National Assembly for Wales

Croeso, bawb. Welcome to the Health and Social Care Committee this morning. This meeting is held in hybrid format, with some Members here on the Senedd estate and some Members virtually. And all our witnesses today are joining us virtually as well, but Standing Orders remain in place as normal. There's translation from Welsh to English, so those who want to ask in either language can feel free to do so. Is there anything else I need to say? No, I don't think there is. There are no apologies this morning, and if there are any declarations of interest, please say now. No. 

In that case, I move to item 2, and item 2 is in regard to hospital discharge and the impact on patient flow. This is our second meeting dedicated to taking oral evidence from various stakeholders to inform our piece of work on hospital discharge. For this first panel this morning, we have three stakeholders joining us to give us evidence, and perhaps I could ask you to just introduce yourselves for the public record.

Bore da, bawb. I'm Nicola Stubbins, representing the Association of Directors of Social Services Cymru.

Bore da, bawb; good morning, everyone. I'm councillor Susan Elsmore, representing the Welsh Local Government Association. 

Bore da, bawb; good morning, everyone. I'm Allison Hulmes, and I'm the national director at the British Association of Social Workers, representing our members in Wales.

Thank you ever so much for being with us. Gareth Davies has just indicated that he wants to come in on declarations of interest. Gareth.

Yes, thanks, Chair. I just wanted to refer you to my declaration of interest as I'm still a member of Denbighshire County Council until the May 2022 elections, and one of our witnesses is an employee of Denbighshire County Council. 

That's it. Thank you, Gareth, for that. That's on the record.

Okay. Thanks, all, for being with us today. Just to set out perhaps the current situation, I suppose the question is: to what extent or severity has this current situation with social care capacity—? And I'm thinking both in terms of the current situation and your position on the future and increasing demands as well. So, it's a very wide question, so I'd appreciate just a brief answer to that, but it might just set the scene for the session. Who would like to go with that question?

Nicola and Allison both came in. Go on, Allison, you go first and then Nicola can come in after you. Allison Hulmes.

I think some feedback from our members who've been social workers for more than 30 years, and they've experienced a lot of difficult times in that period, is that what they're telling us is that this is the worst that they've experienced in terms of feeling that they're unable to do their jobs in those 30-plus-year careers, and that's the first time that I've heard that, really. So, the situation in terms of not being able to access the care and support that people need and deserve is the worst that they've experienced in over 30 years.

Okay. That's powerful. Nicola Stubbins.

Diolch. Yes, I would agree with Allison. The situation with social care has been pressured for many years, and pre the COVID pandemic the situation was becoming more and more challenging. However, the COVID pandemic has certainly exacerbated what was already a very challenging situation, and we are finding ourselves now in a position that I've certainly never experienced in my career within social care, and that's across all parts of the service, whether it be adults, whether it be children, within the local authority itself, within the independent sector. The challenges are just in every part of the system.

Thanks, both. Can you just outline to what extent care packages are being handed back to providers?

In my own local authority, we had a number of providers hand back packages of care towards the end of the last calendar year. That was in direct result of staff shortages. So, those agencies that we've worked with for many, many years and have had really good relationships with them just were unable to recruit and retain staff in order to meet the packages of care that we had commissioned with them. So, they had to hand those packages back. Some of those providers have had to reduce their provision, whereas some have actually left the market. So, it is a mixed picture, and certainly we've had over 1,000 hours of domiciliary care that we've been unable to commission that are waiting for support within the community.

And just tell us a little bit about the contingency plans that will have to, perhaps, be in place as a result of what you've outlined, and what we are likely to see in the coming months.

We've been utilising contingency plans now for the last two years. Obviously, with the COVID pandemic, the situation changed rapidly. Eighteen months ago we started to see some real challenges in the workforce itself. Initially it was in residential care, but then very soon we started to see the pressures particularly picking up within domiciliary care in the community. TAs to the contingencies we've put in place, we risk assess all of the individuals who are waiting for care and support. We do that jointly with colleagues in health. We look to third sector support where it's available. What we've had to do for a lot of those packages is we've had to provide that care directly ourselves, again with district nurses, but that then means that those other services that we would have been providing are either not happening or are happening in a diluted way. So, we are covering those individuals where the risks are very high. We're also relying very, very heavily on family and friends—those informal carers—who, as you know, social care has relied on for many, many years, but that in itself brings its own complexity and pressures of carer breakdown situations are becoming increasingly more prevalent as well. So, I think every contingency that we've had in the bag has been used. We're working very, very hard with providers and with partners to try and attract new individuals—either individual workers or individual providers—into the sector, but it's a difficult place at the moment, and it's not as attractive as some industries.

Thank you. You've set the scene well there. I'm going to let other Members come in with questions based on what you've said there. Can I perhaps address my last question in this opening section to Councillor Susan Elsmore? Have I pronounced that right, Susan? There we are. Can you just perhaps give your view on whether the Welsh Government recognises the urgency of the current situation and is taking appropriate action?

We can't hear you yet, but—. You shouldn't have to unmute yourself; it should happen automatically. Councillor Susan.

You've got to give permission, Chair, on one screen. First of all, I'm going to respond to your question, Chair, but actually what I want to do—we've heard from Nicola and Allison—is actually express my gratitude to everyone in the care sector, to those in relation to private providers, local authority employees, and people in the third sector. People are doing phenomenal work, and you asked for the view in terms of Welsh Government recognising the urgency; they absolutely have.

Can I say, in relation to me as one of the three spokespeople in relation to health and social care, we meet very regularly and have bilaterals with the Minister for Health and Social Services, but, more often than not, with the Deputy Minister for Social Services, Julie Morgan? In that way, they are very—. Let's just say we have full and frank discussions there in terms of the reality of the situation across Wales.

I was going to say, when you say you have frank discussions, what takes place in those frank discussions?

There are lots of discussions as I'm—. It's not going to surprise you, in terms of issues around funding, issues around—we've heard already from Nicola in terms of workforce capacity—actually ensuring there's parity of terms and conditions with health colleagues, and it's great that, in terms of Welsh Government recognising the urgency of the situation, in terms of the manifesto, which is now in the programme for government, of course, for the first time, in April, care sector workers will be paid the real living wage. For my own authority in Cardiff, we pay our own care staff—that's in-house care staff—the living wage, as we do for all employees.

So, it tends to be around capacity. It will always be around resourcing, and the conversations will also, Chair, be about how the whole system is working, because, for me, we've got to get the whole system right, and it's not just about, if you like, picking—. Yes, of course we can pick apart and examine individual pieces of the jigsaw, but actually it's about how those individual pieces fit together.

Thank you, Councillor Elsmore. I'll move on to Rhun ap Iorwerth next, but if you do want to come in, just lift your hand, and I'll know who wants to come in, or, by all means, just speak out if it's appropriate. Rhun ap Iorwerth.

Diolch. They are multifaceted reasons, I think it's fair to say, and whilst we welcome the Welsh Government's move to the real living wage for social care workers, we still don't feel that that's comparable to other aspects of the workforce. So, for example, local supermarkets are advertising for staff at a significantly higher amount than the real living wage, and that includes money off your grocery shopping as well, and with the situation at the moment with the rising cost of living, individuals are having to make choices around their family and how they do that. I think the pandemic has certainly highlighted the difficulties of working within social care. At the same time, it's also highlighted the positives. And, as Councillor Susan Elsmore said, the workforce that we have are absolutely phenomenal, dedicated professionals, but we do have to recognise the whole workforce as professionals, and that equity and parity of esteem with NHS colleagues is really important. I know a colleague director has recently lost two occupational therapists to the health board, because they're paying £10,000 a year more on their salaries. So, salaries and terms and conditions are really crucial, but so are the conditions within which individuals work. If we don't value this workforce, then we will see what we've seen over the last 12 to 18 months: not only difficulties in recruiting to the sector, but individuals positively choosing to leave. That's devastating, because this is a vocation; it's not a job working in social care, it's a vocation. And to lose people who have committed years of service because they don't feel valued, they're tired, they're exhausted, they don't feel that they're paid enough, they can get more pay around the corner, that's a real travesty.

Absolutely, yes.

Diolch am y cwestiwn. Nicola has outlined very clearly, I think, the major barriers. You've asked us to not be afraid of stating the obvious, so I'm going to, which is that people are absolutely, after two years of giving their all, exhausted, as in our health system. We know that. And, as Nicola has outlined, people only have to walk a short distance within their community to see supermarkets promoting job opportunities that are paying far more.

I also think one shouldn't underestimate the impact of the number of deaths that we've had due to COVID in our older—and, I suppose, particularly our older old—populations, whether that's people who've died at home or within care establishments. That has a great impact on individual care workers. Of course, social care has been working alongside Welsh Government, WLGA, BASW and the association of directors for a number of years in terms of improving the situation in terms of qualifications, registration and value.

The one thing I personally saw, and Allison mentioned it in response to the Chair's first scene-setting question about how are things—. In my eight years—it's nearly eight years in elected office, and I've always had responsibility for adult social services—I've never seen a situation as poor as this. It's really, really, really difficult—very, very difficult—and it does require all hands on deck. And it requires our whole system to—. My thing always is that, for the greater good, we have to let go of individual egos and power—you know, power brokering—and we really have to find those joint solutions together. Does that start to—?

Diolch, Rhun. In terms of the size of the shortage, at the moment, in terms of sickness rates, the most recent estimate that we've got is that we've got 2,333 absences, so that's about 10.5 per cent of the workforce. I think if I go back a little bit to your earlier questions around some of the barriers to entering the profession, we have to talk about—. We talk about parity of esteem all the time, but it's not a noun, it's a verb; you have to do something. So, we have to address the student bursary question. We're not getting that pipeline into the profession and we're seeing attrition rates at the highest that we've ever seen them across all of the programmes, including the Master's, and that used to have the lowest attrition rates.

We know that student social workers in Wales do not have parity of bursary with nurses and with allied health professionals. One easy way of trying to increase the number of social workers that we have is addressing the bursary question. Student social workers in Wales have been running an absolutely fantastic campaign to increase the student bursaries, but that has to be addressed as a matter of priority. In terms of real-life impact, I spent two hours last Friday speaking to a second-year Master's student who has lost his home, he's sofa-surfing and any savings he had are completely used up. I spent two hours on a Friday evening, until half past seven, with a Master's student who is at the point of qualification but is so desperate because of his financial situation, seeing no light at the end of the tunnel, that he was at the point of leaving his studies. This is the real-life impact of not having those parity of bursaries.

