National Assembly for Wales

Croeso, bawb. Bore da. Welcome to the Health and Social Care Committee this morning, and welcome back to this new term as well. If there are any declarations of interest, please say now. No, there aren't any and there are no apologies today.

With that, I'll move to item 2. This is our final evidence session for the committee's inquiry into gynaecological cancers, when we will be hearing from the Minister for Health and Social Services, Eluned Morgan. So, welcome, Minister, this morning, and perhaps I could ask your officials to introduce themselves for the public record.

Yes. Good morning. I'm Dr Chris Jones. I'm Deputy Chief Medical Officer for Wales.

Good morning. Nick Wood, deputy chief executive of NHS Wales.

Thank you, all, for joining us this morning. Members have a series of questions, but can I first of all ask—? You're very welcome to make some opening comments following my first question, Minister, but I'd probably say that we've had some very powerful evidence in this inquiry, and the most powerful evidence was when we heard real-life experiences, particularly from Claire O'Shea and Judith Rowlands, who told us very powerful stories. I'm not expecting you to have, but I don't know if you've had chance to look at any of the evidence that they provided.

I'm afraid I haven't had a chance to look at that, but I'll make a point of making sure that I do. As it happens, in the past week, I have been speaking to people who've had gynaecological cancer and there are issues that need to be improved, so it's something we're very aware of. You'll be aware that cancer is one of the six planning priorities that I gave to the NHS, so it's very much at the top of the agenda in the targets that I set for chairs. Cancer is very much something that I have focused on. Cancer, generally, is something that we take very seriously, and it's obviously top of the agenda. You'll be aware that we've got some significant financial challenges at the moment, but cancer is one of the areas where I've made it clear that I don't want to see any reductions in our support.

But what I think you're focused on is, in particular, gynaecological cancers, and the statistics in relation to those are not where we want them to be. One of the things that I've done is to ask the NHS Wales Executive to focus on the three cancers where we're not getting the kinds of results that we should be getting—one is gynaecological, one is urology and the other is upper gastrointestinal. So, those three, I've asked them specifically to take a look at, and we've been undertaking some significant work on that over the past few months. I don't know if Nick wants to add the specifics of what's happening there.

Yes. Obviously, the Minister held a couple of cancer summits with clinical leads, managerial leads for cancer services across Wales. The outcome of that was that we issued, firstly, the cancer implementation plan through the work of the NHS executive. Within that, there were four or five very key objectives specifically designed to set us on an improvement path for those three cancers and cancer in general across Wales, specifically focused on establishing very clear pathways for patients through the system, very much from the first interaction with their GP, right the way through to any treatment. So, that was, if you like, the first stage—to agree some very clear pathways, all led by the clinicians and clinical leads for each of the cancer modalities. And then, it is how we can support the delivery of those pathways through either digital changes, support around regionalisation, patient information, and being very, very clear with GPs and secondary care clinicians around how and when to access diagnostics and then, clearly, through to some of the treatment settings.

That work has been under way for six months. There have been a number of workshops featuring all of the cancer clinicians for each of the different cancer pathways and that has resulted in—I saw the presentation last week—a list of about 30 actions that are now being taken forward to deliver those pathways across Wales. We are challenged in terms of the number of patients that are being referred into cancer pathways—that has increased substantially—and the available capacity to then support that increase in referral is also challenging. There is progress being made, but as the Minister has alluded to, the current performance of cancer against the single cancer pathway target is not where we want to see it, but as I say, some progress has been made and we will continue to monitor the progress over the next six, 12 and 18 months. 

Thank you. I'm grateful for that summary as well. I suppose one issue that was picked up on is that you don't intend to include gynaecological cancers in the up-and-coming women's health plan, and I know you stated in your paper to us that the reason for that is because you've already set expectations out already. But, 'A Cancer Improvement Plan for NHS Wales 2023-2026', which you pointed to, doesn't perhaps acknowledge the complexities of gynaecological cancers, so is that something you could reflect on?

I think there is recognition that gynaecological cancers are more complex than lots of others, and obviously there are lots of different types of gynaecological cancers that need to be taken into account, and some are more prevalent than others. So, we just need to ensure that GPs have an understanding, for example, of where the risks are. Can I invite Chris to elaborate a little bit on the complexities?

The cancer improvement plan was drawn from the integrated medium-term plans of the health boards and I wouldn't necessarily expect them to mention every single type of cancer individually, but we are very aware that the grouping represents five broad cancers of the female reproductive tract. They all present differently, they all require different diagnostic approaches and they all require different clinical pathways. So, there is a lot of complexity behind this, and I think that is recognised in the system. Following the quality statement for cancer in 2020, a number of nationally optimised pathways have been published by the NHS executive, four of which are for gynaecological cancer—so, four different pathways—and there is a lot of work being done to support GPs in their individual decision making. So, the NHS is rolling out some decision-support tools, including one called GatewayC—which is quite a flashy-looking app, when I had a look at it yesterday—to help provide information, and in a sense, guidance about when to refer people with sometimes quite vague symptoms. Some of these cancers will be fairly obvious, or the symptom will be obvious that you have to investigate, like post-menopausal bleeding as a possible sign of uterine cancer, but for others, say, ovarian cancer, which can be quite hidden within the pelvis for quite a long time, the symptoms can be very vague, and then I think quite a different approach to decision making and referral pathways are needed. And I think all of that is recognised out there, so I think there is quite a lot of complexity, and the support and the leadership around the work on these cancers.

I suppose some of the witnesses that we heard evidence from, their view would be that there's potentially a missed opportunity here because we've got the women's health plan, because there's the cancer improvement plan, and because of those complexities, then, perhaps there's a missed opportunity in not addressing some of those complexities in either of the plans. 

I think, what we don't want to do is to make things more complex and to have the system have to refer to lots and lots of lots of different overlapping recommendations. We do have a clear statement for cancer, the cancer quality statement, we have a quality statement for women, and what happens then is that there's a plan that follows up that cancer quality statement and the women's plan. These are owned, and they should be owned by the NHS itself. I think what's important is that they are the ones who work out, 'Right, if you're doing that already in relation to cancer, why are you doubling up on it in relation to the women's health plan?' But, I think there are a lot of other issues that we do need to pick up on in the women's health plan, and as I say, I think we can give some pointers, but it's up to the NHS to come up with what they think should be in that as a follow-up to the quality statement. But one of the things that I think is clear is that women quite often are not listened to, they feel that they are ignored and so on, and I think that's the kind of thing that I'm very keen to see emphasised within the women's health plan. So, it won't be specifically cancer, but it'll be things around some of the frustrations that I'm sure you've heard in some of the evidence.

I'll bring Sarah in, but that is right, because a large part of our evidence is women not feeling that they're being listened to. Sarah, did you want to come in on this?

Yes. I just wanted to reinforce what you've said, Minister, because I've got constituents at the moment, but I've also got many friends and many women in my life, and this is very common to women out there. They will go to their GP with pain, their GP will ask them about their menstrual cycle, try to kind of like attribute it to that first and foremost, in quite a dismissive way sometimes. They will do a blood test, they will be told they will be given a call if anything comes back that they should know about. They fret for days, weeks on end, and then, eventually, ring and ring and ring until they get through, to find out their blood tests, and then they're told—usually by the receptionist, who is doing their best—'No, the GP doesn't want to see you again.' And that is it. I've got constituents at the moment who have just been left. There is nothing being done to then bring them back in and see, well, what else could it be? So, I've got many women out there right now who have had this. It comes back, it goes away. They've been dismissed once, what's the point of going back? And then we're hearing the evidence that too many women are being diagnosed late, and through emergency departments. I think that that's something that has to come through in this: that it has to be that that will to want to investigate and actually find out exactly what the problem is has to be there, and I don't think that is there at the moment in women's health.

So, I suppose, the question is, is whether the cancer improvement plan, or the women's health plan, can be strengthened to address some of the issues that Sarah has outlined, and some of the issues that have been provided to us in evidence through our inquiry.

I'm going to ask Chris to come in a second.

Yes, a very powerful testimony. I mean, the women and girls' health quality statement is founded, I think, on the principle that women have, in the past, not always been heard. You know, there is increasing evidence of that, that a lot of medical training and experience has been within a kind of male frame. And women do feel very, very concerned about the symptoms that they get, and I know that there is a lot of evidence that, over the years, women haven't been listened to adequately.

What I suppose I would say is that there is evidence, though, that GPs are actually, collectively in Wales, doing really well. Because if you take the National Institute for Health and Care Excellence guidance for gynaecological cancer, which was first published in 2015, and then again in 2021, it recommends referral, anticipating an ideal conversion rate of 3 per cent from those referrals to a diagnosis of cancer. And that would be the kind of conversion rate to try to diagnose as many early as possible. The rates of GP referrals in Wales have increased enormously in recent years, albeit interrupted by the pandemic. And actually, most health boards now are demonstrating a conversion rate of around 5 per cent. So, for every one person who has got gynaecological cancer, 20 others are being investigated and reassured. That 5 per cent isn't 3 per cent, and so, that shows there's further to go, but it equally does show that GPs are generally referring at the rates that NICE recommend. So, although there will be individual incidences, I have no doubt, collectively, the evidence seems to be that they're improving significantly, but that bit further to go.

I can bring Joyce in.

Just a quick question on the referral rate having gone from 3 per cent to 5 per cent, or the expectation—and that's post-pandemic. So, have you been able to analyse whether that is because people are presenting late? A figure's a figure, but what we want to know is what's behind the figure. So, I don't expect you maybe to be able to answer it now, but if we could have that information, it would help us assess that it's early referral and that things are improving, because that's what this is about.

I don't think we have the evidence yet, because we need people post-pandemic to go through the whole pathway so we understand, in a sense, what the conversion rates are and what the stage on diagnosis is for people, and I don't think we have all that information. What I think we do know is that, to some extent, the system has been overloaded since the pandemic by the catching up, but also the increasing rate of referrals, even over the last year. And many people we know are sort of stuck within the diagnostic parts of the pathway. So, that is something that we're working very hard across Government to try to unlock. But only when people find their way through the whole pathway will we really know the answer to your question, I think.

Jack.

Diolch, Cadeirydd. I think we've covered the main points of the questions from Sarah and Joyce there. But if you'll indulge me, Chair, just to read into the record the statement from Claire O'Shea, who I believe we all know around this table this morning, because I think it emphasises again the point. The Minister will be aware of this; we held a short debate in the Senedd and the Minister responded positively to it. But, if I may, Chair, she described her experiences:

'So many phone calls, me chasing, being dismissed. I called it medical gaslighting by the end, and I think the reason I ended up in tears with the final GP appointment was finally feeling vindicated, like I'm not a neurotic woman who's making a fuss over nothing, which is definitely how I was made to feel.'

I don't have any questions to the Minister. I just thought it was crucially important to put that on the record. You've cited the women's health plan, Professor Jones has cited the NICE guidance, and I'm assuming that's how you will monitor the progress of addressing the problem of women being—. I think the term 'medical gaslighting' is one that stuck with me. It might not be the correct term, but it's certainly how they feel. If there's no further comment, I'll accept that, and move on, Chair.

