would have thought, to all of us. So, I suppose that leads us on to the next question. You started on it, Sue, about vacancy levels, et cetera. So, how can we recruit more staff? What is it that we need to do? I know that you're going to say that these regional hubs will help. I support that, I understand it. So, that's probably one answer. But how else are we going to manage to recruit the staff that we truly need to deliver the service that we all would like to see delivered?

That's the million-dollar question. I think the first thing is: we need to not look at this as a short-term solution. So, as I said earlier, to train a—. When did I qualify? I qualified in 1985; I was a consultant in 1997. So, to train someone to a consultant level, surgeon, you probably need to be looking at five years medical school, plus 10 years at least in practice. So, there is no quick fix for this. We need to be training more medical students and we need to be training more nursing students. And one of the great shames, actually, of the United Kingdom as a whole is that the figures now are that we employ more medical doctors who graduated from foreign countries than we do train our own doctors. And that's a disgrace, because not only are we not training enough doctors for our own needs, which we should be doing, we are, in many cases, harvesting doctors from countries who have greater need of doctors than we do. And although individuals might do well financially to move into our system from their own system, we're actually taking doctors away from developing countries who have a greater need actually of surgeons than we do ourselves.

So, the only solution, the first solution, is to look at it as a long-term problem; there's no quick fix. We need to start putting more medical school places in Wales and we need to have more nursing places. Then, I suppose, the big argument is: why don't people want—? I think there are people who do want to go into nursing and medicine, but there are not the places available to train them, and we need environments that are nice to work in. I like being a surgeon; I love doing surgery—maybe I had a vocation back in the day—and I enjoy doing it, but sometimes the environment is not great, and sometimes even I get fed up with it. Even I have thought, 'Well, I could earn much more money if I was a banker; it's not that I'm less intelligent than the bankers.' So, we need to make the working environment good and we need to support people to go into these jobs. Nursing is a pretty rough job, and it's hard work, and people swear at them, and they—.

The people I think we actually should really be making an effort to recruit are social care workers. Social care staff earn tuppence. They get given minimal time to go and do their job, travel from one person to another, have 15 minutes in each place. They don't get the opportunity to do a good job. They're paid very poorly. They're not given any career progression. That's what we need to do, Joyce. We need to have career progression, so that people can go into a job and feel they're progressing and earning more money after five years than they earned after six months. And it's not all about money, but there should be some financial inducement. And they need to be allowed to do a good job. So, if I'm the only nurse on a ward of 12 elderly patients who need a lot of care, I cannot provide them with good care. That gets demoralising. It's the same for surgeons now. I know I've got a lot of patients who need an operation; I had to cancel one today. I couldn't get him in because there was no bed. It's demoralising. We need to build an environment that actually is nice to work in.

Are you aware—

Sorry, Joyce, Jonathon wanted to come in on your question as well, if that's all right. Jonathon, do you want to comment?

Yes, if I could, Chair, very briefly. I absolutely agree with everything that Sue has said, and about the workforce challenges, they're fundamentally about recruitment as well as retention of staff as well. It's well known that we went into COVID with a severe workforce crisis in this country, across the UK. We have made progress against some of the core manifesto targets on increasing the number of nurses going into work in the NHS. However, I would raise questions about whether the new workforce who are coming through are making it to the right parts of the country and the right parts of the health service. And what I would stress there is the real importance of long-term workforce planning, and that being a role for central Government in Cardiff or Westminster.

And then also—to pick up on Sue's vitally important points about whether it's a nice place to work—the importance of compassionate, inclusive leadership in the NHS, of it being a place where people are doing incredibly difficult, tough and relentless jobs, is the structure, is the governance in place to be supported and looked after? And I think, often, the answer to that, the experience, is 'no'. So, there are a lot of challenges around the culture within the NHS as well.

I'll come back to you, Joyce, but just if we can be—. We're nearly out of time, we've got one more section I really must cover. So, just bear in mind to be succinct with answers. I hate to say that, because we want detail, so apologies. Joyce.

Just quickly back to Sue, to what extent is the national health service now dependent on retired people coming back into the service?

Sue.

In actual fact, there was a lot of that in the press, but not very much, actually—certainly not in my experience. Colleagues of mine who've retired have gone and given vaccinations, but we are not seeing many retired doctors coming back into the service. Sorry, I've lost you.

No, the connection is fine from my end. So, the last five minutes, Jack Sargeant.