The other perverse situation that we have is that we have these perverse market supplements that local authorities apply to try and address some of the shortages of staff. We have 22 local authorities, so lots of opportunities for social workers to move easily if a local authority is offering—. You know, there are all sorts of reasons why social workers might want to change local authorities, but at the moment, although initially they start on a good salary, we know that social workers are living in families where family members have lost jobs, so social worker salaries, now, are supporting adult children, but also partners who've been furloughed, but also lost their jobs. So, market supplements become an attractive reason for—. But of course, that just leaves problems and vacancy gaps behind. We've talked for decades about a national pay structure for social work, and again, in terms of solutions, that could be quite a straightforward solution to close some of these perverse incentives. You know, we have one local authority at the moment that is offering £8,000 to social workers in children's services to address some of these issues.

Yes, it has an impact. Thank you very much, Allison. I know a colleague wants to talk about assessment, but if I could, Nicola Stubbins, just come to you with one question about something you tell us in the association of directors written evidence—that the community should have most responsibility for the discharge policy function. Could you just explain a little bit more about why that's important, why that's where the balance should be and the policy changes that would be needed to deliver that?

Most people are actually in the community, being supported in the community, as opposed to in a hospital bed. Therefore, we firmly believe that the focus has to be on that community support, including health, local authority and third sector support. I think focusing continually on the acute sector—. I understand the reasons for that, but it actually then doesn't look at the number of people who we are supporting in the community and preventing from needing to go into hospital. With that whole situation of early intervention and prevention, the more we can focus on supporting people and enabling people to remain independent and well for as long as possible, not requiring statutory services or health support, is money well spent. There are actually better outcomes for those individuals as well. A healthier, longer life is something we would all aspire to. But, when support is required, that support absolutely should be in the community. We know getting people out of hospital and preventing people from going into hospital in the first place is absolutely what most individuals would want. People don't choose to go—

Sorry to interrupt. Where does the policy change happen to make sure that that balance is addressed?

I don't think it's just policy change; I think it is the focus of society. How many times do you turn on the news and you see photographs and journalists outside A&E and talking to ambulances? How much of that focus needs to be on the positive things that are happening in communities, where local communities are stepping up, providing microenterprises and supporting neighbours and their local citizens? So much activity happens within communities that we could harness, we could do more with, but the focus of the public and of policy is on that fighting-the-fire end rather than preventing the fire in the first place.

Thanks, both. Joyce Watson.

Thank you, and thank you, all, this morning. I'd just like to pick up where Nicola left off, on the microenterprises and the circular economy that Lee Waters has talked about, and also progressing and promoting co-operatives in terms of delivering care in the community. I absolutely agree with you that most care takes place within the community, and there's a whole section later on about the unpaid carers who somehow don't quite make the cut. So, I just want to know if that circular economy debate that's happening, which is a policy change, if you see that as an advantage in terms of what you were just discussing.

Diolch. Yes, absolutely. We do have to do far more with that and look at the opportunities that that brings. In my own local authority, we're working with Community Catalysts, which is a social enterprise, and that actually supports the development of microenterprises in our local community. It's been really successful and is about local people delivering local support. For my local authority in particular, that's really important, because we have both rural and more built-up areas. We have a high population where Welsh language is absolutely crucial, and you can't have dignity of care without it being in the individual's language of choice. So, having local Welsh language speakers developing those microenterprises and supporting individuals in their own community is absolutely something that we need to do more.

The challenge is, we're focusing so much on those individuals who we're trying to prevent from being admitted to hospital, or trying to support being assisted to come out of hospital, that that development side of work that absolutely is crucial doesn't have the capacity and resources that are required. It's really difficult to balance your attention to all of those aspects when you are continuing to address what is the emergency at the hospital front door.

Okay. Well, I'm going to move on, I'm afraid, to the hospital front door, because I'm going to talk about assessments, and I'm going to ask about the delays in patients waiting for assessment in hospital before discharge, because we all know that, in those situations, there are effects elsewhere, so whether you think that there is an issue—I'm sure you're all going to agree there is an issue, but we need it on the record—and the particular issues that you feel need addressing. 

Am I okay to start on that one? Sorry, I seem to be dominating—

I'm just thinking, did Allison Hulmes want to come in as well at all? I'm not sure whether you indicated.

Yes, Allison first, maybe.

I think capacity is an issue in assessments happening in a timely manner. That's consistently been reported to us by our members. Again, I was surprised that, again, they were consistently reporting that, at stages during the pandemic, even hospital-based social workers weren't able to access wards, because they weren't deemed to be part of the clinical team. So, again, in terms of breaking down those barriers between clinical and non-clinical, social workers were clearly part of that essential team within the hospital. So, if the hospital-based social workers were struggling to get on to the wards, then that struggle was magnified for community-based social workers.

So, yes, capacity, accessing—and I think, again, in terms of those—. Hybrid working has had an impact, particularly when those assessments couldn't happen face to face. When you think about some of the frailty, when you factor in some of the sensory or the cognitive impairment, undertaking those assessments was really tricky and really difficult. We know how hard social workers and all parts of the multidisciplinary team have worked to ensure that they're undertaking robust and ethical assessments, but remote working has created huge challenges to the robustness and the timeliness, and, I think, the ethicalness of those assessments also.

I think it's fair to say that waiting for assessments isn't just waiting for social care assessments; it actually includes different specialised medical assessments as well. So, that picture is quite a complicated picture. It may require a specialist physiotherapy assessment, occupational therapists, it might be a psychiatrist assessment, a mental health nurse assessment, or it could be a social work assessment. So, there are a multitude of assessments captured within that figure.

What I would say is, though, that we have had a programme called discharge to recover and assess that is really about ensuring that individuals are discharged timely and then assessed in the community, either in their own home or in a residential care setting. But, again, in order for us to be able to do that assessment, we need that social work, we need that therapy, assessment, and we have a shortage of workforce not just within the social care workforce, but also within those crucial therapy posts as well. So, what we can't do is discharge somebody and then leave them without an assessment, because that is just as bad, if not worse, for the individual and likely to end up with the individual then being admitted back into hospital unnecessarily.

So, the whole system really needs to be considered, those community resources, those hospital resources, and we need to be able to work together. I still, unfortunately, hear some of my social workers say that they've gone on to a ward, having been let on—as Allison said, that was not always easy—but, having gone on to a ward, having been told somebody was ready for an assessment, to find that individual is not ready or is still waiting for certain procedures to be completed. So, that then is a waste within the system that we absolutely have to avoid. Unfortunately, sometimes, though, the pressures on trying to move people through the system quickly mean that, sometimes, we push the responsibility for that individual to another organisation rather than actually looking at that individual as a whole to see how we can all work collectively together to support that individual, and take time with them as well to understand what matters to that individual. I do think we rush people out of hospital without actually spending sufficient time talking to the individual, understanding what their needs are, what they want to achieve in terms of outcomes, and, as Allison said, that ethics of how we treat people is absolutely crucial. Individuals deserve dignity.

Joyce.

Okay, but what needs to change? What is it? You've described the picture, and there are pressures everywhere. What needs to change, going forward, so that we give a better, more holistic, rounded service to individuals?

I can see Allison Hulmes wants to come in, and Councillor Elsmore as well. I'm just conscious of time as well. So, if you have got just one question after this, Joyce, as well, that would be helpful. Allison Hulmes. 

Sorry, I was going to add to what Nicola said about the impact on the workforce of not being able to undertake assessments that sit within their code of ethics. We're seeing an increased amount of moral distress with our workforce at the moment, and that is impacting on sickness levels and on their mental well-being.

Thank you, Allison. Councillor Elsmore.

Thank you, Chair. I wanted to respond, really, just by reminding us all, of course, that the measurement, in terms of delayed transfers of care, is the only measurement that we use and, actually, as you've heard from colleagues this morning, and in my view and in the view of the WLGA, it's not a helpful measurement.

In answer to Rhun's earlier question, in terms of, well, actually, the responsibility should be to the community, I just want to say, of course, the pandemic, I suppose, has been a major roadblock. In some respects it's been a roadblock in terms of us working much more closely together and producing the shift that 'A Healthier Wales' wants into the community. But, of course, what it's absolutely done is it's shone the brightest light on where our whole system is working well together, but it's also made hugely visible the gaps. I think, seriously, because, of course, as the Wales Audit Office reports, it is the only measurement, do away with that measurement and actually look for better measurements of care, because, actually, having sat in lots of meetings, where—. There can often be a blame game between health and social care. That has to be avoided. But I think the measurement is wrong and, actually, the measurement forces the culture and the behaviours, particularly, perhaps, discharging people, as Nicola was describing—and Allison—in terms of moral distress, late on a Friday night without all the proper services being in place. We have—. I think it's fair to say we have a long way to go in our system.

Thank you, Councillor Elsmore. Joyce, is it okay if we move on? I'm just a bit conscious of time, but we can come back if there's anything further later on. Is that okay, Joyce?

It's fine.

Thank you. So, just be aware, we're struggling for time to get all the sections we want to cover in, so just to remind witnesses in particular, we really want detailed answers, but just keep that in mind as well. Gareth Davies.

Diolch, Cadeirydd. I want to touch on the relationships between health and social care, because the Association of Directors of Social Services told the health committee in the fifth Senedd about the breakdown in trust between health boards and care homes. So, I'm just wondering about the intricacies of the relationship between health and social care, and some of the communication problems there might be as a result of that, because quite often we see the lack of sharing, say, of clinical notes between discharge from a hospital setting to a social care setting. I'm just wondering how it would be possible to improve that, bearing in mind the difficulties around general data protection regulation data and privacy rules, and whether there's any way to navigate around that to try and eliminate some of the problems that are in the communication and the relationships between health and social care.

Who'd like to address that?

Can I go first?

Absolutely.

Yes. And you've hit the nail on the head in the sense of the absolute, crucial importance of data sharing and communication. I know you're going to be hearing later from Care Forum Wales, and they will be able to talk with direct experience as care providers in terms of the relationships. I would have said one thing that the pandemic has been able to do—a very positive thing that the pandemic has been able to do, and particularly locally, in my region of Cardiff and the Vale—is to absolutely improve—. Relationships were good, but it put the types of close working in all sorts of ways, whether it was test and trace, vaccine, logistics, the Dragon's Heart Hospital and building all of those together—. So, I think the relationships are good. I think the relationships are good amongst senior leaders, but I'm not sure that those relationships, and the shared understanding and training, are there when it filters down to particularly front-line hospital staff.