I think, as well, that's perhaps why I highlighted it's certainly worth watching that evidence. We can make sure we send that to you, because we saw two very powerful testimonies that focused our minds. So, I think it's important for you and officials to look at that evidence, as well. Thank you. I'll bring in Mabon ap Gwynfor at this point.

Yes, Mabon.

'there is a real issue of accountability at the moment'.

Nick, do you want to add to that?

Yes. Thanks, Minister. There is a cancer clinical network that Tom Crosby is the chair of and the clinical lead for, which has been established for a good number of years, which is made up of clinical leads for each of the cancer modalities, alongside members of Public Health Wales and other parts of the NHS. We brought all of the clinical networks into the NHS executive, and, as the Minister said, that was formed in April, so 23 weeks ago, I think.

As part of that, there is—which I alluded to in my opening comments—a taskforce, if you like, that is focused on picking up the improvement that we require within cancer services across Wales, with a specific focus on the three modalities that we've highlighted. Tom does play a crucial role in that, in terms of bringing together the clinical leads who represent each of the sub-specialties so that we ensure that we've got clinical sign-off, clinical buy-in and clinical leadership around any improvements that we need.

The NHS executive, I think, is presenting itself in the way in which we intended in the work that it's doing on cancer, because it has brought together elements of what was the delivery unit, the clinical networks and NHS collaborative, alongside colleagues from Improvement Cymru, who are focused on quality and safety improvement within the NHS.

As I alluded to earlier, there's a whole list of actions that are now being taken forward on the back of that, which the cancer network—led by Tom—have signed off and are now being implemented across the health boards. In my role as deputy chief executive of the NHS, I meet with the NHS executive leadership team on a monthly basis to discuss progress with their work, and from an accountability perspective, we hold each of the NHS organisations to account on cancer as part of their regular monthly interface with us, where we track their progress, both against their performance improvement trajectories, but also the actions within the cancer improvement plan.

So, I think there's a very clear governance framework around the improvements that we're trying to seek, but I think it's important to state that this will take a degree of time to implement. One of the things that I think we've all heard through the testimony and evidence is the challenge that patients have had in accessing that referral into secondary care. The big blockage we had was in out-patients, so that first referral, which should be within 14 days. That's improved significantly, and we've now seen the wait for out-patients come down over the last six months. But of course, that's resulted in a big bulge in the diagnostic part of the pathway, which we're now seeking to resolve as we move forward. And that's a key part of the work that the cancer clinical network needs to be involved in and is involved in.

'We've seen in south-east Wales and south-west Wales, between organisations that are just 10 to 15 miles apart, there's 1.5 to twofold variation in performance across the pathway.'

I think from a regional perspective, the Minister has set out very clearly through—. Part of the planned care recovery fund, which covers cancer, included a set of proposals around regional funding for regional diagnostics—hubs and centres, one of which will be in each of the three regions, if you like: the south-east, south-west and the north. All of the health boards have now participated in the regional planning work, centred around the NHS executive. So, we've got teams of people working on how we can work regionally. It always sounds far, far easier than it actually is to pull together patients into a region. In order to do that, you need to merge the three patient—. So, in the south-east, for example, with Cwm Taf Morgannwg, Aneurin Bevan and Cardiff, you'd have to merge the three patient treatment lists into one from the three separate systems to then be able to treat patients in turn or on a cancer pathway—pick off those that are in need of the next stage of the pathway. That sounds really easy, but in that particular region there'll be over 1.5 million people on these lists, so how we do that is quite challenging.

What we have got already is regionalisation of specialist cancer services. So, patients are referred for particular treatment into tertiary centres, such as Cardiff, Swansea or in north Wales. So, we need to just expand that so that it becomes clearer how patients get equal access then to services across different parts of the region. That is a clear priority of the cancer implementation plan; it's a clear priority of how we are establishing services. It's also a clear priority for how we consolidate and make services more sustainable in Wales, because in many areas, we lack both the workforce and/or the resources to provide it at every level in every part of the country. So, bringing together those specialists in specific areas is a key aim and plan of where we're going with the health boards. But they have to work together to solve some of these problems, and they recognise that, but it always sounds much easier than it is to actually implement. And I'm sure that we will start to see much more regionalisation once we get the diagnostic hubs open where patients are then referred in from different areas to a single centre, but, again, that comes with the challenge of patients having to travel et cetera.

Mabon, if you haven't got any more questions on this section, do you mind if I just bring Joyce in, and I'll come back to you then for your next set of questions? Joyce Watson.

We had evidence from Dr Louise Hanna of the cancer site group, and she talks about resilience—building in resilience. And she also points to the fact that some gynaecological cancers are fairly uncommon when you compare them with other cancers and that the teams of healthcare professionals are small. So that, of course, then, brings to the fore, which she says, the issue of resilience within those teams. So, if we link that, then, to the regional working and the fact that a specialist that you are, as a patient, seeing and expecting treatment from, we can see that there are clear resilience problems. So, how is this built into your plan, going forward, particularly in the more rural areas? You talked about the challenges in areas that are more densely populated, but in rural areas, of course, it becomes perhaps—and I don't know; I want you to tell me—more of a challenge.

I think that's why we're looking to consolidate in these regional centres, because actually that's where you get the resilience. If you have one or two people who are experts and one of them goes on holiday or goes off sick, then obviously the system is under huge pressure, whereas actually if you've got a group of people working together who are experts and one of them goes on holiday, then the cover is just easier for everybody. So, that's why if what you want is resilience in the system, we are going to have to move towards a more regional approach, and that's exactly what we're looking to do.

And you'll be aware that, actually, a serious part of the blockage is in diagnostics. We've got a very clear plan in relation to diagnostics. We will be developing these hubs, the diagnostic hubs, and that's where we will need to unblock. And, as we've mentioned, part of the issue is that people may have to travel a little bit further but what you will get is a more resilient service, and I think, when it comes to cancer, people probably will be prepared to travel a little bit further. Anything to add to that, Nick?

Yes. I think you make a really good point about the rurality challenge that there is, and the conversations that are ongoing currently between colleagues in Hywel Dda and Swansea bay, which covers a huge geographical location but very small populations, is that we need to get into a much more shared service provision so that we provide services across the whole of that region but also encourage the clinical teams to travel, so that they interact in a way—rather than always asking the patient to travel, you actually put the clinical teams in, I don't know, Withybush or wherever it is, so that you run clinics on an irregular basis but that you join that up by getting a regional plan, if you like, of how you work. So, Swansea and Hywel Dda are working on some of those specific challenges in some of their specialties, not necessarily gynaecology.

In, I think it's Aneurin Bevan, they've consolidated some of their gynae services into a single site and a single service, which again has provided more resilience. The work that Cwm Taf are doing around women's health hubs will help, again, in bringing together a more resilient workforce to deal with some of those issues. But, it is a real challenge, because there are obviously the workforce recruitment issues and availability of workforce. So, it's not just—. We're happy to recruit, but sometimes it's about the availability of the workforce as well.

Thanks, Nick. I'm just conscious—I'm saying this to all Members and the Minister and her officials—we've only got half an hour left of the session and we've got more question areas to cover than we might have time for. So, can I just ask the Minister and her officials if you mind if Members politely interrupt you if you're not quite getting to the question we want?

Sure.

Thank you very much. And bear that in mind in terms of the lengths of the questions and answers that are given as well. Thank you. Mabon ap Gwynfor.

Chris, would you like to add to that?

Yes, so we need to build resilience in workforce terms across the whole pathway, clearly, and that is local provision of gynaecological services. Obviously, people working in gynaecological services are looking after many other conditions apart from cancers, as the Minister was saying, and also, throughout the pathway, people are working on different diagnostic investigations for different pathways. And then when people arrive in a specialised centre, such as Velindre in the south or the Swansea cancer centre, then the oncologist will be looking after them amongst many other people with different cancers as well.

We do recognise there's a need to build oncology capacity, and the health boards have agreed with HEIW and the Minister that there would be an increase in the training programmes for clinical oncology, I think, of four extra training places per year, and in medical oncology—they don't do the radiotherapy—for three. So, between 2025 and 2030, there will be 35 extra oncologists coming out of the training scheme, and we've also increased numbers for clinical radiology as well because that's been a pressure area. We can't easily say how many people are working specifically in gynaecological cancer because most people are working in a wider sphere, but we are trying to promote resilience across the whole pathway in workforce terms.

Thank you, Mabon. Gareth Davies. 

Thank you, Chair, and good morning, everybody. I just want to try and establish why health boards are performing so badly against the single cancer pathway for gynaecological cancers. Is it the complexities around gynaecological cancers themselves, or is it any other wider factors that could be contributing towards that?

I think we've touched upon the complexities already of—

I'm hoping to dig a bit deeper into those issues. 

So, if you think about symptoms, and where they're generally picked up—so, mostly, they're picked up in GP surgeries—you think about—. They generally pick up about eight a year, but in order to find those eight, they have to refer literally over 100. So, it's very difficult for GPs, who've got eight minutes to assess, 'Right, do they meet the threshold?' And one of the things we've got now, of course, are rapid diagnostic centres. So, where they don't quite meet the threshold of cancer suspicion, there's a mechanism for them to go down a different route through the rapid diagnostic centres. Chris, would you like to come in?

Yes. I think we touched on the problem, which is the rapid increase in recent years in referral rates, and the ability of the diagnostic pathways to match those referral rates. I think the capacity gap is in diagnostic services, principally. Hysteroscopy—a very important procedure for the diagnosis of endometrial or uterine cancer—there's quite a long waiting list for hysteroscopy, so that needs to be increased in capacity. So, I think the problem is in the greater referrals increasing in recent years, and the capacity of the pathway, particularly at that diagnostic stage. Nick will be able to tell us more about the diagnostics programme, but that's the problem, I think. 

We've spoken a lot about regional approaches. Are you able to expand more on what possible regional differences there are across Wales, whether it's more prevalent in certain areas, and whether we can sort of heat map it, if you like, to say, 'Well, if it's more prevalent in rural areas, or coastal, then we can perhaps look at where to streamline those services.'?

I don't know of any regional differences in the incidence of these cancers. I'd be very surprised, in a relatively small country like Wales, if there would be regional differences in the public health incidence. But there are clearly regional differences in the capacity to pick up those referrals, which I think is probably at the heart of your question about performance. 

Yes. 

And if you think about the NICE referrals, which changed in 2015, then, GPs kind of went, 'Well, we need to refer more people in here in order to pick up the numbers early enough in order to make a difference.' So, those numbers have doubled since 2015. We've had the pandemic since then, so, if you think about that massive increase, obviously, you can't switch on that kind of diagnostic capacity overnight. So, we're in the process of switching on that diagnostic capacity, but we're trying to do it now on a regional basis, to build in that resilience, to make sure that we are responding to that huge increase, which is a good thing. You think about the resources that need to go into that—that's a lot of resources in order to catch the cancer as early as we can. But that's absolutely the right thing to do. Nick.