Diolch yn fawr, Chair. I'll try not to go over too much of what's already been said today, but in particular, I'd like to just look at solutions. We've already spoken about workforce, and it's not a quick-fix. Sue, you quite strongly put the idea of mandation from the Minister, which I think was a strong point, well made. Can I just ask then, what does fair prioritisation of waiting lists look like, in terms of prioritisation by clinical risk rather than chronological need, or perhaps prioritisation about the impact it's having on one's mental health? What does fair prioritisation look like? And I'm opening that up to all witnesses here; I'm not sure who would like to perhaps go first.

Jonathon looks like he wants to answer that question.

Yes—well, I was mulling over an answer. And I think, to be as brief as possible, the correct answer is whatever works for a local area. So, I'm very much thinking it should be about place and about working to get through waiting lists in a way that is inclusive and minimises inequalities. So, different parts of Wales will know their population better than Government does in Cardiff, and will be able to make those prioritisations. But there will also be clinical factors as well, which I think Sue is probably better placed to talk about than me.

You may have frozen, Sue.

[Inaudible.] I'm sorry?

Your connection is a little bit unstable, but it's come back now, Sue. So, go ahead. Hopefully, it'll be okay.

Well, I'll try—[Inaudible.]

It's still a problem, Sue. No, okay. Sue, if you want to try turning your video feed off. 

I could write to you—

Do you want to try turning your video feed off, Sue? It might help to get a more stable connection. Go ahead, Sue.

Is that better now, Russ?

It is at the moment, so, go ahead. Thank you, Sue.

Right. Sorry. So, we introduced priority categories with the surgical specialty associations. So, each specialty association gave us their priorities. Of course priority 1 is life and death this minute; priority 2 is the things that are going to kill you that need to be done pretty quickly over the next few weeks—cancers. And the problem is going to be with priorities 3 and 4. And typical of those are hips and knees, for example. So, you're not going to die from needing a hip replacement, but it's making you pretty miserable. It is very difficult, Jack, to then look at the fact that I need a hip replacement and you need a hip replacement and prioritise it on anything other than the long wait, because who's to say that my pain is worse than yours? And that is the trouble. 

Most of us have all gone through our long waiters and tried to validate the waiting list, and you do find that people disappear off the waiting list. They might go into the private sector and have their hip done; they might die, which is very sad—to die on a waiting list waiting for your treatment—or they might actually, in some cases, like back surgery, they might get better and not need the operation anymore. But it's very difficult to validate waiting lists on anything other than time waited, actually, once you've got them into those categories, I'm afraid.

Very helpful. I'm really conscious of time, Chair, but perhaps one more question to both Sue and Jonathon. With that in mind then, do you think health boards perhaps should be more transparent with their waiting lists? Is there scope to publish monthly planned surgery activities for individual health boards in Wales, and would that provide greater clarity for patients? And do you think that would be of assistance to patients?

Do you want to go first there, Jonathon?

Yes, happily. So, data transparency is an excellent thing. I think if patients know more about how long they might expect to wait as well, that can only be a positive thing. 

Sue, do you want to come in?

Well, transparency in everything is good, isn't it? Everything should be as transparent as possible and I think also expectation management. One thing, there's nothing worse than waiting for your mental health—there's nothing worse than waiting for something and not knowing if it's coming. So, of course, the more information we can give to patients, the more we can manage their expectations, and the more we can support them during their wait, the better. The sad things is, I think there are some patients who are already waiting over 36 weeks and there's a lot of waiting to do. The Minister said she thought that we could get over the waiting list issues in this term of the Senedd. I'm not sure. I think we've got a massive problem on our hands here, just to cheer you all up.

Well, thank you for both of those very useful answers. Diolch, Chair.

Okay, thank you, and, by all means, put your camera back on, Sue. It would be nice to see you before we end the meeting, but it did help, turning the camera off—we heard everything you had to say. Thank you, Sue.

Well, can I thank the witnesses for their contributions today? We'll send you a transcript, so please look over it. If you think you need to add anything to what's been said, or you think there's anything else that can help our piece of work, then please do drop us an e-mail or pick up the phone to the committee team and that would also be greatly appreciated, but—

Chair, I was just going to say, if I may—

Gareth, yes.

—it's nice to see Sue in a clinical setting in scrubs. It adds that element of realism to the whole debate, doesn't it? It's just quite good to see.

I'm real. I've been operating this morning and I've actually got to go back and do some more in a minute.

Yes, that's what we want—at the coalface.

We believe you, Sue. We don't think you've just put the scrubs on for the meeting this afternoon—we absolutely believe you.

That's naughty. No, I haven't, I promise.