In terms of data sharing, I've heard this so, so much, and, if you like, the obstacle of general data protection regulations—. We can have memorandums of understanding amongst statutory organisations and we can have information governance protocols that would allow us to have a truly shared electronic record, and I think until we do— respecting of course individual privacy, but, until we do—I think stumbling blocks will remain.

Gareth.

Thanks for that. I appreciate the open mindedness of your response, in looking at ways in which we can achieve some of this, because we often talk about health boards still having paper notes, and not being able to sometimes actually read what's been written down by health professionals, and I think that's dangerous in itself, because, if people are acutely unwell with and some life-changing or life-jeopardising problems, then it can prove to be a real issue.

Just to push a little bit on unsafe discharges, a view, really—I'll throw out to all the witnesses, really—just to seek a view on how frequently rushed and unsafe discharges are taking place, and whether there are appropriate mechanisms in place to escalate those concerns with the health boards when necessary.

I think it's fair to say that, when an unsafe discharge happens, it can be very, very difficult and devastating for the individuals concerned. Fortunately, they don't happen too often, but when they do, they can be very, very difficult. I think it's difficult then to escalate that in discussion with health boards, because they are so busy and it's almost after the fact. It's really difficult then to have conversations and unpick the reasons that led to that unsafe discharge.

I've reflected a lot on this over the years, and I don't believe there are bad individuals. I don't think people make those decisions because they're bad people and they're looking to harm an individual—absolutely not. I do believe, though, that the pressures in the system cause people to do the wrong actions. They do them for the right reasons, as they believe at the time, but actually without fully understanding the consequences. So, sending an individual home in the early hours of the morning in an ambulance, somebody might think that that's okay to do, but if there's nobody at home and there's no support in place, actually you can't justify that, you can't say, 'Well, hospital is not a safe place to be and they're medically fit for discharge.' It's just not acceptable. But the pressure on individual clinicians in particular to move people out when they've got individuals in ambulances or on beds in corridors is acute. I don't work in a hospital, so I can't imagine the pressure that those individuals are under, but I do think it's the whole system that creates those perverse incentives. And, as Councillor Elsmore said, measuring DTOCs is the wrong thing. So, again, we're focusing on the wrong part of the system, which drives poor behaviours. 

Thank you, Nicola. Mike Hedges.

Diolch, Cadeirydd. I was listening intently to what was said earlier. You talked about care packages being returned, and you talked about the living wage coming in, which is something I really am very pleased about. I have personal experience of people having long waits for care packages to be made available, which is causing problems with discharge. But, of course, back in 1993, 5 per cent of care was provided by the private sector; now it's over 90 per cent. What's your view—and it's probably just Susan as much as anybody else—about moving back to local authorities directly providing services, which is something I believe in, or, if they cannot directly provide them, actually having co-ops set up to provide it, rather than letting the private sector see how they can make a profit out of it, and the people who pay for that are the people who are on the receiving end of care and the people who are providing the care?

Thank you, Chair, and thank you for the question. Philosophically, I agree with you. Of course, I think the impact of the long years of austerity has meant, actually, it has become increasingly difficult for local government to provide the in-house provision that they used to, as you referred to. I would say, particularly in relation to older adults, Wales does have some good private providers, but personally I—and it is something that we're working in my own local authority—would encourage that use of co-ops, co-operative organisations and social, particularly micro, enterprises that can be quickly set up in relation to supporting people with direct payments. But, no, I absolutely agree on the thrust. Perhaps a mixed-market economy would be a good idea, but yes in terms of driving the profit element out of care. 

Can I just add further to that? Whilst I understand where your question is coming from, as a local authority we struggle as much as the independent sector to recruit staff. So, it used to be that there was a view that local authorities, because they paid better or had better terms and conditions, would be more likely to be able to providers of service. But, actually, we can't recruit—we really, really struggle to recruit for care provision for our own residential care homes and for our own reablement teams. So, whilst there may be something in there, we still have to address the workforce issues, we still have to address how we fund social care to be sustainable for the many years ahead, not just for now. 

I agree with you on the funding of social care, and I've said on several occasions social care is the most important and most underpaid and least valued part of the health system, and that's one of the problems we have. I just found the last answer that you gave, Nicola, a bit strange. You think people would prefer to work for poorer conditions and lower wages in the private sector than work for the local authority, is what it appears you were saying. Was that what you were trying to say? 

No, I was trying to say there was a perception that working for the local authority had better wages, better terms and conditions, but I don't believe that that's the case. But, even if it were, we're able to show that we can't recruit the same as independent providers. But, no, I don't believe that's the case. Sorry, it's a perception.  

Mike, Allison Hulmes wanted to come in as well. Allison.

Thank you. I think we just need to have a radical shift in our thinking, and we need to move away from the concept of people needing to go into somewhere to have care, particularly older vulnerable people. 'A Healthier Wales' is all about—. People want to be at home, people want to end their lives at home, so it should be the minority of people that have to enter some form of a care facility, a care home. So, we need to really think in terms of housing as well, the built environment. How do we keep people safe and well and in the right houses and right environments so that they can remain in their communities? Again, we have to think about all of the citizens in Wales, so we have to have a real diverse approach to how we think about, particularly, the future of housing. If I think about Gypsies and Travellers who are living on a site, so many Gypsies and Travellers who either have a disability or become elderly and infirm, essentially, are forced to leave their homes and move into bricks and mortar, whether that's a house or whether that's a care facility, because attention isn't given to improving the trailers, the homes so that they're fit for purpose, fit for them to end their lives, which would be their choice. So, I think we have to have a radical rethink, and it's about moving away again from thinking about primary care, and back to those micro-enterprises and co-ops in the community. Communities have the answers. 

Finally from me—and I thank you for that last answer—everybody else on the committee has heard me say very often how important it is to link housing, care and health. I think that's something that I think you were talking about. Can I ask Nicola Stubbins something I don't quite understand? You've got a private provider. Their terms and conditions and their pay cannot be equal to a local authority's because they want a profit off the top of it. So, they must pay less or have poorer conditions, surely? For the same £1 million of expenditure, it's provided either directly with the local authority not having any profit out of it, or by the provider, who may be getting £50,000 or £100,000 out of it, and that actually comes off the provision of care. 

I wouldn't say it's poorer terms and conditions but it will be different terms and conditions. So, for example, as a local authority we have the local government pension scheme, which is different to what individual provider companies will be able to access through private pension schemes. A lot of providers provide niche, unique services that the local authorities can't and don't provide, because of economies of scale. Therefore, the pay for those services will be considerably higher. So, it's not a single picture; it is a mixed picture. But, as I said before, perception, I think, around—. But, for me, the most important thing is social care as a whole, having that equity with colleagues in the NHS, whether that be in private NHS organisations or Government organisations.

Thank you, Mike. Jack. We're happy to go on to 10:35 if we need to as well, Jack, for your final set of questions. Jack Sargeant.

Diolch yn fawr, Chair, and good morning, all. We've heard this morning about where we are, and I suppose some of the measures that you think could be implemented, and obviously in your written evidence you've identified some solutions as well. We've also heard this is a long journey, but can I look at the short term very quickly and just perhaps ask what specific action you think the Welsh Government could take or what measure could be implemented in the immediate future to urgently release some of the pressure on the current system? I don't know who wants to take that.

Councillor Elsmore.

I'm going to go back to a point I made earlier, which is remove the one measurement target that is only related—it doesn't relate to our whole system—to counting numbers and beds in a hospital. Actually, if we are going to meet the vision, which I applaud, and ambition of 'A Healthier Wales', then I think it's crucial that we look for another measure and, as Nicola has described, a way—and the written evidence that you've received has alluded to this—to move that responsibility out into the community.

I think it's fair to say, as Councillor Elsmore said before, we are in regular dialogue with Welsh Government, with the Minister and the Deputy Minister, about what, if any, solutions we can bring. And to be fair, a lot of the things we've asked for, Welsh Government have supported and facilitated. So, I think, if I'm really honest, on the quick wins, we've done all of those. There are no silver bullets left to fire. We fired those months ago. We are really now talking more medium and long-term solutions and, for me, the workforce is absolutely underpinning all of that. As I've said before, the real living wage is welcomed but it doesn't go far enough, and we are still losing people who are experienced professionals and we're struggling to recruit new entrants to social care across all aspects—social workers, occupational therapists, family social workers, domiciliary care workers—across the board. And we'll continue to lose them to other sectors and to health unless we have that parity of esteem and we have national pay, terms and conditions.

I was going to just quickly ask, then, because you've said the living wage doesn't go far enough, what would be far enough, or what certainly would get us on that journey. It would be the parity of esteem and national terms and conditions.

I believe so, yes. I mean, we look at teachers, they have a national pay scale; you don't have local authorities competing against each other to recruit teachers. The NHS has a national pay scheme. People do move for reasons—as was said before, for positive reasons—but they don't move for money reasons. We are in a situation where we have an ever-decreasing pool of staff resources and we're continuing to try and outbid each other—as Allison said, those market supplements. It's not a situation any of us want to be in. So, until we address that—and one way would be to have a national pay structure for social care—I think we will just continue to go round and round.

I'm conscious of time, Chair, but I jut waned to give an opportunity to Allison, really—what would be your one key message to the committee that we could recommend? I obviously know the Petitions Committee are looking at a petition on bursaries at the moment, and I'll be sure to share any response we have. But what's your one key message to the committee that we could recommend to Government?

I would agree with Nicola on a national pay structure for social care. Workforce—. I would agree, there is no silver bullet. The workforce is in crisis now. It is about medium and long term. If it's not a priority now, we certainly won't have a social work workforce into the next five years that is any way fit for the challenges that are ahead, so, absolutely, looking at a national pay structure, and also I think an easy win is that parity of bursaries. We need to get students into the profession.

Thank you. I could see Councillor Elsmore wanting to come in just before I interrupted her.

For the purposes of transparency, to illustrate the point that's being made, because I absolutely agree with the central premise of a national pay and terms and conditions, that parity of esteem with health colleagues, Cardiff pays the—. I gather, we have the lowest—I don't know why—pay scales in terms of our entire social work workforce. So, that's the professional workforce. We are now moving to market supplements, but a national pay framework—. I'm not saying it's going to necessarily be easy to implement, but it will make a lot of difference.