Just picking up on the performance point, so, generally, across Wales, in terms of cancer performance, since the pandemic, it has fallen and is below the levels that we would like to see it. I think, looking underneath the headline percentage number is quite important, because we are treating more people; we're seeing more referrals and we're treating more people, and we had a big backlog. So, if anybody who is treated is over 62 days, in effect, that adds to the negative percentage on the performance. We specifically have said to health boards to treat the backlog because, as we've heard already, the experience of women has been a poor one in many cases, and therefore focusing on those who have already waited longest and getting them through the system either to say that they haven't got cancer or treat the cancer will bring the performance number down quite markedly. Because for every one—. So, we treat around about 100 patients for cancer every month and around about 35 to 40 are within the 62 days. And at the minute, it's about 50 or 60 that are over 62 days. Inevitably, therefore, the performance is poor. Many of those over 62 days may be 65 days or 70 days or 80 days, but they've breached the performance target, but, actually, their experience is a reasonable one.

Does that mean that the 62 days, then, is accurate enough, is a good enough indicator of performance? Because, obviously, that's where the bar is, so, obviously, that's where the standard has to be, and if it's not there and there's a higher proportion of people not meeting the 62, then that's a problem, isn't it, because whereas experience—

It's a problem from a performance statistic perspective. From a patient experience perspective, I think patients want to have their treatment as quickly as possible, and if they had it on the sixty-fifth or sixty-sixth day, as opposed to the sixtieth or sixty-first, their experience is virtually the same, but they've breached the target. So, I think it's—. Targets are clearly an aspiration and a benchmark of where we'd like to see health boards and services achieve, but more important is probably the patient's experience in overall terms. And what we've got to get to is a stability in the service, so that there isn't an enormous backlog, and, actually, then, we can get people through in less than 62 days, which is the clinical optimum pathway, if you like.

And the ambition's great—I obviously welcome the ambition to get to the 62 days. But what would be a realistic timeline to try and achieve better numbers in that in terms of—? Because the people who've given evidence to the committee over the last few months will want to see when this will be achieved and when it can happen. So, are you in a position to give a future timeline of when that could be achieved, or certainly work to try and get there, anyway?

So, I've been clear with the NHS that, actually, in a sense, when it comes to cancer, right, the 62-day limit—. I'm more worried about the people who've breached the 62-day limit, right, and I want those people treated, because they're waiting a long time; they're waiting longest. But treating them is not going to help me with my targets, because I've breached those targets, so—. But I don't care, frankly, because I want those people seen. So, I've made it very clear that they have to be seen before, which means that we are less likely to hit our target. But I think that is where it should be, and I'm happy to defend that position.

Does that mean you're in a constant downward spiral—

No, because, actually, they've come down. They've come down significantly.

—and you're stuck in a cage that you can't get out of, because of the cyclical problems?

No, no, no. They've come down significantly, but I think it's absolutely right to concentrate on those people. So, what we've got—. We've got the single cancer pathway. It was interesting to see in England over the summer that they've reassessed how they do the cancer pathway. I can't remember when we introduced ours, but it was several years ago, and they've had several—I think five or six—different cancer pathways, and then they stop the clock, they start the clock, and then you start, you go on a different pathway, you start your diagnostics and—. So, they're now going down to, I think, a couple of pathways, so still not a single cancer pathway, which we've got. So, I think it's right, because if you're a patient, you're one patient, that clock is ticking, and I think they want to know how long—. They're not interested in stopping clocks anywhere along this process. So, I think the single cancer pathway is the right way to go.

But probably what the English system would put back to that notion is to say, 'Well, is the single cancer pathway correct, and is it right that you have to have a live and nimble system in order to change, according to the patients that we serve?', isn't it, you know.

We developed this—

Just for time, I'll ask the Minister to come back on this, and then we'll move on to the next subject area. I'm sorry for—

Yes, sorry, we're being a little bit distracted here. But, listen, that single cancer pathway was developed with clinicians and with patients, and I think it's certainly something that's appreciated by the third sector organisations who are involved in this.

Okay. Thank you, Chair.

Thank you. The next set of questions is from Sarah Murphy. If we can try and do this section in about five minutes, that would be really helpful.

Absolutely.

That will be hard.

No, that's fine. I think the answers should be able to be given in that time, for sure. So, we've mentioned analysing data today, we've mentioned the comparison with the English NHS as well. So, I'm going to ask some questions now about the data and intelligence that we've received through this. So, the Welsh Cancer Intelligence and Surveillance Unit registry data shows that the proportion of women diagnosed at stage 1 of ovarian cancer has been decreasing gradually towards the end of the last decade, whilst, simultaneously, stage 4 has been increasing. An international cancer benchmarking partnership research paper, co-authored by Professor Dyfed Wyn Huws, with many others from cancer registries around the world, showed that Wales had the third highest proportion of ovarian cancer diagnosis and emergency presentation out of nine high-income jurisdictions with comparable models of healthcare systems. So, I do understand that it is up to the health boards to plan how to address this, and we have talked about your goals when it comes to referral rates. But NHS England has just set a target to improve their survival rate for cancer, generally, of five years or more by an additional 55,000 people by 2028, and plan to diagnose 75 per cent of cancers at stages 1 or 2 by 2028. So, what is the Minister's ambition for improving cancer survival rates in Wales, specifically gynaecological cancers?

So, effectively, our ambition is set out within the targets that we have—so, 62 days from suspicion. And that's all they've done in England is to say, 'Right, with this new cancer pathway, these are our targets.' We already have those targets.

What are our targets, then, for survival rates?

So, we could crunch the numbers on that quite easily, couldn't we, I guess, Nick.

Yes. I think we could—. If we got everybody through in the 62-day pathway, so, let's say to 75 per cent, then, yes, we could crunch a number that then gives us an indicative improvement or otherwise in the survival rate. We would have to look at the volume of patients coming through and do the necessary analysis, but we can have a look at that.

Could you write to us then, and follow up with us on that?

Yes.

Brilliant. Thank you. And then the most recent data on cancer incidence and survival covers the period 2017 to 2019, which really does limit its usefulness, especially as it was pre COVID and so much has changed, particularly with access to in-person appointments with GPs. When it comes to disaggregated data, the Welsh Cancer Intelligence and Surveillance Unit does routinely collect population-based gynaecological cancer data on every case in Wales, and it does it to a very detailed sub-type level, and they publish this at a granular level. But the single cancer pathway referral data isn't disaggregated to particular cancer types and sub-types—it's all lumped in under 'gynaecological'. So, firstly, who is responsible for ensuring the Welsh Cancer Intelligence and Surveillance Unit is adequately resourced to validate the statistics in a timely way? Why do we not have this four years later? And why isn't the referral data for suspected gynaecological cancer broken down by sub-type as well?

So, Public Health Wales provide the surveillance and incidence data. They've not informed us that they have insufficient resource to manage that system or produce the data that's required, so we—

So, when you ask them, 'Why haven't you done it?', what do they tell you?

I haven't asked them that question. So, we can ask them that question.

Okay. Because aren't you worried? It's 2019 that's the last—

All survival data is always, clearly, in the past, but we can ask them the question as to why they haven't published any up-to-date data, and do they have the sufficient resource to do that.

Absolutely.

And so they would be responsible for that element of it. We can ask that question. In terms of the disaggregation of the single cancer pathway data, the CaNISC system that supports the cancer pathways is being replaced with a business information tool, which will then allow us to start to disaggregate the data around each of the individual modalities or types of cancer. We have a similar issue in terms of understanding the different types of diagnostic tests that are required, and the data related to that. So, part of the NHS exec's work, as well as the new chief digital officer for the NHS in Wales, is to look at more, I suppose, intuitive and interactive use of the data. We've got all the data; what we're not good at is pulling it out into visible support mechanisms that help us then start to identify the problems. So, that is one of—. Mike Emery, who's the chief digital and innovation officer, it's one of his chief challenges as we go forward. It's one of the key objectives of replacing CaNISC as the system. And as I alluded to earlier, it's one of the key objectives around the digitalisation, if you like, of pathways as part of the cancer improvement plan. 

And do you have a timescale for that? 

I haven't got a specific timescale and I wouldn't want to say, 'Oh, it's by x date', but I think it's a work in progress that needs to improve over the next 12 to 18 months. 

Right, okay. My last question. Again, the Wales Cancer Intelligence and Surveillance Unit's population-based cancer registry official statistics demonstrate that one-year survival has been decreasing slowly in Wales for uterine and ovarian cancers since around the middle of the last decade. It also demonstrates that five-year survival in Wales has changed little since the middle of the last decade for cervical and ovarian cancer, and has been decreasing since early in the last decade for uterine cancer. So, you've already touched on some of the examples of where you think the pinch-points are, but it would be good just have an idea of what types of gynaecological cancer may be contributing to the increase in these referrals. What are the ones that we are particularly bad at catching? 

Firstly, I think the Wales Cancer Intelligence and Surveillance Unit is a highly reputable unit that works with other similar units across the world, as you indicate, and does publish official stats, including those for cervical, ovarian and uterine cancer. And it is true that five-year survival rates have increased for cervical and ovarian cancer. Survival rates have decreased for uterine cancer, and that is not unique to Wales. I don't know exactly which countries in the developed world show that, but I think it's apparent in the US. And I think one of the arguments is that it's possible due to the prevalence of risk factors for uterine cancer, which include obesity, diabetes and hypertension in an ageing population. How that causes uterine cancer I don't think is entirely clear, but I have read some research evidence that suggests that fat cells that are metabolically active alter the ratio between oestrogen and progesterone, so that the protective effect on the uterine lining of progesterone is diminished. So, that is a problem. It's a public health-type problem. So, there are encouraging signs for the other two main cancers, but uterine cancer is going the wrong way. 

Okay. Thank you very much. Thank you, Chair. 

Thank you, Sarah. Joyce Watson, you've probably got about five minutes for this section. 

Thank you. I read the same article. I want to look further at the rapid diagnostic centres. There are really good reports about them, and it means that all those tests that people need when they're referred happen in the same place, and that the results are given on the same day or very soon afterwards, which is all the things we would like for people. So, my question's obvious. We have one, it's very good, it's had really good reports, the one in Neath and Port Talbot. When can we expect to see others? That's the question. 

We've gone ahead of the rest of the UK on these rapid diagnostic centres. I think a delegation went over to Denmark to see how is it that they catch things earlier, and this was one of the lessons that we brought back and we've taken up and we've implemented. So, now we do have rapid diagnostic centres—I think you said eight. 

We have eight. 

Eight rapid diagnostic centres—three in north Wales, you'll be pleased to hear, Jack. So, I think that's positive. You know about the financial constraints we're under at the moment, in particular in relation to capital. So, I think it will be difficult for us to go much further for the time being. But I think we're very pleased that these have been set up.

And obviously you have to be referred to a rapid diagnostic centre, and you did talk about the weakness in the diagnostics because of the growth, obviously, and, I'm assuming, a shortage in staff. But my question is this: there's really positive news about GPs having training. We're talking about the GPs who are already in existence rather than going through training. So, my question is: is it compulsory for them? And are they all taking that opportunity up? Do we know, if that is not the case, that we have areas maybe where we might have an issue about GPs not availing themselves of the workshops you've described?

I think this goes back to the issue of equity of outcome, and also the role of the NHS executive, because we can measure GP referral rates and we can measure conversion rates when referrals are received, and we can see there are variations between health boards. That’s the sort of monitoring and measurement information I would expect the NHS executive to become really very, very hot on. And then to actually engage them with health boards on the data, to actually challenge areas where we think maybe GPs are referring less. But for me, that would be the mechanism, and I think, then, the data through the NHS executive would then be triggering the next planning process, and then the improvement support would be to facilitate the training and education or whatever it is that the GP communities need. For me, that is where the NHS executive, working when fully fledged, will bring added benefit. 