Okay, thank you. Thanks, Chair.

Thank you, Jack. Can I thank—? Well, I'll ask the witnesses if they have got any final comments that they feel that they need to make or anything else they want to make that's not been drawn out through questions at all. Are you all happy and content that you've been able to impart to us what you think is important? That's great. Thank you very much. 

What we'll do is we'll send you a copy of the transcript of proceedings, but please also follow the rest of the journey of this inquiry, and if you think there's anything you want to highlight to us, then we'd of course welcome that. But diolch yn fawr. Thank you very much for joining our session this morning, and for your evidence papers in advance of the session as well, so thank you very much.

Diolch.

Diolch yn fawr.

Diolch yn fawr.

Good day. Right. And we'll take a 10-minute break and we'll reconvene just before 10.45 a.m.

Welcome back to the Health and Social Care Committee. I move to item 3, and this is in regards to our inquiry and piece of work on hospital discharge and its impact on patient flow. This morning we have three witnesses all from Care Forum Wales, and I'll be just ever so grateful, as I welcome you, if you could introduce yourselves for the public record.

Mario Kreft, chair, Care Forum Wales.

Sanjiv Joshi, board member of Care Forum Wales—[Interruption.] Apologies, I'll just switch off the other—.

You were confusing us then. I was wondering where that was coming from.

Sorry. 

Don't worry. There's a slight delay. We'll wait a moment. That's fine. We'll let you just sort that out while I ask the first question. Lovely. Thank you, all, for introducing yourselves and for being with us today, and also for your written evidence ahead of this morning's session as well. Can I, perhaps, just ask you, Mary, initially, to give us an indication of how severe the situation is with regard to care providers' capacity to meet the current ongoing and increasing demands for services? So, perhaps an overarching comment from you to set the scene.

Thank you. I think I'm probably going to repeat what I heard in the first session you had this morning, that things have never been more difficult in terms of not just recruitment to the sector, but also retention as well. And I think the retention issue comes back to the pressure that people have been under for the last two years, dealing with the pandemic. It has been absolutely unprecedented. We're seeing people leave the sector because they can earn similar amounts elsewhere for doing less pressurised jobs, but we're also seeing people move into health, where they can earn better amounts for doing very similar jobs.

So, what we have is a real pressure cooker in the sector in terms of delivering the services that people need. And I think that that pressure is still there. As the rest of society is moving back to normal, or closer to normal, our staff are still working in PPE and masks for understandable reasons, because they're working with some of our most vulnerable citizens. But that pressure and that concern—the weekly testing, the wait for your result, the worry about whether you're infecting one of the vulnerable people you're working with. I think that pressure has just been absolutely unprecedented.

Thank you, Mary. It's useful that you were listening in to the first session as well, so feel free to comment on or disagree with earlier witnesses' views as well. But can you also, Mary, perhaps just talk a little bit about continuity plans and the extent that they're in place, and what's likely to happen in the coming months?

I think every provider obviously has its continuity planning in place, but those have been tested to extremis over the last two years. We've seen COVID spread through the workforce very rapidly, meaning that staff just aren't available. I mean, most recently, we saw that with omicron over the Christmas and new year period. And I can see Sanjiv nodding; I know he has personal experience of this and I don't know if he wants to come in and give an illustration of just how quickly these things can turn and how you're actually just worrying about tomorrow's shift. And every provider was just waiting, braced for more positive tests coming in, more staff having to isolate and how could they hold the service together. And obviously, people have been trying to work with local authorities to get that support there, but we've just never seen anything like this.

Okay. By all means, as well, if any of your colleagues want to come in at any point, just lift a hand so that I know that you want to come in and that'll be great. I can see Sanjiv might want to come in, but perhaps I could also ask as well, Sanjiv, in terms of your views on the Welsh Government in terms of recognising the urgency of the situation. Perhaps it would be useful to have your view on that, as well.

Sure. I echo everything Mary has said. The pressure is unrelenting. Although, with omicron, we're seeing that illnesses aren't so severe and that's the success of the vaccination programme, however, for our workforce, our staff, it is unrelenting. We're still seeing shortages of staff on shift due to isolation. The infectiousness of omicron is sweeping through our workforce, through community infections and within our homes. So, although it seems like the worst is behind us, as far as the care sector is concerned, it's been the same and it is continuing. I've just come back today from trying to organise staffing in some of our homes where we're not even able to provide a safe level of staffing because of isolation. So, it's still continuing, and it needs to be understood that it's likely, with the nature of this, to continue for some time on, despite the outcomes being better than in the past.

Coming back to the Welsh Government: I think the support has been incredible. Welsh Government recognised very early on in the pandemic—and the financial support, as well as the authorities, and CIW specifically, moving to a light-touch regulation process early on in the pandemic, without which I think a lot of our providers and care homes would have collapsed. But it's good to see that the health boards and the local authorities also recognise and joined in in the support and that co-production and collaborative work, for example, in the second wave, was immense and very supportive of the sector. So, it couldn't have come early enough for the recognition on the pay rates, on the real living wage, as well as the bonuses—the interim bonuses too. Wales was the first to introduce those and they were very well received by our staff. So, it does show that there is recognition and support for the sector right from the top of our organisations.

Thank you, Sanjiv. And just to ask as well: other witnesses have told us that there's a scarcity of specialist elderly mental health, infirm and nursing care capacity. Is that your view as well? You're all nodding, so I'll take that as a 'yes'. So, I'll leave it there. That's fine. Jack Sargeant.

Mary, Mario, good to see you again, and, Sanjiv, pleasure to meet you. I just want to touch on workforce and, Mary, in opening, it seems like, obviously, you've watched the session before, so I don't want to go over what has been, but it seems that you agreed with what they were saying regarding the workforce. But I'm just reading here now there is also a suggestion within the industry, or a perception, that it's actually a riskier job than ever before now, and that reward isn't there for the risk. Perhaps you want to comment a little bit on that, obviously due to COVID, and then just to ask what you think the key solutions are and what needs to be prioritised to try and address these issues and some of the issues that we heard earlier today.

Mary, by all means answer, or direct to one of your colleagues. I'll leave it to you.

I don't know if Mario wants to come in at this point.

No, I'm very happy for you to take that, Mary.

Okay. So, yes, at the start of the pandemic, the front-line workforce in the care sector were absolutely putting their lives on the line pre-vaccination. Obviously, the pressures aren't quite the same as they were 18 months, two years ago, but I think what that's also done is just eroded people's capacity. At the start of the pandemic, we were all learning. It was something absolutely new, we were dealing with new infection prevention and control procedures, just levels of infection and danger that we'd never seen before, and people having seen quite devastating outcomes with some of the people they'd been caring for, in some cases for many years. That's all taken a mental toll on existing staff, and while I think the pressure isn't at quite the same level now, people just don't have the capacity and reserves and resilience that they had at the start of the pandemic in terms of dealing with that. I'm sorry, I've now forgotten the second half of your question.

Just in terms of what key solution could be implemented by the Welsh Government. Just to move on from that: what could be implemented right away? Because we saw—and again heard in the last session—that there's no silver bullet, and colleagues will talk a bit more about solutions later on with you, but is there an action that could be taken now to help ease pressures?

We've seen the announcement this morning of the bonus added to the real living wage, and we know it is about recognition: financial recognition, but I think, also, respect for the work and the skilled work that people in the sector do. But this is only the first stage in it. We have a complicated system. The Welsh Government's White Paper 'Rebalancing care and support' looks at setting up a national framework and a potential national fee structure, because, at the moment, we have 29 variations on a theme, with local authorities and health boards all setting their own fees. Many of those use a toolkit that has, up until now, assumed that half of staff, the majority of staff, all staff in some cases were just paid the legal minimum wage. Now, that's not good enough given the work they do, and we need to ensure that the funding that Welsh Government is putting through local authorities and health boards for the next financial year gets to providers so they can pay the staff what they deserve, or at least something closer to what they deserve for the work they do.

But there aren't any quick solutions. The sector was fragile going into the pandemic, as the First Minister himself has said, and I think we're making steps in the right direction, but we've got to really have a robust sector that people want to be a part of and feel respected for being a part of.

Sanjiv, you wanted to come in.

Yes, echoing everything Mary has said, and there is no silver bullet. However, there are lots of areas that we can work on. The sector was fragile before we came into the pandemic outbreak, the problem is that a lot of the fragility needs to be addressed going forward, and I think there are some great ideas that have come through during the pandemic when different areas have collaborated, and I think we need to build on that. This should be a journey to getting to a stable sector where our most vulnerable citizens are looked after and can have a service that they deserve.

Thanks, just to put on the record from me, Chair, on behalf of the committee, our thanks and recognition to the workforce, for certainly what they've done over the two years, but way before that as well.

Absolutely.

Diolch.

Rhun ap Iorwerth.

Thank you. I think the delays are far too long, far too frequent, and I think the simple reason is the system is not as joined up as it needs to be. It has taken a pandemic for people to recognise the value of social care. Both Mary and Sanjiv have just referred to respect; it's very, very important that we look at the capacity that we have in Wales, both workforce and provision—that's domiciliary care, care homes, right across the gamut—and we try to bring together, as we have. The best of the pandemic has been people working closely. We are seeing far too many people waiting far too long in hospital, and we know this, we're all involved in it. I'm a provider, Sanjiv's a provider, and we could find you today another 500 or 600 providers who will all say the same thing, that the delay is with the bureaucracy, the funding system, the complication.

I think this issue, going forward, about almost like a national social care service, I think there needs to be a level of consistency. It isn't just about fees, it is about actually saying, 'What are we trying to do here? What are we trying to do as a pathway?' We've got to unlock the NHS to be able to deliver the services it's going to have to deliver in the years ahead. We are seeing light at the end of the tunnel with the pandemic, let's hope that's the case, but there are going to be many years now of pressure, and we've got to bring the social care sector and the health sector together.

I would just say this: it's taken a very, very long time for us to recognise the value of social care. It's always been about the cost. We've got this marvellous concept here in Wales, it's been given a lot of support by all political parties, about the value of the foundational economy, about making sure that we're supporting people, we're paying people well, we're having vibrant communities. That opportunity now to bring together social care and the health service is the way forward.