Okay. Because, as you say, it is about equity. So, if those GPs aren't availing themselves of the training, and therefore—. And I understand they're all individual private practices in the main—in the main. Maybe, I suppose, following on from that, the new training programme for the GPs who are entering now, or are in training to enter—are they being trained specifically in this area?

I'm not aware of specific training in gynaecological cancers for GPs. Obviously they've got to cover an incredibly wide range of experiences, haven't they? But I do think that the support that I described at the outset is available to all GPs. All GPs will be aware of National Institute for Health and Care Excellence guidance. They may struggle at times to follow it, perhaps. But some of these conditions are very difficult to diagnose clinically. You, I think, know very well that, particularly for ovarian cancer, which has the lowest survival rate, the symptoms are very non-specific. You have no symptoms in the early phase, but then even in the later phase the symptoms are very non-specific—abdominal bloating, urinary frequency, this type of thing—and it's very difficult, I think, then, for a GP sometimes to distinguish what warrants a referral. Clearly, if those symptoms happen in someone over the age of 50, I think that's more of a concern. If they've got major risk factors, as I described, that would be a concern. But this is all quite difficult because so many people present with so many symptoms, and the vast majority of them do not have anything serious underpinning them.

Thank you, Joyce. Sarah—Sarah Murphy. 

It's not me, is it?

Okay—I'll come to Jack next.

Diolch, Cadeirydd. Minister, the World Health Organization has a target of 90 per cent uptake of the human papillomavirus vaccination. Wales has got a high target—I think it's around 84 per cent, 85 per cent, for the first dose; a bit less for the second dose. That target's by 2030. Is it achievable, and if it is, what steps do we need to take to reach it?

Well, I think we're already on quite a good journey in relation to that. I think the figure was about 70 per cent uptake already, so that's not bad. Of course, we were the first part of the UK to introduce the HPV screening, so all of that means that the alarm bells are starting to ring even before there's any cancer anywhere near. So, HPV gives you an indication that, actually, we should monitor more readily. What that means is that we only need to recall people once every five years, but if we think that there's a problem, then we're recalling them far more frequently. So, I think we're on about 70 per cent now, so that's not a bad figure to be starting off with, I think.

Is the ambition still to try and get to 90 per cent by 2030?

Look, I think we should be ambitious, and if the WHO is recommending that target, we've got to take it seriously. We know that it's really difficult to get to some sectors of the population. We've learnt a hell of a lot through the vaccination programme on how to get to those hard-to-reach people. So, we're putting some of that into practice now in terms of reaching out into those communities, but it's a hard slog to get to some of those communities. Of course, what we do know is that the incidence of cancer in more deprived communities, which are some of the more hard-to-reach areas, is greater, so it makes sense for us to make sure that we focus on those areas as well. But it's quite resource-heavy to do the kind of really intensive work we did in relation to the vaccination programme.

Some of those concerns and some of those barriers in place with the HPV take-up are similar to the barriers with cervical screening in general. The UK National Screening Committee will look at a report from NHS England—I think it was YouScreen—in London on the trial of in-home cervical screening tests. You may be aware that there's a petition, actually, by women's rights activists, Molly Fenton and Councillor Jess Moultrie, and they call for introducing an at-home smear test option in Wales. If the screening committee recommends that this is a valid option and gives its approval, will the Welsh Government make it a priority to introduce that at pace, and do we have the resources to be able to do that at pace?

I think we need to take it very seriously, particularly if that's what helps us to get to the hard-to-reach areas, and I think there's some evidence to suggest that people are more comfortable using that approach. We are financially challenged at the moment, but I think we would definitely need to look at that as a principle, if it looks like it's a successful pilot.

Okay. Diolch.

Thank you, Jack. Sorry, Sarah. Now, Sarah Murphy.

Just to double-check, we're on section 8, aren't we?

Yes. You had some questions around research and innovation, I think.

That's right. One moment—sorry. The main question I think we needed to ask on this was that Sarah Burton told the committee that some new cancer drugs and treatments had taken longer to introduce in Wales than in other parts of the UK because the funding isn't always available. And then Professor Iolo Doull argued that,

'potentially, Wales has faster access to new medicines than the rest of UK'.

So, who is correct? Is the Minister aware of the frustrations that some clinicians have in accessing new cancer drugs? I know that this is something that I've had constituents come to me about as well.

We've got the new treatment fund, haven't we?

Yes. So, they're both correct in the sense that we have a commitment that we're meeting to make drugs available within 60 days of approval by NICE. So, Iolo would've referred to that. The other colleague that you mentioned would've referred, though, to the implementation challenge that some of these new medicines bring with them. So, some of the new medicines require whole-scale changes in the clinical pathway, sometimes more testing by pathology services, and they naturally take longer to implement. So, the drug is available, but actually not rolled out because of the implementation challenges. And some health boards are struggling to meet those implementation challenges. It requires whole new pathways to be set up; it's extra work for some services that are already under considerable pressure. So, we do understand the challenge, but still, the commitment is there to deliver on NICE-recommended medications.

Okay. And could you just give us an example that you have, especially if it's in relation to gynaecological cancer, where this may be something that's being delayed?

I'm not aware of any examples in relation to gynaecological cancer. There is a drug for prostate cancer, the name of which I think—they're all a jumble of consonants. I think I forget the name. But that's one that's come to my attention. But I think, increasingly, as these approvals come for certain patients with certain clinical and often biochemical or histological criteria, then it's great, because this is precision medicine starting to be seen, that, actually, we would expect these drugs, when they're targeted at the right people, to be more effective. These do represent new ways of working, and they do bring with their implementation practical challenges.

Of course. Okay, thank you. Just my last question, then, more around the clinical trials: is expanding Wales's research capacity and providing a supporting infrastructure for cancer research and clinical trials a priority for the Welsh Government, and are you satisfied that what's being provided is a clear direction on what needs to be achieved and when?

In July 2022 the cancer research strategy for Wales was published, with the aim of developing a well-resourced collaborative, which really focused on the community that's going to support developments in relation to that. So, the Wales cancer research centre is providing strategic oversight in terms of the implementation of that strategy.

Okay. Is there anything you'd say specifically, then, about the gynaecological cancer clinical trials that you expect to see or are happening in Wales?

I understand there are 17 clinical trials ongoing that are recruiting people with gynaecological cancers, which I think is quite impressive. There also are research groups working across Wales, and gynaecological cancer is also one of the seven multidisciplinary research groupings that Health and Care Research Wales have put in place, so that combines clinical investigators with non-clinical investigators and creates that community of practice. I was interested to see that in Swansea University, there's one group I think that call themselves a cluster for epigenomics and antibody drug treatments, which has £5 million in funding, and that's specifically for ovarian cancer. That's looking at drugs that can influence certain proteins, which then influence gene expression, but that is specifically around ovarian cancer. So, we do have a presence for gynaecological cancers in research terms in Wales, but, obviously, ultimately, we're dependent on the global research community.

Of course. Thank you. That's really positive to hear. Thank you very much. Thank you, Chair.

Thank you. Can I just pick up on Sarah Murphy's first point, because we had some evidence that new cancer drugs and treatments have taken longer to introduce in Wales than other parts of the UK? The suggestion is it's because funding isn't always available. Can I just ask you to clarify that? Is that the case?

I think that's a bit anecdotal. I think it's hard to say that Wales is slower than England in this respect. I don't know, and I don't suppose our colleagues know, about the data in all of the English foundation trusts and elsewhere. But there are some challenges in relation to implementing some of the new NICE-recommended drugs.

I suppose it wasn't so much I was trying to draw out a comparison with England. The evidence that was there was that it's taking longer to draw out in Wales than other parts of the UK, but you're saying you don't have—

I'd be surprised if there's any evidence.

That's not your knowledge. Okay.

We've got the new treatment fund that exists and it's a significant amount of money. So, I'd be very surprised if that were the case.

Okay. Well, that's a clear answer. Thank you. Any other questions from anybody at all? No. Thank you. We rushed through that last session quite quickly. We've had lots of questions today, but thank you, Minister, and I thank your officials for being with us this morning. Diolch yn fawr iawn.

Thank you.

I move to item 3, and I propose in accordance with Standing Order 17.42 that the committee resolves to exclude the public for items 4, 7, 8 and 9. Are Members content? Thank you. We'll go into private session and be back in public session at 11.30 a.m.

Croeso, pawb—welcome back to the Health and Social Care Committee. I move to item 5, and this session is in regard to that, earlier in the year, the committee agreed to hold a scene-setting session with relevant experts to gain a clearer understanding of health systems across Europe and how we in Wales might learn from other areas. So, this morning, I would very much like to welcome Mark Dayan and Professor Scott Greer. So, thank you ever so much, both, for being with us this morning. Just to say that it's a hybrid meeting, so one of our Members is on the screen, Mabon ap Gwynfor, and the other Members are in the committee room here in the Senedd in Wales.

It might be helpful to start with if you just give us a little bit of background about yourselves, a bio, that would be helpful, and your background, and tell us where you're beaming in from as well. That might be helpful as well. So, shall I come to Mark Dayan first? Mark.

Yes, thank you. So, I'm Mark Dayan. I am head of public affairs and lead our Brexit programme at Nuffield Trust, and I've done responsive and comparative policy work for us for a few years as well. We've worked on programmes on integrated care in the different UK countries, and on a number of reviews at the request of different parts of the Welsh health system, or the Government. So, I have worked through our comparative within the UK programme's work, which hopefully should be relevant. I'm also our correspondent for the European observatory's health systems policy monitor, so I feed in items of reform from across the UK, including Wales, and discuss those in a wider context, which I hope should be helpful in his session. I'm beaming in from London.

And Professor Greer.

Thank you for having me, above all. So, I'm Professor Scott Greer. I teach health management and policy, global public health and political science at the University of Michigan. I'm beaming in from Brussels, because I'm also senior expert adviser on health governance to the European Observatory on Health Systems and Policies, and I've spent a lot of time in my past working on Wales, but haven't done any original research in Wales now, so I wouldn't consider myself an expert in Welsh health policy but I’ve done a lot of work on comparative European health systems and ways that they choose to allocate their resources over the last few years.

Thank you, both, and I suppose, in one sense, we as committee members won't expect you to be that familiar with the Welsh health system, because we want to pick your brains on health systems elsewhere across Europe, but, of course, it's helpful that you know some context of the Welsh health system because we want to look for comparable nations.

So, as a health committee, our job is to scrutinise the Government, make recommendations to Government. So, perhaps just give us a starting point, for us, in terms of, as a health committee, what might be your suggestions of places that we could look or areas that we could look to, and, I suppose, in the context of perhaps looking at systems across Europe that might be similar to us geographically and population wise and have some of the same character—that might be helpful in that context as well. Give us some pointers where we should be looking to additionally. And perhaps also, if I can add as well, how our health outcomes compare as well. Ultimately, we want to look to countries where there are good health outcomes and that we can learn from, I suppose, as well, in that context. Who wants to go first on that? Go on, Mark.

I'll go first, that's fine. Then I'm sure that Scott can give a much better informed take in terms of European health models.

I think the first thing to say is that there is potentially some really interesting work for this committee to do at perhaps a more fundamental level, which is just in terms of how difficult it really is to compare Wales to other countries’ health systems and to understand some of the differences and similarities. You’ll be familiar with the difficulty of comparing Wales to other parts of the UK—data tends not to align. And unfortunately, that is magnified when you take that through the fairly limited number of types of data that are collected in an internationally comparable way, mostly by the Organisation for Economic Co-operation and Development, and then you try to look at other countries.

So, much of the data that we have treats the UK as one unit. Somewhere out there will be more or less comparable Welsh data because the Welsh Government is submitting it through to form a full UK figure for a lot of these indicators. And so that does offer a potential resource to improve understanding. But, beyond that, I think there’s also a lot of detailed work that largely has never been done, as far as I know, in terms of whether you compare Wales to comparably sized autonomous nations, regions, elsewhere in the UK or comparably sized countries at a much finer level of detail than we’ve ever really got through the OECD and prefabricated international data—so, lining up basic things about how the workforce works, how admission and discharge work. There’s certainly scope for studies into that, which would have to go much deeper into those countries’ data, but it’s not something that’s been very extensively done so far.

And then the second thing just to reflect is that the overall context is increasingly one that’s defined by financial strain, and that’s true everywhere—financial strain and the drive to maintain capacity and activity. We’re seeing bigger overspends within Wales at the moment than I think has historically been the case. Wales is within the UK, which is a strained spender in terms of having a relatively small state for a country with universal healthcare and that has been passed on in a Welsh context. And so I’m sure that this is something that’s very much on your horizon, but looking at ways that that context of strain on resources and strain on finance and in particular long-term investment, which has been a longstanding UK, I’m afraid, I think generally, including Wales, weak point—. And what other countries can teach about that is important. But, at the same time, there is always a risk, frankly, of finding a much better funded country and seeing the interesting things it does, but discovering that, actually, that would be really challenging to transpose into a country where funding is considerably lower.

So, I think I’ll stop there. I’m afraid those are more general, scene-setting points than suggesting individual countries, which I’m happy to come back to, but I'm conscious of the need to let Scott have a go.

Sure. Before I bring in Professor Scott as well, I think, from my perspective, we're used to, in this committee, comparing Wales to England. It's quite common. But I suppose, in this session this morning, in a wider context, Wales is relatively the same as England in terms of how our systems operate. So, I suppose when we're asking questions about Wales, it's Wales/UK on that basis, compared to some other countries as well across Europe. Yes, Professor Scott.

I'm really glad that Mark went first, because I want to underline that, in a comparative context, frequently the most important thing about all the UK health systems is how hot they traditionally run, no matter how you count it: fewer beds, fewer nurses, fewer doctors per capita, less percentage of GDP. That's not quite as true for Wales as it is for England, but it's still striking compared to countries like Belgium and Germany. They just have more resources. And what that means is that, in many ways, a tradition of austerity shapes the NHS systems and gives them really, really—. They deliver a lot of healthcare for the amount of money put into them, but we don't know much about what their culture and performance would look like if they had higher expenditure, because we had, essentially, one short period under the Blair and Brown Governments where they had a level of funding that you would expect from western European peer countries. 

That also matters because, when you're picking comparator countries or regions, one of the important things is all the other social determinants of health that come in ahead of time. So, one of the things I like to point out is that the United Kingdom Government and the Swedish Government do about as much to equalise income, Gini coefficient, as each other. So, the United Kingdom Government, through taxes and transfers—so these are UK powers, overwhelmingly—they redistribute about as much as the Swedish Government. The difference is actually in the pre-existing level of equality, which is down to things like the structure of the Swedish economy. So, when you compare to Sweden, you're starting with a very different population before taxes and transfers and also before they have or need any social services.

What that means is that I would echo Mark's point that it's tricky to identify regions, but it's really useful that you identified areas that you might want to think about, because there are a couple of ways that you can think about Welsh problems that are very comparable to the problems of other parts of Europe, and I would just highlight two of them. One of them is workforce. There are a lot of health systems right now that are undergoing a great resignation, that are having trouble attracting and motivating and retaining workforces and adapting them to the needs of a changing skill mix and changing technologies. And the other would be the extent to which, outside taxes and transfers, outside remodelling the entire economy, there's a lot of local-level activity that's very effective in terms of prevention and promoting healthy lifestyles, where a lot of Governments in Europe are comparable in that they control local government, they control a lot of infrastructure, they control the design of a lot of public services and they can do a lot. So, I'd look at those two policy areas for really interesting precise comparators on where you could solve problems. 

Thank you, Professor Scott. This is a free-flowing discussion as well, if Members want to indicate to come in. I know, Joyce, Professor Scott just mentioned workforce issues and I know you had some questions around that. Do you want to come in on those now?

Yes. Good morning, both. One of the things about workforce is, of course, combining health and care workforces, because one is mutually dependent on the other, and if you can you give any examples of other European countries, and maybe a reference to pay, terms and conditions and staff retention, that might be useful to us. 

I'll take that in two parts. One is that I would say there is a consensus, and there has been a lot of research and research synthesis because a lot of European countries are facing serious workforce problems. And broadly, the three-step plan for working on your workforce is to make sure that you adapt training to skill mix changes, so, if you're investing in primary care and you have a lot of surgeons, you're going to end up with demand created by surgeons that will reduce the effectiveness of your shift. One is better working conditions to reduce attrition and retain staff. Notice I said 'better working conditions'. Pay matters, but so does the nature and organisation of the work. And the third one is ongoing retraining and professional development for all professions. It's very easy to focus on especially nurses when you're talking about retraining and forget all of the other occupations in the health system. And I think that's pretty close to the consensus of what works from research and policy experience.

Integration is tricky, and we have, including within the UK and Northern Ireland, for example, a lot of cases where literally integrating health and social care was no panacea. It didn't solve the problems because, essentially, the hospitals ate much of the social care budget, as you would predict from the way the politics of medicine tend to work. What does seem to work—and you can do this in any organisational format—is thinking about how to have a better resourced, better working conditions, better trained care workforce, because right now, in most countries, if you don't spend enough on it you default to all the problems we know about: privatisation, meaning people finding somebody from another country to look after grandma; you get a lot of low-quality operators; you get a lot of turnover; you get a lot of demotivated staff; and problems like that. So, thinking hard about the care workforce as the object of policy is a necessary complement to reorganising the nature of the workforce itself, I would say.

Mabon wanted to come in as well. Joyce, did you want to—? I'll come back to Mabon and Sarah. Do you want to jump in as well afterwards? Shall I come to Mabon first?

Do Mabon first.

Yes. Mabon.

Yes, thanks, and thank you both for coming into this committee and giving your expert evidence. I suppose, if we go back one step, albeit that we have different legislative frameworks in the various regions and countries, one comparison that's used every time is how much money per head is put into the health service, and we see that in the UK. In Wales, we have this amount spent per head, in England it's this amount, in Scotland yada yada yada. So, can you, just on that basic level, give us an idea, if you have that information, on the various spends per head that we have on health, and who spends more, who spends less, and which countries are more effective in their spends?

I was going to add to that, as well, to Mabon's question, in terms of: does it also follow through that the more you spend on health follows through to outcomes as well? Is the chart the same for outcomes and spend?

Yes, that's a great question. Unfortunately, in terms of the year we're asking it, it's an unusually difficult time to give a really robust answer, because we have had the issue that additional spending during COVID-19, particularly in the UK—or a lot of it—got counted as health spend. It's caused these quite sharp fluctuations that we've seen in the last few years' worth of internationally comparative data, and to some extent it's done that in the UK as well, boosting apparent spending in England that is arguably more categorisable as COVID-19 spending related to the pandemic across the UK as a whole.

With that said, I think, if you go back over a slightly longer time period, there are two basic points that I think should underpin understandings and hopefully will answer your question a bit. One is that Wales does have a reasonably consistent position in terms of its spending per head on health, and that's basically somewhat higher than England, but certainly lower than Scotland and Northern Ireland. So, if we look at the pre-pandemic years, Wales is usually spending 3 per cent to 10 per cent more than England, which is a significant additional sum. I think, insofar as this work's been done, it's potentially a bit less than the additional need that Wales might be expected to have, and it's slightly less than a proportionate translation of the Welsh total public spend compared to that of England, which has prioritised the NHS more within a public sector generally subjected to quite sharp austerity in the last 13 to 15 years. And then you can take the UK, bearing in mind that Wales is spending slightly more than that, and compare it to other countries.

A complicating factor here as well is: what are these other countries you're comparing it to? For a northern European country, the UK is usually spending a good 1, 2, 3 percentage points less of GDP on health than most of its neighbours, countries like France, the Netherlands, the Nordic countries. It spends a much more similar amount to southern European countries like Spain or Italy, sometimes more, and, of course, a far lower proportion than the USA, which has very high health spending. So, generally, Wales is a slightly above average spending nation within a slightly more below where you'd expect spending overall state.

And I think one last point to pick out there, just to bring back something I said earlier, but I think it does bear repeating: historically, although this has slightly changed in recent years, another notable thing about the UK has been its low level of fixed capital investment in health—so, less spending on buildings, IT purchases and initiations, equipment, than comparable countries. At times, that's been really strikingly low. And while there's a lot of ups and downs in that in Wales, because, as a relatively smaller country, individual projects can mean quite a big increase in capital spend in-year, the draft budget for this year, which I was looking at recently, would include still a relatively low level of capital spend as a proportion of overall health spend compared to what you'd see in many other countries. 

Mabon, do you want to come back at all, or carry on with the discussion? No. That's fine. I suppose, from my—. I'm coming to Sarah next now, but, from my perspective, what I would hope to get out of this session today is to see if there are countries' or aspects of countries' health systems that we can look at that you think would be worthwhile us exploring as a committee to improve outcomes in Wales. I suppose that's where I would want to try and head in some of our discussion today. Sarah. 

Thank you. So, we've had a discussion—. Sorry, first of all, thank you, both, for being here today; it's wonderful to be able to pick your brains about this. So, we've talked about how much funding there is, but I'd like to look a little bit more at how that money is being spent and where it's being spent, specifically in relation to the research that you've done around building up community health and care services. So, I'll be honest with you, I have some people who have described some of our hospitals now as actually just being care homes. I have a hospital in my constituency where we maybe have about 300 beds, and, at any given time, maybe about 80 to 100 of those patients are probably ready to go home, but there's not that link-up at the moment—although we're getting there—with the social care service for them to be able to leave. And I noticed in your research that you've said that most countries with similarly low numbers of acute beds to the UK but with shorter lengths of hospital stay tend to direct more of their healthcare spend towards non-patient, in-patient services. So, you've said Netherlands, Sweden, Denmark, Norway. And it seems to be that that degree of—. By long-term reallocation, you've said, of resources—. It needs that long term. And I think the problem that we've had is we've been going through so much crisis that the long term is difficult to plan, right, but this has been happening everywhere, to be fair. 

So, it would just be really helpful, I suppose, if you could expand a little more on this and what's the progress with those countries, I guess. Are they seeing that it's making a difference, having more services in the community? A little bit more on the benefits would be very helpful. But, mostly, coming back to what the Chair just asked there, Wales does have an ageing population. We are older and sicker in comparison to other parts of the UK. So, it's all well and good, I suppose, looking to the Netherlands, Sweden, Denmark and Norway, but it would be particularly helpful, right, looking at countries that are similar in demographics to us as well, so we can learn from them is this working, do we need to really make a conscious shift to that long-term funding.