And I would just point to one final thing: there is a real need for our health boards to really engage with the providers in Wales. When I talk to colleagues like yourselves, like I have done over many years, there's no question that Members of the Senedd value greatly those small providers in their communities, in their constituencies. They are absolutely the lifeblood of the ability for people to return from hospital to their communities. So, we need to ensure that we have a model of care that is specific for Wales, and I would strongly urge everybody—and it's very much what Care Forum Wales is about, and we're almost 30 years old in a couple of weeks—we want people to build on the value that we have, on the services that we have, and I think that co-production and that partnership is going to be crucial.

Yes, I think you're right, and what you say in your written evidence to us is that what is needed is an ongoing and trusted working relationship, and, of course, that trusted relationship does exist in parts of the interaction between health and care. Is too much of it perhaps down to individuals and personalities and not enough structures driving that? You're nodding, Mary.

Yes, I would agree with that. We've seen even just over the past few months and the past couple of years some real examples of good practice. So, at the moment, in one health board area, they're looking at commissioning discharge beds. What they've done there is—. They got a slower response than they expected because they didn't engage the sector well at the start, but, actually, when providers took on to deliver a small number of beds as part of that service, they've now got a dedicated liaison with someone in the health board. They're always talking to the same people about discharges, so they've got that ongoing relationship, and they know how much they need to individually assess because they've got to satisfy their registration requirements that they can care for an individual before they can take them into their care home, but, equally, they can have that relationship and know it's an ongoing relationship, whereas sometimes—and I think this was referred to in the last session—hospital staff can feel, 'It's really important that we get this person out of hospital and into a care home bed', and they can give not quite the right impression about the person's care needs. And once people have been bitten by that, they're going to be more reserved in future. So, those ongoing relationships really matter.

Time's fairly tight. If we can maybe just have some brief answers on a couple of points. Is finance the main sticking point often? Is that where even personal relationships don't count for much when somebody's got to look after their own budgets?

Sanjiv—

No, I think there's two separate issues, in a sense. I think it's that understanding of the sector within the health board and the people making the discharge arrangements, so that they know that one care home isn't the same as another care home. Finance is more of a sticking arrangement when there have got to be financial assessments before someone can be discharged.

Sanjiv wanted to come in, I think.

Sanjiv, do you want to come in there as well?

Yes, just to agree with what Mary is saying. It's not all about finance. The relationship side also, in some areas it is good and others it isn't. It's the structure that we're working in: it's very much that the gear is transactional as opposed to collaborative and working together. So, you always have good officers who work through it and will build up those relationships, but the overarching transactional nature of working with care providers is at the heart of why you have so much tension.

And in getting a good working relationship, the balance needs to be right, I guess, between the input of the hospital and the care provider. I know that Care Inspectorate Wales has raised concerns about the quality of assessments taking place in hospitals, as too often they see the 'what matters' template completed by hospital staff when, actually, the view of what should happen next should be a shared venture. Do you agree with that?

I would say that is at the heart of it. You can't transfer the risk to the care provider without the overall support mechanism to make sure that that placement doesn't fail. So, you would need, for example, along with the assessment, the support when the resident moves into the care home of GP contacts, medication and physiotherapy. All the other aspects that the hospital were maintaining need to be transferred over, and for that you need more than just a discharge relationship.

Mario, take us through what could be done to address that issue of where the balance lies and the role that the care provider could have in that process of assessing and releasing patients.

Well, first and foremost, I would say, just going back to what's just been said, trust is absolutely crucial. And when we're trying to discharge people from hospital, we know those hospital beds are vitally important for others to come to. Somebody is there, they don't need any more medical attention. There has to be a process for discharge that is trustworthy on both sides, because it's often the case that a proper assessment will only take place in the weeks following discharge, and if it's done well, there's every opportunity, possibly, for that person to go on again to, possibly, even go back to their own home with domiciliary care. So, we've got to look at it as a pathway. It's not about, 'Well, they're going to a care home, well, that's it.'

But there's a very, very important point that I think we need to bring to your attention. I think it's been touched on already today, and that is the care of people with dementia. There is absolutely no doubt that there's the ability already to care for people with very complex medical needs in their own homes—there are all sorts of innovation and technology. But those people that require a high degree of personal support and care, dementia is something that is becoming so prevalent, and it's something very, very difficult for hospitals to deal with, because they are also under pressure.

So, what I'm really coming to is that we've got 12,000 nursing beds in Wales—just under, actually, 11,500, thereabouts—and a similar sort of amount of residential care beds. We need, as part of this national debate, post COVID, to start actually analysing where those beds are and what their speciality is. We need to grow certain specialties in some areas. And this is where I come back to that word 'trust'. We can't do this by a tendering process that's a race to the bottom on price. We've got to build on what we have.

What COVID has shown us, and it's just been mentioned by Mr Sargeant, is that we have this incredible workforce. It's still working in Wales—social care at the front line. As Mary said, people putting themselves in harms way. It is a marvellous story. We must build on that, and I think that is capable of being done, but we've got to come at it in a consistent way, and we've got to make sure that we map out the services that are there. It's simply not going to work if we start going to build huge, big homes near big district general hospitals and tender with contracts with people who are financed from wherever. We've got wonderful capacity in Wales, in small communities. It is totally different to so many places over the border, and we need to build on that Welshness of social care and build on the workforce. And, let's be fair, the Welsh Government has recognised this in a way that has not really been recognised in any other part of the UK.

Thank you. Diolch.

Thank you. We've got three sections to cover, each being led by a different Member, so that gives each block and each Member about a five-minute window. So, if I can just ask you to manage your time appropriately on that. Mike Hedges.

Diolch, Cadeirydd. Do you see rushed, potentially unsafe, hospital discharges still taking place?

I think the short answer on that is 'yes', and particularly, I think, when the hospital system is under pressure. One thing that has just occurred to me as a quick, short-term solution that we're talking about but haven't quite got there yet is in terms of transfers of records. In other parts of the UK, they've now given care providers NHS e-mail addresses, which enables records to be transferred more easily and more securely. It's something we're in conversation about in Wales, but it hasn't happened yet. So, it might be something that you want to recommend as part of the system changes.

Certainly—. Sorry, Sanjiv wants to come in.

Sanjiv.

Yes, just to add, yes, the pandemic has exacerbated the situation within our hospitals. And, if anything, the pressure on discharge is even higher now than it was prior to the pandemic, and it inevitably leads to unsafe discharges.

I'd like to thank Mary for that comment. It's something I've been arguing for a long time: we need to have social care, we need to have hospitals, we need to have GPs and we need to have care providers on the same system, sharing data so that everybody knows what's going on. And GDPR does not stop that, despite the fact that the first thing that somebody who doesn't want to do something says is, 'Well, we've got problems with GDPR.' Do you agree with that as a way forward, Mary?

Absolutely. It's really frustrating for care homes when they take someone in to provide their care and then can't access all of the information about their care needs easily. And it does slow discharges as well, because people are concerned that they won't have those links with the GP or with other community support—it might be community mental health nurses, for example. Just being reassured that that support is there makes it easier to take people and makes it easier to take people, for example, at the end of the week, rather than worrying that if you take them on a Friday rather than a Monday you'll then be left without support if things turn out not to be quite as you'd thought with the person you were admitting.

Thank you. Can I go back to Mario Kreft about something you said earlier about people getting reabled and then going back to their own homes? Should we be doing more of that? Hospitals deskill people. Put somebody in hospital for months, they sit in a chair, they have their food provided, they don't get properly dressed, they do very little movement, they can lose up to 30 per cent of their muscle capacity within a couple of weeks. Should we be doing more to reable people, rather than, you go in fine for a minor operation on your knee or hip and you end up not being able to go back home at all, but end up in a care setting? Should we be doing more to reable these people so that they can go back home after a period of time?

The simple answer is 'yes', and I think the reason that we can see a way forward is that we can actually develop pathways. But, to do that, I think it's very important that we utilise, as I just said earlier, the capacity that already exists in Wales. Therefore, we need to be able to trust people, we need to have an understanding that people can move through the system quickly. I saw this first-hand recently, last year. My mother lives in France, and there wasn't a question mark: into hospital, had the hip done, reablement, back home within about four weeks. There wasn't a choice of care home, it was just a rehabilitation facility, and we have got numerous settings already existing in Wales with the capacity to build reablement and, actually, to then manage domiciliary care back into the community. There's nothing that could stop it happening if we had the will to do it.

Sanjiv, you wanted to come in. Sanjiv.

Yes, absolutely. It's a fantastic way to go forward, an excellent utilisation of care homes in the reablement process. We managed a successful unit, pre-pandemic, on reablement. It was extremely successful, but the details were important. It was in collaboration with the health board and local authority, we had physios on site, along with occupational therapists, et cetera, working from our care home, and the outcomes were excellent for the patients who came to us from the hospitals. So, it's certainly something that needs to be worked on, but it needs to be organised.

Thank you, Mike. Gareth Davies.

Thank you very much, Chair. I just want to guide us onto the commissioning of social care services. I'm just wondering if you can talk us through some of the main issues that services are facing, bearing in mind the fact that the rates that local authorities and health boards are paying providers are too low to cover the rising costs of some of the service delivery.

[Inaudible.] I'd just like to say this: I think it would be enormously helpful if we agreed in Wales what the proper costs should be and we actually moved away from the almost adversarial, 'Who provides it? Is it public, is it private, is it voluntary?', and actually looked at the costings. There's some wonderful work that's been going on—LaingBuisson is one of them—to look at costings. Most of the care homes that are often in the front line of this discussion are paying—and Sanjiv will bear me out on this—60, 70 per cent of their income on wages. That's why wages have been where they are. We need to have an open and transparent conversation in Wales about what is a reasonable return on investment, and we need to have that because in the future, whether it's going to be public, private, not for profit—whatever it's going to be—these organisations have to be sustainable. And it is remarkable that we're having this conversation today and only a couple of days ago, a large nursing home that had been trading for nearly 40 years, highly valued in the community of Mold in north Wales, has closed its doors or will be doing by the end of the month. So, we really need to understand how we can make these sustainable, and how the commissioning process needs to work.

Sanjiv. 