Right. Well, I'll respond to that, because I think that's our report that you're talking about. 

Yes.

I'm glad that you've seen that. Yes, I think, to answer the first part of your question there, this is, potentially, an area that's very relevant to Wales, because this report, in which—. For those of you who haven't seen it, we sort of looked at the UK as a whole, and then further drilled down to England, as this country that, just as Scott said earlier, runs very, very hot, and we looked at other countries that have comparably few hospital beds per person, and several of them are managing a shorter length of stay in hospital, which, generally, is indicating that you may be able to cope better with that lower bed base, because you're, essentially, fitting more patients through each bed each year. So, that's relevant to some of the sorts of access and waiting times problems that we discuss so much.

And for Wales, this is maybe an even more pressing issue, I think, because Wales doesn't have that many more hospital beds than England, but it does have a considerably longer length of stay. And there's a lot of uncertainty about—and you've probably been through this as a committee—the comparability of the data. So, I don't think anybody would dispute that patients in Wales tend to spend much longer in hospital, which potentially suggests there's more to be gained from finding ways to move them through faster.

So, those countries that we looked at, they are the star pupils in terms of having the shortest length of stay in Europe in the OECD, and there are so many interesting points to learn from them. I think the point about demographic differences between Wales and them is one of two caveats to really bear in mind. And certainly, I think that's not just a question of the ageing population, because all of these countries will have population ageing. They, I think in all cases, will have a higher life expectancy than Wales, and so they certainly have large and growing populations of older people. But there are other really important demographic differences as well, and those will include, for example, where the population is in Wales, the levels of deprivation and some of the public health problems being inherited. So, that's one thing to really think about when making the comparison, and then, of course, the other is the level of resourcing. These are all relatively high-spending countries, which may make it somewhat easier for them to trade off that idea of shifting some of the capacity out of in-patient care and into other things. But, with that said, as you will have seen, some of the themes that we pick up for further investigation about how these countries may be achieving that are that some of them have had a really conscious long-term process of change to streamline their hospital sectors. Several of them are actually spending a lot more on out-patient care, not just on community and primary care, although they are doing that as well. And mostly all the Scandinavian ones, at least—

Sorry. Where are these countries, Mark? Sorry.

Sorry. These are—. So, the four that we really focused on are Denmark, Norway, Sweden and the Netherlands. In the case of the first three there, so the Scandinavian countries, what they also have is a model where responsibility for health and social care is much more blended. So, their municipalities, which are local government areas on a really quite small level, share responsibility for both non-hospital healthcare and social care. So, they have a wider remit across that. In some senses, that's a degree of general decentralisation as well that goes beyond what you see in any of the UK countries.

I was going to say I'm trying to make this a free-flowing discussion, so if anybody wants to come in with a quick question, to clarify, then just indicate; I'll bring you in straight away. Jack, do you want to come in now?

I think Professor Greer might want to add to those points, and then perhaps I'll come in after that.

Oh, yes. Thank you. Great. Thank you.

Thank you. I just wanted to say there are also countries where part of this intentional process has been to create a happy and professional and fairly stable care workforce, so it's a job that you could legitimately have for life, and view as skilled and as having professional prospects. And you see the benefits, that a happy and professionalised workforce gives you better quality, and it also gives you better quantity. And there are a lot of sad experiences around Europe of something much more comparable to the UK systems, where there's not enough of the publicly funded care and just a lot of not-very-good quality private operators working for all sorts of different sources of income.

Just in terms of comparison, the other thing is these are very equal and basically healthy countries, so that's a good starting place. I was trying to take up your challenge to think of comparable parts of Europe. Northern Spain runs NHS-model systems, and they have a lot of the problems of—. Essentially, they have a lot of mountains, they have a wide variety of different kinds of economies in a place like Asturias, which runs from former coal-mining towns all the way to very beautiful green mountains. They also have a relatively ageing population, a fairly high level of income inequality as part of Spain as a whole.

It sounds just like Wales except for the weather. [Laughter.]

They get most of the—. Spain gets as much rain, overall, as the United Kingdom. It's just that all of that is in the north, so don't leave your anorak behind, if you go.

Ah. Okay.

The other place, though, I think, if you're looking at what can you do with social determinants of health problems, is northern Germany, northern France, large parts of Belgium. They're totally different health systems. You're not going to learn a lot of directly applicable lessons from getting into the weeds of Belgian social insurance, but you can learn a lot about broader determinants of health—things like the built environment, things like dealing with pollution, things like the nexus between social care and recapacitation and care in the community. The things that influence health—you'll often find they're dealing with many of the same problems and many of the same constraints in the formerly industrial northern half of Germany, the northern parts of France and Belgium.

Do you want to jump in, Jack?

Yes. Thanks, Russ. And thanks, both, for being here, as others have said. We've talked about a few policy areas. I wonder if there is perhaps another policy area that is looking at the efficiency of current systems and infrastructure, and rather than buildings and hospitals et cetera, more IT systems and the infrastructure around the digitalisation of our healthcare and social care—the integration of those. Because we've had numerous examples where information can't be shared from GP to GP, or NHS service to NHS service, or social care service—we speak a lot about electronic prescribing, which will hopefully be sorted. But there's a case, perhaps, to focus on the efficiency of our system and how we can increase that. Is there any particular region or area where the efficiency of their system is pretty good, pretty sharp, that we can perhaps take a quick look at from a policy level?

And just to jump in on an earlier question, you've mentioned northern Spain and a part of Germany, just to understand, is there a degree of devolution in European countries? Perhaps talk to that point as well as addressing Jack's wider point.

Yes. I'll answer the country point before I go to Jack's subsequent question. Spain would look very familiar to you. The regional governments run their health systems, they were basically all set up, quite literally, on the NHS model—they hired consultants in from the United Kingdom. And they therefore have a lot of the same policy mix. There is a social security administration run from Madrid, but there is a health system and local governments that are quite clearly under the control of the regional governments. So, if you look at the data on the population, they're fairly comparable and they get some pretty good outcomes, and they are grappling with some of the same problems, such as their care workforce is not the professionalised, happy, Dutch care workforce, it's much more kind of what countries in the world default to, which is small, private homes of varying quality. So, I would think seriously about them.

The Germans and the French, they're devolved, in a meaningful way, in things that aren't directly healthcare. So, social services, the built environment and local government—basically, things and not health people stuff you'll find are under their power. So, if you're looking at, for example, encouraging people to walk to work, that's a thing on which a French, German or Belgian regional government is quite able to talk.

On efficiency and technology, technology generally gets you better quality, it doesn't necessarily save you money. Over and over again, we find that if, for example, you introduce really good health IT, you frequently end up getting more tests, because one of the reasons you introduce health IT is so that a dialogue box pops up and says, 'Have you checked this patient for sepsis?', to pick a currently very salient topic. Well, then you get more looking for sepsis. If you throw in, 'Has this patient had a screening for a particular cancer?', you get more cancer screening and you're likely to get more cancer treatment. And it doesn't necessarily reduce the duplication. It can reduce miscommunication, but you'll often find that you have a patient who arrives for an orthopaedic consult with an x-ray, and your average orthopaedic surgeon has no respect for any x-ray not taken by a specialist orthopaedic x-ray facility. So, you end up with two x-rays, both of them effectively saved in the system.

I spend a lot of time arguing with people who see health IT as a panacea, and I would say that you'd want to control it very, very tightly, because you can improve quality, you can spend a lot of money—the efficiency gains are often really not that impressive and it can really distort the practice of healthcare if you don't manage the introduction of the system well. There's a standard of care for many countries of, 'You should, if attending a birth in a hospital, have two nurses', and most nurses will tell you that one of the nurses is there to nurse everybody in the room and the other nurse is there to nurse the electronic health record.

I've got some questions on technology myself. Did you have anything else, Jack?

No.

I suppose I was a bit surprised to hear what you said, because we have lots of evidence about—. We just did a piece of work on dentistry, and dentists telling us there's a lot of bureaucracy and duplication of systems, there are two or three systems operating, or dentists have to duplicate data rather than it being populated. So, there's a lot of improvement in IT that could be done to make things more efficient. I had a constituent last week who contacted me saying, 'Look, my GP can't e-mail the x-rays to the hospital because they operate on different systems.' So, to me, it seems like it's an obvious thing that IT can help save and make efficiencies.

Yes, but what we're talking about often is precisely the legacy of previous IT systems that were introduced to create efficiencies. And it's very, very easy to find that you're stacking new systems on top of the others. So, you can simultaneously get better quality, because now a dialogue box pops up to say, 'This patient needs a cervical cancer screening', but at the same time, somehow, if you were to have two non-interoperable electronic health records, you're not getting the efficiency—you're getting twice as much bureaucracy. So, rationalising existing health IT and often replacing it with better integrated systems that do the same thing will probably get you an efficiency gain. But, in many ways, it's solving a problem created by the previous legacy in health IT.

Okay. I can see Mark wants to come in. All the time in my mind as well, I've got—. We want good examples of elsewhere in Europe where something might be done better that we can learn from. So, Mark.

Just to come in on both halves of that, we've done some work looking at comparable digital initiatives in different countries. And what Scott said generally about the impact of technology absolutely is—. What we see with almost all types of technology in healthcare—they are not going to deliver efficiency. And I think there has been a definite tendency across the UK to greatly overestimate the ability to twist some policy lever and suddenly you'll be delivering productivity gains of 10 per cent or 20 per cent. It's never happened, and it would take something pretty extraordinary. But with that said, are there countries that do better in a couple of key dimensions? From our research—and this is a report I'll certainly share with the committee—yes; there are certainly countries that are better at interoperability. So, that's the sharing of data between different services that he describes. You won't be surprised to learn again that Denmark is probably a reasonably good example of that, and Finland too, I believe. That was done in both those countries with quite a concerted national programme.

Another really important dimension to think about—. Because we've very much been talking about digital technology as something within the NHS, beyond its front door, but the role of patients in some of these countries is quite a lot bigger. So, they have greater control over their health records. And there's a higher level of trust in many of these countries, which facilitates removing some of the political difficulties that are often associated with why permissions for interoperability and the legislative framework that enables that aren't always easy and non-controversial to get off the ground. So, a lot of these countries, over some time, and across sectors, have built trust in using digital tools to manage your interactions with the state, which, in both those countries, like Wales, includes most of the health service. And so there are certainly areas of digital technology where there are good examples in other countries, although there are deep reasons why that may be.

On efficiency, I hate to sound a note of pessimism—I would love to give you a brilliant comparison point that you could go and learn a lot from—but, on across-the-board efficiency, that is really incredibly difficult to map out. And that's for the very simple reason that, to really learn about efficiency, you need to fully understand both the outputs and the inputs. And on an international level, we're a long way off doing that for the UK or Wales versus other countries, really. There are interesting studies looking at proxy measures, like administrative spend and just the number of discharges that you do relative to your amount of funding, your amount of resources, but we're a long way off having that level of understanding. So, I think, in a sense, you'd need to pick a country first, maybe based on more specific areas like length of stay or interoperability, and then try and go in there and build that kind of comparative data, to really understand that.

Great. I've just got Sarah, then Mabon waiting. So, Sarah first, and then Joyce.

Thank you. So, this is coming back to a few of the points that we've covered. I'm looking at the report and its talk of alignment of incentives and joined-up delivery to enable integration. So, one of the things that you've picked up on—and, obviously, I know this is England but it's the same for Wales; it's the same structure—is that accountability tends to be split between local councils and the NHS. We have the same issue here. And you've used the example of Denmark where what they've done is that the municipality—so, their local government—has full responsibility for determining the appropriate level of health and social support needed following discharge from the hospital. So, you've said GPs will do follow-ups, nurses, different community-based staff, and then it's all under one umbrella. And I suppose the themes that seem to be coming out here, then—you've mentioned a couple of times the decentralisation of power. So, would you suggest, then, that—? You said about being blended. Do you think it's better if it's all under one umbrella? Does that seem to have better outcomes? 

And the other thing that this highlights again, which you mentioned previously—we are very big in England and in Wales, really, on the preventative and getting out to see people in the community. But another theme that seems to be coming through is that we need more focus on the aftercare, on the out-patient on the other side of it, because I do think that that's something that's showing in our data, that people are going back home and then coming back in again very quickly, right? 

Those are both very good points, I think, that very accurately reflect our report's findings. I think on the prevention versus post-discharge elements of out-of-hospital health capability, I certainly wouldn't suggest that, on some fundamental level, prevention isn't much more important in a wider sense that includes all the determinants of health through society, in that that's determining the total disease burden, essentially, that your health service is facing. Where I think that a lot of countries in the UK have run foul of this—a slightly characteristic UK tendency is to try and use everything as a way to save some money next year, in assuming that you can do a little bit of that with GPs going out and helping people to take their asthma medication better or whatever, and you'll immediately see some sort of drop-off in people coming to hospital. There have been plenty of attempts to do things like that.

In England there was an aspiration that the better care fund that they had there was a local government/NHS joint initiative that would save 10 or 15 per cent of emergency admissions in its first year. Obviously, it had essentially no effect at all, just because the drivers of disease are very, very deeply rooted; there are all kinds of complex interplays with what services are available. So, if you're trying to solve health system problems, then the thing that's near in focus, yes, is your ability to discharge people, to have them looked after safely somewhere that's less resource intensive than a hospital and closer to where they live. And, as I say, there are very good grounds for thinking that should be a big priority for Wales, because it does have longer lengths of stay in hospital, or beyond what you would obviously expect compared to England and Scotland.

On the other part of your question about pooling responsibility in these countries, you're absolutely right to pick up the axis of decentralisation and not just combining responsibility, because in a country like Wales or England it's not just that there are two sides, but that one of them really answers nationally and the other one answers locally. So, there is quite a deeply rooted de-alignment that can't really be overcome just by improving joint working locally. These are definitely interesting models for Wales to look at, but I think you've also got to be really aware of the costs of structural change like that and the risk that a structural change doesn't translate through to a cultural, practical change.

Looking much closer to home, there's obviously the—. One part of the UK has fully integrated responsibility for social care and health for decades, which is Northern Ireland, where social care has essentially moved over to the NHS, because there were concerns about the way that councils were using the services for different community groups. And it's not an exemplar of perfect joint working and I think you'd find very few people there who'd say it was, because although the structures are aligned, it doesn't mean the incentives and the culture are. And that may be what works quite well in some of these examples in those countries.

Thank you. 

That's fine. Mabon, do you want to come in? 

Yes, thanks. I guess there are two parts to this, which are interlinked. First of all, just to give a picture, of which you're probably aware, Wales is a very rural, sparsely populated country, or at least parts of it are sparsely populated, and the distances that people have to travel, even though we're a relatively small geographical country—. The mountains, the valleys and the rivers mean that people have to travel a long way. I'm thinking of a Beveridge-type health system; are there any comparable countries out there with that type of healthcare where they've transcended those distances and meant that people can travel from a rural area to a centralised hospital system that we can look at? And also, because of the devolution that we have in Wales, health is largely devolved, but a lot of our health services are provided by English hospitals, and I'm thinking, are there other comparable countries where a lot of the health service is provided in other jurisdictions?

I'll jump for the rurality. Everybody is dealing with this in one way or another, and there's no top-line place where they have solved the problem. What we do often find is that there are real limits to your ability to centralise services. I was just looking at the data from the US, which I think we'll all agree is a much more car-centric, driving culture, and for a normal medical care appointment Americans drive 14 minutes, and they drive 27 minutes for a hospital appointment. And that's in the United States, which has far, far, far greater tolerance for living behind the wheel. It tends to be the case that you end up trying to figure out how to provide as many services—in particular primary care, preventative and after-the-fact, after hospitalisation, chronic care and so forth—in the community, because otherwise adherence just drops off by a lot.

Obviously, you also want to work on the actual quality of the transportation, which is a really, really easy thing to make false economies in, if you end up with a patient sitting in a dialysis clinic for four hours waiting after they've had their procedure. So, fixing healthcare transport is important, but there's no easy answer to how do you centralise services. A lot of the time the answer is think hard about how to maintain a strong level of local services through things like changing the skills mix and models of provision. For example, doctors really like to live in cities. This is definitely a problem that affects large parts of Wales. Basically, they want to live in Cardiff, and that's not unique to doctors in Wales. Nurses and other health professionals are far more likely to be scattered across the entire country and like where they're living. It's a different career trajectory. So, there's a lot of work on nurse-led models essentially everywhere, because to the extent that you can have the nurses as the face of the healthcare system, you're much more likely to be able to staff it in every town.

I've got Joyce waiting to ask a question, but there's an overarching question I just wanted to raise as we have this discussion. Is there any European country that has significantly changed their model—their funding model or their model generally—and what has the impact of that been? Because we may as well stop having a discussion if it's going to be—. If we're going to look for a significant change to how we operate in Wales, you might tell us, 'Don't bother changing what you've got. Just tinker round the edges'. 

The Dutch made their system much more expensive.

What was the impact and the outcomes?

It was more expensive, but otherwise it was about the same. It was essentially the same people delivering the same services but with a very complicated new insurance model sitting on top. 

So you're telling us, 'Don't make significant changes to a model, but perhaps adapt the model you've got'. 

Change is hugely costly. You're usually doing some form of double running, no matter what it is, while you're trying to do the change. It creates a lot of incentives you don't understand. The Dutch had their ways of preventing bad behaviour, but they had to invent new ways of preventing bad behaviour when they introduced a whole new insurance scheme. And also, if you're thinking about things like integration of care, continuity of care, prevention, most of the other health system models have less incentive to invest in that. So, if you move towards, say, a social insurance model, you might get higher patient satisfaction, but you're much less likely to get preventative care, for example. 

Okay, I understand. Mark, you wanted to come in, sorry.

I think this comes down to what you mean by significant changes to the model, because as Scott said, there are very few examples recently, apart from some of the former Soviet-aligned countries, of countries really massively shifting their model from NHS-style in terms of being tax funded, to being funded from social insurance, from payroll level for ease, or private. Once something is set up on that level and it's consuming a tenth of GDP or something, that is just an absolutely massive shift that it's very difficult to think of that many examples of. That's absolutely not to say that there aren't fairly significant shifts short of that, which other European countries do, like shifting responsibilities between a regional authority and the centre, changing the role of GPs and whether they're gate keeping like they do in the UK, whether they have lists of patients, changing how professionalised social care is and, in some cases, reforming social care quite extensively—you know, that sort of level of change, which is a significant change, but whether it's a change to the model depends on what you define that as. That absolutely does happen.

I think you've answered my question—there aren't many examples of significant change in models or systems.

Joyce is next, but I just want to perhaps focus discussion, in particular for us as a committee, to have examples from across Europe that we can learn from, I suppose, and very specific examples of countries and systems that we can learn from, in this next half an hour or so. Joyce. 

And that's where my question leads exactly, because everything has to be paid for; whichever system you adopt, everything has to be paid for, whether it's—whatever. So, my question is in terms of any models that may or may not, if there are any, be advantageous in terms of collecting the money that we need. We have a system at the moment where it's collected through national insurance, and we have fewer people paying it because of the age demographic, obviously. So, have you any examples where people are willing to contribute, financially, more money and accept, then, that they've had a better outcome as a consequence of that? And, of course, the other side of it is the expectation that we have here in the UK, the right to inheritance and the unwillingness to pay for care later in life. I think those are key questions, going forward. So, if you have any examples of those things, they might be useful.

On paying for long-term care, which is where we're having these—. A lot of countries are having the conversation very directly. Some of the UK ideas attracted a great deal of interest around the world. There are basically two models that are being taken up. One is to make it essentially an individual, insure-yourself scheme. So, leaving it completely to families to organise turns out to be a really non-viable idea. How do you get a stable funding base that will allow you to have adequate quality and adequate quantity is the problem. In Germany, for example, they set it up as a long-term insurance scheme, and it just doesn't look like the finances on that are going to work; it looks like the contributions that people are willing to accept for their old-age security are just not in line with what it's actually going to cost to deliver a reasonable quality and reasonable quantity—[Interruption.] Sorry?

Sorry. I said that's almost what I expected. So, what's the answer?

So, the alternative? When you individualise it, you don't raise enough money for a specific long-term care tax or insurance policy, and also, there is intergenerational redistribution, people are paying into something in their twenties that they don't expect they're going to see until their eighties, and possibly they just think that their Government will take the money and run. The other way to do it is to frame it internally to the system—that you pay for it out of general taxation or the general social insurance contribution and you kind of reform it and make it better, but you attach it to the same funding systems as the health system broadly. And that seems to work better, because, otherwise, people below age 50 really are sceptical of the idea that they should be paying into something that they're not going to get benefit from. People don't mind paying for their parents, but they don't necessarily believe that an insurance policy does that.

Can I just underline something Mark said as well, that there's this UK tendency to improve asthma care and expect fewer hospital admissions next year? Getting better quality is good, right? So, with better managed asthma you might not see the hospital budget reflect it, but you see somebody with better quality of life, you see somebody who can engage in paid work more productively and pay taxes. You also see somebody who can do more unpaid work, which is the absolute beast of what actually provides care. So, enabling unpaid care is a policy goal in itself, even if it doesn't show up in fewer hospital admissions for something.

I'm looking around for anyone who's got questions. I wanted to ask a question around prevention. The significant part, obviously, of a health system is preventing people from going into the health system in the first place. Are there any examples across Europe you can point to where we can learn lessons in that regard from? You're both looking like you can't think of anything.

It's such a broad question in some senses, I think, because—

Yes, I understand.

—as you'll know, there are so many drivers of ill health, most of them well beyond the health system. Lots of countries have, frankly, considerably better public health than the UK generally on almost any metric. How do they achieve that? It goes all the way down to the structure of their economy, it's the regional distribution of opportunities, it's factors like pollution and diet. All of these are incredibly important, but the reason I was staring into space a bit is: is there a country that had some sort of special targeted initiatives specifically to stop people going to healthcare and it's had a massive overnight effect? Well, I'm not sure, because, in a sense, much of what's been done in these countries in these areas will have had improving the health of the population as their primary aim, just like Scott was saying, and benefits to healthcare are almost secondary.