Just to add, the fee-setting process is by the commissioners, whether it's local authorities or the health board, and we are price takers and we've got to work within the fee that's been set. Most of the fees are set utilising the national living wage. So, automatically when we're spending 60 to 70 per cent of our fee on wages, we're not in a position to improve the terms and conditions of our staff, because, really, they've been priced at that rate by the fee. There's a myth that, with private providers, our focus is on profit, but what I would point out to you is whether you're a not-for-profit organisation or you're a local authority, the fees and the costs seem to be similar. So, I think the focus on profit is looking at the wrong aspect. The business is highly capital intensive. There needs to be a high level of return on investment so it can be reinvested within the care homes, and so on. So, therefore, there needs to be a mature, grown-up conversation about funding and where the funding is going, rather than focusing on the micro details and playing one sector off against another.  

That's really helpful and it answers most of my second question, because I was going to factor in some things around the staffing and wages around contractual obligation for staffing levels. Just to end my contribution on this subject, I'd look for views on whether you think enough is being done to improve the situation, and the likely consequences if commissioning practices don't sufficiently improve.  

We're obviously seeing the potential for more money going into the sector the next financial year—the bonus to the front line and then the real living wage funding through local authorities and health boards to enable providers to pay the real living wage, and differentials above that to recognise people's experience and training. I think if we're going to solve the system, going forwards, it involves building, actually, on the White Paper work that the technical groups have just started in terms of developing that national framework for commissioning. I think it is about, as colleagues have said, understanding the costs of care, the need in care homes for continual investment in improving the fabric of the building, for example, partly wear and tear, but also to meet people's greater expectations. There's got to be a return on capital to enable that, whatever sector providers are in, and Care Forum Wales represents private providers, we have third sector members and we have housing associations who are members. And, actually, what is striking is that all of them say exactly the same in terms of the viability, and we just haven't got the detailed knowledge to have those detailed negotiations, 22, 29 times over within our local authorities and health boards. So, that national framework for commissioning and fee setting that's envisaged in the White Paper I think is absolutely vital as a system to build on, going forwards. And I suppose I'd compare it to, in some ways, what we do for GPs and pharmacists with their contracts—you know, they're independent providers but they have a contract to provide the services they do within Wales.

It seems you've voiced the views of many bodies there, but do you think personally that enough has been done to rectify this situation?

I think there's policy there that gives us enough to do, but we're on a journey, and we've got to see how that journey evolves. There's certainly potential for us to solve this system, but we've got to work through that journey. And, as we've said already, there isn't a kind of magic wand that is going to enable us to deliver this overnight. 

Can I just say, we've got to understand how we've got to this place? We were a fragile sector. Even though vitally important to the NHS, it was fragile coming into COVID, it'll be leaving COVID in an even more fragile state, despite very good support in Wales for the sector, there's no question about that. I think we've got to remember that we've tried for 25 years to manage a market, but it just hasn't worked. We've got to do something different otherwise we'll be having similar conversations in the future and we won't have had that dynamic change. We need some radical reform and we, first and foremost, need to understand the quality of what we've got and try and make sure that we're building on that. This notion of the foundational economy, I think, is absolutely vital to social care, because what we know is people want to work in social care; let's give them the tools that they need and I think we'll see a better place, going forward.

I think Sanjiv wanted to come in as well.

Yes, just to follow up on Mary saying we have the policy. Wales commissioned '"Let's agree to agree"' by Professor Bolton, which was setting out a fair basis of setting fees, but, for whatever reasons—we had the pandemic occurring in the last two years—local authorities or health boards have not really implemented that. This is not a blame game, but what we're saying is that there are pressures that are faced by the health boards and by the local authorities in their budgets and they do get in the way of trying to promote and get to that final point. This is why we need an overarching approach to funding to try and address and try and work through these hurdles and roadblocks in trying to get to the right place.

Good morning, all. I want to talk about solutions, but I think we need to separate things out. You talk about a pathway for people—that's good. But most of the people that you're seeing who reside in care homes permanently are very elderly with multiple conditions, and that's why they're there, more so than ever they were before. So, in that context, because it hasn't been mentioned, I would like you to give us something in terms of a solution and a way forward that we can then take—because our job is to take forward a recommendation from you to the Government.

So, if I understood your question correctly, and I suppose I'm referring back to some of what was said in a previous session as well, yes, people reside in care homes because they have that kind of multiplicity of needs, and there's rightly been a focus on keeping people in their own homes as long as possible, perhaps with domiciliary care support, but we have some people whose needs are just unpredictable, need that 24/7 care, and also need that kind of additional support and get the community rather than loneliness from living in a care home. So, I think, going forward, we've got to recognise that there are always going to be people who need that sort of facility, and it's about how we build that structure that enables us to work better. And I think, for the reasons we've outlined already, that national framework is the way to move forward in terms of giving us that. 

Can I just add that I think we should also really talk up the sector? I think we've had the opportunity now to see the value of this incredible sector, this incredible group of people and what they've actually done for the country. And I think now what we really need to do is make sure that it's a positive thing. And, look, we in Care Forum Wales have also got to look at some of the messages we send out—we all have a job to do. But we've really got to make this a positive step forward—social care being a vital component of a health and social care system. I think that is crucial.

Okay. That's fine.

Jack Sargeant.

Thank you, Chair. Just one brief question; if it's not a brief response, perhaps we could have a note sent to the clerks on it. Just going back to something you said, Mario, earlier, about understanding what we have and that being the baseline that we build on there. What does that piece of work look like, then? What's the recommendation for us to take forward there about understanding and mapping out—what's the exercise?

Right, I shall be as brief as I can. It's now a generation that we've understood that we had to manage the market. Local authorities have an obligation to map out the services in their area. And I think, working collaboratively with our colleagues in health, we need to undertake a piece of work that starts, by local authority level, actually analysing what we actually have and what we can build on. Let's not think about reinventing wheels, building new capacity. There's a wonderful example that has come about recently in another part of north Wales other than your constituency, where a huge, big nursing home has had planning permission, despite the health board not wanting it, despite the local authority not wanting it, despite the fact that, if it was successful, probably three times the beds would be lost that already exist. We've got to think about things differently, we've got to build on what we have, and let's manage a market for the people of Wales, not for providers, not even just for the people who work in the sector—for the people who need the services. And I think that the shining, almost Holy Grail of this for us, is if we can get a pathway that people only need to reside in hospital as long as they need to be there, and they don't go into care homes necessarily—end of; they only go there when they need to be there. And let's keep as many people living in their communities, in their own homes, if we can. If we have that pathway, with a group of people who are truly respected in our society for what they do and the skills that they have, then I think we are going to have something we can build on for the future.

Okay. Thank you for that. Thanks, Chair.

Thank you. If no other Members have got questions, and, looking at our witnesses, if they feel there's something they want to say that's not been drawn out by questions this afternoon or this morning, by all means, indicate. But it looks like you're all content. Sanjiv, did you want to say something, to finish?

Just to thank Mario for how he expressed it. Absolutely we're part of the solution; we're not the solution, but it needs to be an integrated solution that works for Wales.

Thank you, Sanjiv—a good note to finish on. Thank you very much. Diolch yn fawr. Thank you, all three of you, for your evidence this morning, and thank you for your evidence paper ahead of the meeting as well—that's greatly appreciated. We'll send you a transcript of proceedings, so, by all means, have a look at that and add anything you feel appropriate. We've got a couple more items of business to do, so you're welcome to stay, but we won't be offended if you disappear from our screens either. Diolch yn fawr.

I move to item 4. We have one paper to note, which is a response from the Minister for Health and Social Services to reports published by us and the Legislation, Justice and Constitution Committee, on the legislative consent memorandum for the Health and Care Bill. That's just to be noted, if Members are content. Thank you for that.

I move to item 5. I propose, under Standing Order 17.42, that the committee resolves to exclude the public from the meeting for items 6, 8, 9 and 10. Are Members content with that? In that case, we'll be back in public session at 12:30, with evidence from the Minister and her officials.

Welcome back to committee. I move to item 7 and this is in regards to the impact of the waiting times backlog on people in Wales who are waiting for a diagnosis or treatment, and our scrutiny session this afternoon with the Minister for Health and Social Services. And we're also looking at the Welsh Government's health and social care winter plan as well. So, I welcome this afternoon the Minister for Health and Social Services, Eluned Morgan. And, Minister, I'd be grateful if you could introduce your officials for the public record. 

Thanks very much. I'm delighted to be joined today by Judith Paget, who is the new director general of health and social services and is the chief executive of NHS Wales. I'm also joined by Chris Jones, who is the deputy chief medical officer for the Welsh Government, and by Nick Wood, who's the deputy chief executive of NHS Wales.

Thank you very much, Minister, and welcome to officials joining in as well today. Minister, I'd just like to kick off in terms of your plan to address waiting times—you stated that that plan would be published before April 2022. I suppose there is some urgency in that plan being published and I'm just wondering whether that's going to come any earlier than perhaps before the April 2022 timescale that you've provided. And perhaps also it'd be useful to know the level of detail that's going to be in that plan as well.

Well, thanks very much. In fact, I've just come from a meeting this morning where we met with the leaders of most of the health boards in Wales and other representatives who are going to be instrumental in terms of delivery of the planned care proposals. 

The system we use, as the committee will know, is that we ask all health boards to come up with their integrated medium-term plan proposal. So, it's their decision in terms of how they see the way that they are going to be targeting this plan. We've obviously given them some very clear directions in terms of what we'd like to see in terms of addressing the backlog. We are not expecting them to introduce those proposals until the end of March. So, we won't be producing our planned care plan before April because it's important that we look at what they are proposing to do. We make sure that that conforms with what we're expecting to see on a national level. Clearly, we've put in place the funding in order to support this, so £170 million on an ongoing basis to make sure that we can really get to grips with tackling that backlog.

I think it makes sense for us to wait until April in order to look at recovery, because omicron at the moment is very much still with us, despite what you might hear from Boris Johnson and the UK Government. I think it's important that we understand that there are still sub-variants that we know very little about, that we have to consider the impact of the need to make sure that we have measures in place to stop the spread within hospitals. All of those things have an impact on our ability to tackle the backlog. But in terms of the backlog, and I'm sure that Judith can help here, and also Nick, who are responsible for driving that plan, there will be some very clear objectives that we expect health boards to meet, and, in particular, some specific specialities. I think we've got to be really careful, though, that it's not just about numbers. So, actually, getting the numbers down is sometimes quite easy to do, because there are certain areas where—. You know, diagnostics—you can rush those through pretty quickly. Cataract operations are far easier than some very complicated orthopaedic work. So, we've got to think about urgency and how long people have been waiting as well, and those are the kind of nuances that you hopefully will see in that plan. But if I can ask Judith, maybe, to elaborate on that a bit more, if that would make sense for you.

That's fine. If I can just ask for confirmation again. So, I understand that the plan's not going to be available before April, but the plan will be published in April. Is that still the case, Minister? Yes. And just to perhaps reiterate my question to Judith Paget about what we're particularly interested in: will the plan include targets? Will it include timescales for the reduction of those on the waiting backlog, and will it include specific actions to support people that are waiting for care and treatment?

Thank you. Yes, I can confirm that it will include specific ambitions and milestones in terms of improvement of the backlog. I think we all know how important it is that patients understand and can have confidence that we are working to reduce those, particularly the long-waiting patients. So, yes, we will have some specific actions around those very long-waiting patients, to give them confidence that we haven't forgotten them, and our plan will ensure that they do get treated. Also, clearly, we'll still continue to focus on those who are clinically urgent. We will still focus on cancer services to make sure that those continue to have a priority. Diagnostics will be important in that, so making sure that we continue to build on the progress that we're already making in terms of reducing the number of patients waiting for a diagnostic test. But also it will set out some of the changes that we might want to introduce in terms of how planned care is delivered for the future and how we might organise ourselves, both at a local and a regional and national level, to address some of those issues. And it most definitely will set out what support patients can expect whilst they are waiting—the support that the NHS can provide—and also how they can help themselves get ready for their surgery when it is offered. So, I hope that's helpful.

Thank you. Thank you, Judith, for that. It seems that diagnosis services seem to be recovering at a faster rate than out-patient and in-patient procedures, so perhaps you can either agree with that or not, if that is the case, but do you think there are any lessons that can be applied to different stages in the patient pathway?

Thanks very much. Well, unlike in England, the wait for diagnostics is actually counted within our waiting lists, and I think it's really important for the committee to understand that, and diagnostics, of course, are absolutely key so we know what we need to treat. I think if you look at the numbers of people waiting for diagnostics, we've seen a massive increase. So, in March 2019, we had 69,000 people. In November 2021, 106,000 people were waiting. That's a 53 per cent increase, and obviously the pandemic has a lot to do with that.

I think it's really important for us also to understand that, actually, this is a way we can reduce the numbers on the waiting lists very significantly, very quickly. So, if we just take cancer, for example, I think about 92 per cent of the people, or even more of the people who are suspected with cancer are taken off fairly quickly, and, of course, that gives great comfort not just to those who are told that they haven't got cancer, but also it means that we can crack on then with treating the people who do have cancer. So, in November, for example, 1,700 people started that cancer treatment following that diagnostic service, and 12,400 people were given the comfort of knowing that they haven't got cancer, and I think it's really important to understand the importance of diagnosis within the pathway that we set out for people who are suffering. Chris, I know, has a bit more detail on this, if that would be helpful.

No, that's fine. I'm just wondering if Chris can perhaps address this further point as well, in whether there's actually a risk that perhaps more people will know what treatment they're waiting for, but they're potentially having to be waiting longer for that treatment.

It's obviously clear that diagnostic services are vital, and they form a critical point in nearly all of our clinical pathways, and, actually, it is always good to know your diagnosis, or to know if you're free of a serious diagnosis. Clearly, if everybody can get the diagnostic test that they need, for those that know from that test that they will require further treatment along the pathway, that is very helpful, and they can be prioritised according to the findings of the diagnostic test. But as the Minister has said, the majority of people who have diagnostic tests can be reassured after that, and leave the clinical pathway entirely. So, actually, the importance of diagnostics cannot be overstated, really, and it makes absolute sense to focus on diagnostics upfront.

I wonder if I could just comment a little bit on the background to radiology capacity and the investment that Welsh Government's made in recent years. We're in a relatively strong position, because although we know we've got a challenged workforce with consultants, some of whom are due to retire over the next five years, we have anticipated the demand. In 2018, with £3.4 million of investment, we established the imaging academy, and that now brings together the radiology community across Wales to draw in in a common approach to delivering the Royal College of Radiologists curriculum for radiology training. We aspire to progress 20 trainees each year through south, mid and west Wales and a further two trainees in north Wales, and we'll start to see completed consultant training follow in 2023 from that investment.

The Minister has also recently announced further investment in training places in Wales, with an 18 per cent increase in those for healthcare professionals. So, we know this is a challenge, but it is vitally important, and it is an excellent thing if we can progress and put in place some diagnostic capacity quickly. It is relatively easier in some ways than putting in place outpatient or surgical capacity, because we have very often the machines that are required and we just need to maybe extend the operating hours, but also we can enter into private contracts, insourcing or outsourcing with providers to increase capacity further.

Thank you, Chris. Minister, can I just ask, what is the current surgical activity rate across Wales, and what percentage of the activity undertaken pre-COVID are each of the health boards now operating at? Perhaps you could direct one of your officials to go into some detail on that. I think Judith Paget was looking like she may want to answer that one. 

Yes. If I can ask Judith to come in, but I just think it's important to note that COVID is still very much in circulation, and we still need those infection control measures to be in place within those sensitive hospital environments, and, obviously, that has an impact, and obviously, COVID also has an impact on our staffing levels and you saw the impact of that over the Christmas period; it is still not insignificant in terms of the numbers of people who are having to self-isolate, either because they've got COVID or because they've been in contact with somebody with COVID. So, obviously, that does have an impact on our capacity to carry out that surgical activity. But if I can ask Judith to come in with a bit more detail on exactly where we're at in terms of the percentages that we're at compared to where we were pre-pandemic.

Thank you, Minister. Yes. So, in terms of just building on the Minister's comments, for elective, in-patient and day-case activity, in December, the management information that I've been able to see suggests that, at an all-Wales level, the activity is now back to 81 per cent of pre-COVID levels for surgical activity. We continue to see an increase month on month, which is really positive. As the Minister says, those activity levels are impacted on by infection prevention and control measures and social distancing controls. The committee might also be interested in terms of the out-patient activity, which is now at 89 per cent of the pre-COVID levels through December. I suspect that in January that might have been impacted by omicron, but, clearly, we haven't got access to that information yet. But December was 81 per cent for surgery and 89 per cent for pre-COVID—for out-patients, sorry.

Can I just ask, Judith, that's an all-Wales figure; I'm just wondering whether there are large variants between the health boards across Wales, and perhaps whether one health board over another is pushing up or down the statistics in one direction or another? Are there variations across the health boards, and to what extent is that happening? Is that the case?

Yes, there most definitely is variation across in-patients, day-cases and out-patient activity. Some variation you would expect, and there would have been variation pre-COVID as well. So, when I give you figures, obviously I'm giving you an average across Wales, but, across all health boards, some might have focused in December on in-patient rather than day-case and some areas might have been able to do more day-case activity, and everywhere has been focusing on trying to maintain that focus on out-patients, because, of the numbers waiting in Wales, a significant proportion of them are waiting for their first out-patient appointment. So, I can see, by looking at the figures, that all health boards have been trying to make inroads into their out-patient waiting times.

So, and I'm not particularly, perhaps, asking you—. I'll bring you in now in a moment, Mike. I'm perhaps not asking you to detail now, if you haven't got those figures in front of you, but is that something you could quickly provide to the committee in terms of the various figures for the health boards, rather than the all-Wales figure, Judith?

Yes, certainly. I can send them to you very quickly, and, if it would be helpful, maybe some commentary about why they might vary as well.

That would be extremely helpful. It saves us asking further questions on that now. Thank you, Judith. Mike Hedges, you wanted to come in.

Have you get anything on the variation within hospitals in the same health board? Because my experience has been that variation in hospitals in the same health board can quite often by different and bigger than that between health boards.

If I could come back, no, I haven't got any information between hospitals. Health boards will use their total capacity to try and ensure that they are treating in turn, and there will be the variation within health boards in terms of how they're able to make that capacity available. So, we don't personally collect the information at an individual hospital level, we just have it at a health board level.

Can I just add, Russell, that one of the things that also impacts on the surgical activity rates is actually our ability to get people out of hospital? So, the delayed transfer of care is really quite significant. So, we have almost as many people in hospital now who are there because of delayed transfer of care as we do who are there because of COVID. We are putting a lot of effort into this as a Government. You've seen that we have made a commitment to the real living wage, trying to give people who work in the care sector that dignity that they deserve. You've seen our announcement today that we will be giving £1,000 in addition to those people to pave the way towards the real living wage. And all of this is with a view to recruiting more people in social care, so that we can get those people out of hospital, to get on with the surgical activity that we're also keen to see, but also to relieve the pressure at urgent and emergency care as well.

We're obviously very aware of that, hence the piece of work that we're, obviously, undertaking—absolutely. Joyce Watson.

Right, I am unmuted. Anyway, good afternoon, everybody. I'm going to ask a number of questions in different areas, and I'm going to start with mental health demand. Of course, the Welsh Government has increased significantly the funding for mental health services, and that's obviously welcomed by everybody here. But the Royal College of Psychiatrists say that mental health demand is hard to quantify because of poor data collection. Could you tell us, Minister, how you aim to resolve that? Because the importance of data can't be understated; it will drive policy development and therefore also funding decisions in future.

Thanks very much, Joyce. Well, you'll be very aware that mental health is extremely complex, because the term 'mental health' is used to describe a very wide range of emotional and social and mental health needs, many of which are often not medical; they're about social circumstances and all of those other things. And that's why, crucially, we're trying to take a cross-Government and multi-agency approach. You'll know about our whole-system approach in schools, but also we're doing a huge amount of work with the police, for example, in relation to crisis care. We've increased the amount of funding that we've put into tier 0 and tier 1, that non-clinical support that is so essential. You know, if your parents have just got divorced and you're traumatised by that, it's not a medical condition, but you may need some emotional support to get through that. So, the question, then, is: how do you collect that data? In what category do you put it? So, we do collect a wide variety of data and that is published nationally, and that includes data on local primary mental health services, it includes data on specialist child and adolescent mental health services and it includes data on mental health admissions.

Now, officials also meet with service leads from health boards and the third sector just to get a sense of what the pressures are on the system and to get a sense of that demand and capacity. So, sometimes it's hard to just kind of lock down what data are you looking for, precisely. So, our knowledge and analytical services in the Welsh Government, they receive regular updates from population surveys and you'll know, as you've just suggested, that we're putting significant additional funding into this—£50 million additional in next year.