I am a bit cautious about over-relying on this, partly because there isn't much evidence for it in the short term. There is always a phenomenon that drives healthcare spending and demand at quite a fundamental level where new things can always be discovered, right? So, particularly in a country like Wales or England, where there is a literal queue in accident and emergency and a metaphorical queue for elective care, it's not totally obvious that fewer people coming forward with certain conditions will mean fewer people coming to the health system. It might mean you can let other people in who can also benefit from healthcare and currently are deterred because access is difficult. So, in terms of are there policies that Wales could learn from that would improve population health—and some of those people needing healthcare now don't need it—yes, absolutely. Are they in a neat initiative targeted to reducing healthcare need, and if they were, would that necessarily work the best? I'm less sure. Scott, who knows more about this, may know of something. 

I'll bring you in now, Scott. I'm just looking at Mabon and Jack. Do any of you want to ask a question on this point?

I'll come back in.

It's a new point. Yes, okay.

A new point from me.

A new point from you. Okay. I'll bring you in, Scott, then, on this point. Thank you.

I just think an example would be cancer. If you want to reduce cancer, reduce tobacco until you get down to the last smoker stubbing out the last cigarette. That's probably the best buy you can get. So, for example, making it difficult or impossible for under-21s to access tobacco is a really good policy, because, under 21, your brain is much more likely to become physiologically addicted. So, if you start smoking after 21, it's far easier to quit again. Tobacco is just an unbelievable driver of health problems, far beyond cancer.

When you talk in terms of preventative healthcare, though, suddenly it flips that not smoking means you're less likely to have a series of health problems. Screening people for cancer produces cancer care. You end up with more cancers identified, more cancers being treated. So, a lot of the obvious preventative healthcare that you can do out of an NHS system does have this way of improving health and improving quality of healthcare and not improving the budgetary situation. So, for prevention, I'd look very much at things like targeting tobacco, targeting alcohol, enabling walking communities, things like that.

Mabon.

I've got a million questions I could ask, but I'll try this one now. Leading on from what you said there, Chair, about preventative care: ploughing resources into sections of health, we know here in Wales and the UK, 80 per cent of the work is done in primary care, yet they only receive something like 5 per cent, 10 per cent of the funding. Now, is that comparable with other countries, or do we see other countries ploughing more into primary care and less into secondary care, funding-wise, resources, and does that have better outcomes?

I don't think there's a happy primary care sector in the world that feels adequately funded, but there's a lot of them that have more resources than any of the NHS systems in the UK. And a lot of the time, again, it comes down to the extent to which they're encouraged and able to hire and offer good careers to people who aren't doctors.

Scott, could you just elaborate on that a little bit?

You can tell this is a bit of a hobby-horse for me. There's so much of a focus on doctors, and to a lesser extent, nurses, and a lot of the time, where you can get really good value for money in primary care by putting any additional resources, and you see a lot of this in the UK—. There's a lot of good practice around Wales and the whole UK toward people who are various forms of physician assistant, nurse, counsellor, home visitor, that kind of job, and it's easy to forget, it's easy to leave those positions unfilled, and it's very easy to make sure that they're not good, desirable careers, and that's leaving a lot of potential health value on the table.

And Jack.

Thanks, Chair. Just trying to draw back to where we started, really, and the question around comparable nations and similar populations, similar Governments, jurisdictions and so on. We've talked a lot about the Scandinavian countries; we've talked a lot about the Dutch and so on, and their models are slightly different. But northern Spain really interests me, in how (1) it's quite similar in terms of economy, it's quite similar in population, and it's also quite similar in the rurality of the country itself, or the region itself. So, that, it seems to me, is the most direct comparison that we can perhaps come up with. Going back to your point, Professor Greer, to start with, we need to do some work as a committee of looking at particular policy areas in which we might be a able to make a difference, rather than the whole model itself. In the north of Spain, are there any particular policy areas where we perhaps could learn from, and look at, to help in our thinking going forward?

The Basques do a lot of innovative things, but they do it with quite a lot of money, because of some quirks in the Spanish overall financial system. Asturias and Cantabria, they're not the most innovative Governments in Spain, but they have put a lot of effort into running services well, so I think you find, at a minimum, a very good confessional of shared problems and sort of ways to address them on the very practical management service and design, that sort of level. So, the Basques would have a lot of good ideas and be willing to share them, but some of them might not fit within your budget envelope. One other one, if you're looking at health IT, is Estonia: a million people, and, basically, the whole country's a website.

That's very interesting. We have lots of discussion about IT here, and I take your point about efficiency, both points about efficiency earlier, but it does seem to me that we need to be at a level where IT infrastructure is sound, if that's the right word for it.

Running IT well: fantastic idea. It's just that, in health, so often that turns out to be hard.

I think there are two policy areas that we need to do some work on, Chair, I think—on what exactly we might be able to do.

Sure. I suppose, as we've only got 10 minutes left of this session, it's about drawing some key things that Wales can learn from our delivery of healthcare and other European countries—that's the general question, I suppose. It's about pointing us to examples, as we conclude, which you think that we can learn from in particular—any particular examples of where we can look to. And I suppose, also, we've spoken to both of you today, but is there anybody else you think that we should be speaking to?

So, on areas to look at, I think—. Scott and I haven't always been immensely helpful at coming up with really unique case studies. We tend to emphasise that it's incredibly complicated and you need to be careful with whatever you do. But on the previous question, I don't think—. I personally wouldn't put a total counsel of despair around the idea of learning from other countries just because they have a subtly different funding model or the political accountability is at a bit of a different level, depending on what the thing you're choosing is. Because the reality of care being actually provided might not fall neatly into matching those neat buckets and there may be some similarities.

So, two of the things that we've touched on as we've gone around—obviously, we've done a report on this—we're very interested in the ways in which countries are able to discharge patients faster in some of these countries. And partly, those will be things that are very difficult to transfer in terms of the level of resourcing or maybe of the ways that systems are set up. But there's almost certainly still interesting learning on the actual details of how that is done: what is considered a safe setting to discharge to? How the assessments work? What proportion of patients are in particular categories in hospitals and how is that different, and what proportion of patients are assigned to different community services? I still think that that could be an interesting thing to explore.

And then, as we've touched on various points—

Which areas, though—which countries are you suggesting that we look at in that regard?

So, the ones we identified were, again, the Scandinavian ones and the Netherlands. The Netherlands has a more different system. The reality is that Wales, compared to England, because it has longer lengths of stay in the first place—. Other countries would also start looking quite a bit quicker at passing patients through, including Ireland, actually, which has a health system in some question in some ways, but does have shorter lengths of stay. 

The other theme that I think is worth maybe coming back to is social care professionalisation and workforce, which, as Scott noted earlier, is something that a lot of countries have really been grappling with. There are lots of examples of different ways they've tried to create a career structure and a more appealing work space—some of them have gone well, some of them maybe not so well—and that includes countries like Germany and New Zealand, where they've tried to improve conditions, in New Zealand in particular, by introducing a greater level of professionalisation. So, there's certainly plenty there as well.

Any other questions at all?

I think in terms of public health pay-off, you might look at Finland for a lot of things, because Finland doesn't have the wonderfully healthy, egalitarian population that you see in the Scandinavian countries. And, it's not in Europe, although sometimes it claims to be, Canada.

Did you say Finland? Isn't Finland a Scandinavian—?

Yes, Finland, but also Canada—

Okay, yes.

—which is an honorary European country. They deal with a lot of the problems and you see a lot of innovative, practical efforts to deal with things like a rural workforce, telehealth, managing decline in some areas and centralising policies in others. So, there are a lot of lessons from different Canadian provinces.

And the Scandinavian countries you've pointed to a number of times. Are they all similar in their structures, in terms of the Scandinavian countries? We're talking about Scandinavian countries. We're talking about are Sweden, Norway, Finland—

So, with Sweden, Norway, Denmark, you have these really healthy populations and that makes a lot of things easier. For example, the finances work out better because you don't have really rich areas and really poor areas, in the same way that you don't have really rich people and really poor people. Finland is different. The Finnish economy doesn't produce quite such a healthy population going in, which means that a lot more of the impact seems to be from actual public health policies.

Jack.

We're talking about different countries—Canada, Finland, everywhere. As I said earlier, I think we're going to have to go away and think about the particular area that, perhaps, we want to focus on rather than the whole-system approach to the policy area. I'm just wondering, away from this meeting, whether you'd be able to maybe draw down—you've said Denmark, you've said a range of countries in Europe and elsewhere—where there might be one or two particular policy areas in these countries that we could really go and have a look at, have a significant way of going—. If we decide it might be social care and parity of esteem for social care, which is crucially important, there may be a country that has got that particularly well developed there, and there may be another country that might be good at IT infrastructure. And when we have a discussion later on about what we want to do as a committee, we may be able to make these comparable choices, well, informed choices, of where to look. I think that might be useful, if that's something that you can provide.

And any contacts that you can provide in these areas that we can perhaps ask for a further discussion on. Yes, Scott.

We both work with and mentioned the European Observatory on Health Systems and Policies. I think they would love to help, and they do spend a lot of their time doing things like organising policy dialogues on specific problems with Governments.

Lovely.

Good. That would be useful.

I suppose, just to end, is there a summary of any main points or areas or elements of health and care delivery that we should be considering?

Something that we haven't really discussed but it is something that stands out about the UK and international comparison is actual clinical outcomes from health treatment, which are incredibly difficult to compare, again, and they're at a UK level not Wales, but in general the picture is not great. Mortality that should be preventable by healthcare is quite high. If you look in years of delay after cancer diagnosis or days after heart attack or stroke admission, survival is not great. That probably takes you down potentially a more clinical path than much of what we've discussed, and it's fairly inseparable from the kinds of health of the population issues for which Scott was maybe suggesting that Finland, which also doesn't have great outcomes, is a good comparator, but that might be another dimension to consider. I often feel like it gets slightly oddly overlooked in UK discourse, given that when you look at what international data is available, if anything, that is the problematic thing that tends to stand out about the UK.

Okay. Thank you. Any other final questions from Members at all? Was that a good summary to end on?

That was very good, really interesting.

Yes. I suppose I'll ask is there anything that you—the last question kind of asked this, I suppose, but is there anything that we've not asked that you think we should ask you? It's good if there's nothing, it means we've asked everything correctly. [Laughter.]

There are a lot of potentially bad questions I prepared for, but I didn't need my responses. [Laughter.]

No.

While I'm talking, I would just say that so many of these problems, more and more, turn into workforce problems, so I would be fully prepared to discover that whatever you try to do an inquiry into you end up with the workforce. 

Okay. Thank you. I appreciate that. Thank you ever so much, both, for your time. We really appreciate it. It was a really useful and fascinating discussion, so you've given us plenty of food for thought in our private meeting now to discuss. So, thank you both for your time this morning, it's very much appreciated. Diolch yn fawr iawn.

Thank you.

We move to item 6, and I've never seen so many papers to note, so I'm not even going to attempt to summarise them. I'm just going to say there are a large number of papers to note that are all available in the public pack. None of them needs a response, they're for noting generally, so are Members happy to confirm the papers are noted? Thank you. In that case, that draws our public meeting to an end this morning. Thank you.