We are committed to producing a core data set on mental health, but that has been delayed, I'm afraid, because of the pandemic. But we are absolutely committed to getting back to that as soon as we can.

Well, we've had evidence from the Royal College of Psychiatrists and they say to us that data is not routinely published on waiting times for psychological therapies, and they very often have to resort to freedom of information requests to get hold of that data. So, we need to understand that alongside it being a key Welsh Government commitment.

Thanks, Joyce. Well, we are committed to publishing the waiting times on those specialist psychological therapies, but, as I say, that work has been delayed because of the pandemic. We do have some data and that operational data is reported by all health boards, and that is used by Welsh Government to hold services to account. But I don't think we're in a position yet to say that the data across Wales is robust enough to publish on an all-Wales basis. So, we've got that operational data at a local level.

I think the other thing is that psychological therapies, once again, it refers to a wide range of different talking therapies. So, sometimes, you have one-to-one talking therapies, but sometimes you have that happening in groups. So, we've got to be absolutely clear about what we're talking about, and one of the things, as you'll be aware, that we've been offering, is online cognitive behavioural therapy and that has been hugely successful and a huge number of people have taken advantage of that.

I want to move on now to dementia care. Again, we welcome the additional £3 million allocated to regional partnership boards to spend in that area. But I just want to understand how you will ensure that money will be spent on increasing access to memory assessment clinics for those who are waiting for diagnostics—and we've already mentioned the importance of diagnostics earlier.

Thanks very much, Joyce. I'm very aware of this in particular, because I know a lot of people who are in situations where they're waiting for those memory assessments. And that's why we've given an additional recurring £3 million to try and support people during that assessment process, and also with a follow-up diagnosis. It is an area where, I'm afraid, we have seen a little bit of backtracking during the pandemic. We're very aware that early intervention can be very helpful here. It is a priority within the dementia action plan, to have that timely diagnosis. And what we've got is monitoring happening now, through that dementia action plan monitoring. So, we're hoping that additional funding will provide the additional capacity for those memory assessment clinics that we're talking about, and that will be accompanied by a data work stream to make sure that we've got consistent information in this area. And I'm pleased to say that what we've got is a national steering group that has been reconvened to review that data and to hold people's feet to the fire on this very important issue.

Thank you. I want to move on now to neurodevelopmental services, and particularly your response to the concerns of the National Autistic Society, saying that experiencing long delays in accessing NHS care and treatment is pushing some autistic people and their families to crisis point.

I'm intensely aware of the pressure that, in particular, those families who are living with people with neurodevelopmental issues have been living with during the pandemic—very, very difficult if you don't have the support that is usually in place. But also, people are desperate for that diagnosis. So, I'm pleased to say that we did publish a statutory code of practice on the delivery of autism services, and that came into effect on 1 September last year, so at least everybody knows what they should be working towards now.

We're also working to deliver a new neurodevelopmental conditions approach, and that's going to be informed by the results of the demand and capacity review of neurodevelopmental services, and they're due to submit their draft findings by the end of plan. So, we'll use the information that they come forward with to let us know, 'Right, where are the gaps here?' to plan future service improvement. So, we know we've got work to do here; it's about just assessing, 'Right, where are the gaps?', so that we can go about filling those gaps. But I'm very, very well aware that we've got more work to do to stand by those people who have been really carrying a very difficult burden during the pandemic.

You talked about the review of demand and capacity in neurodevelopmental services. When can we expect to see the outcome of that review as a committee?

So, we're expecting to see that at the end of March, and, obviously, I'd be happy to send those findings once we've got those.

And just a final one, again on autism. You may be, or may not be, aware that having a diagnosis for a female with autism is very often seven years behind having a diagnosis for a male. I don't know whether you're aware of that—it's not on the paper in front of me—but I'm aware of it. So, I just would like to flag that up as something that might need your attention and the attention of those people in the field. I don't expect an answer; I'm just flagging it up.

Joyce, can I just say something on that? This is an example of where I'm really keen, and I've asked my officials to develop a women's health approach, where we actually look at the culture of the NHS, and what we're looking at and the way we assess how women are affected by health. I wasn't aware of this, but I will make sure that that is fed into a whole range of issues. I wasn't aware, for example, that women are far more likely to suffer heart disease issues than men. So, there are lots of things like that that I think we need to assess through a female lens, and I have commissioned that work to be undertaken by my officials.

I thank you very much for that answer. I'm moving on to orthopaedics now. One patient with lived experience who responded to the public consultation told you that her husband's pain medication had been doubled since waiting for orthopaedic surgery. So, how confident are you, Minister, that everything is being done to support orthopaedic patients with excessive waits for treatment to ensure that they don't develop an opiate addiction?

Thanks very much, Joyce, and I don't go out very often these days, but, when I do go out, I inevitably bump into somebody who's waiting for some kind of orthopaedic operation and they are in pain. I am intensely aware of the fact that we need to get cracking in particular on this area of work. But, while they're waiting, it's absolutely crucial that we give them the support they need in terms of pain relief and the medication that they require. If you don't mind, I'm going to ask Chris Jones to come in with a slightly more medical understanding of what we're doing and how you avoid that dependency.

Thank you, Minister. Clearly, it is an issue that we are worried about. We know that orthopaedic services haven't been prioritised during the acute phase of the pandemic, because it's not life-threatening or life-saving surgery, but we also know that people who are awaiting surgery will have increasing pain in many cases, and they need to be supported. They'll see a lot of different clinicians; they may see clinicians in primary care or clinicians in the hospital, and they all need to support the patient so they can manage their situation, hopefully without recourse to medication, but, when medication is required, to opiate medication as an absolute last resort.

We are in the process at present of appointing two clinical leads for pain management, and they will be working across primary care and secondary care to ensure that we have appropriate protocols, policies and support packages in place, and they will be deploying the psychosocial model of pain, recognising that pain isn't simply linearly related to a physical condition—that it may be affected by all sorts of personal, emotional, psychological or social factors as well. So, an awareness of all those issues that contribute to a patient's well-being will be vital, and if we do that, then the chances of actually requiring serious, dangerous medication are much less.

I might also just mention, in passing, that our orthopaedic community is very engaged at present in a review process from the Getting It Right First Time programme. This is a programme that looks at the state of our orthopaedic services and the outcomes from orthopaedic care and actually will inform a significant programme of improvement and inform our recovery, going forward. But I do recognise the nature of the question and the challenge within it, but we are responding to that.

I met with a community pharmacist last week, and I know that they've got a new contract, from April, and their prescribing will go from 28 days to 56 days. So, in light of what we've just been discussing, prescribing opiates, can we be sure that in that increased time frame from 28 to 56 days' prescribing, they will be carefully monitored, particularly this group of medication, and reviewed appropriately?

I would see it as within the remit of our clinical leads for pain management to ensure that that risk doesn't play out, that the minority of people who end up on opiate medication are kept under review, that protocols and procedures are put in place to try to enable people to come off those types of medication, and obviously there are requirements in community pharmacy as well for an annual review of medication. So, I hope that will not happen with the measures we're undertaking. 

Thank you. I'm going to optometry now. During the Senedd's scrutiny of the First Minister committee meeting in December 2021, the First Minister said that the Welsh Government is considering bringing forward an optometry Bill during this Senedd term to change some of the rules around high-street optometry. Have you got any further details on what that might look like?

Yes. Well, I'm hoping it's going to be a very, very short Bill. So, that's my opening line. I think it's something that we'll be going out to consultation on next month—so, in March—and we're hoping that it will be introduced into the Senedd in September, and then we'll get Royal Assent in May. So, one of the reasons that we really need to see this happening is because at the moment the Wales Act allows us to have the general ophthalmic services carry out sight tests only, and what we're interested in is enlarging their ability so that they can do eye health care. And, if we allow that to happen, we think that that could help us to reduce hospital waiting lists by around a third. So, there's a really important reason for us to move on with this really quickly, because obviously that links to the first question, which was about waiting lists. So, everything is lined up, we're all ready to go, and hopefully we will hit the deadline that we're working to in September.

I'm sure we'll all look forward to that, because once you lose your sight, you don't regain it, and time is, in this view particularly, of the essence, as it is in my next area, which is cancer care. I know you've answered some, so I'm not going to rehearse all of those questions, but we've had evidence where there have been concerns raised about significant difficulty in accessing clinical nurse specialists for those diagnosed with cancer. What steps, if any, are being taken to ensure that vital source of support is available for those who are diagnosed with cancer, particularly when they're waiting for that treatment to begin?

Thanks, Joyce. Certainly, it was a very sobering debate yesterday in the Plenary, and I'm absolutely determined to give cancer the attention and the focus that it certainly needs. We're clearly not hitting our targets at the moment, but I think it's really important that we make it clear to people that this has always been an essential service, that we've never stopped cancer treatment throughout the pandemic, that in November 1,700 people started treatment—that's the joint highest number since we started counting—and 12,400 people were told that they don't have cancer, which is really important as well. So, just in terms of prioritising what we do here—something, again, that we've been discussing this morning—it will be a part of that planned programme of care, setting out what our ambitions are in relation to cancer. But, in relation to the specific issue of clinical nurse specialists, if I can ask Chris to help me out with this one, I'd be grateful.

Thank you, Minister. We have to acknowledge there will have been occasions when someone with cancer would not have been able to access their clinical nurse specialist, and that would be due to the demands of the pandemic, and we regret that that's the case. But, as the Minister said, cancer care is part of the essential services framework that we've had in place throughout the pandemic. A requirement of cancer care is that everybody with cancer has a key worker, who in most cases will be a clinical nurse specialist. They are a tool for personal support, for signposting to associated services depending on need and also accelerating or escalating the need for clinical review. But, at times during the pandemic, clearly some clinical nurse specialists have been deployed to the front line. These have been difficult decisions that health boards have had to make. They've made those decisions within the framework that we've provided them with, which is the local choices framework, but they have really tried to minimise, at all times, the impact on cancer care, because it is an essential service. So, I regret that there will have been occasions where people haven't been able to access it, but, hopefully, that will now settle down and everybody will have a key worker, who, in most cases, will be a clinical nurse specialist. We are working with Health Education and Improvement Wales on a national workforce plan for nursing, and we're maintaining the budget that we do have in place for advanced and extended practice education at £2 million annually. As you know, cancer is a priority area, and health boards have also been told that it's a priority area for their framework investments as well.